description sample_name transcription keywords medical_specialty string string string string Cardiovascular\ /\ Pulmonary Neurology Orthopedic meta meta title=True meta include=True meta class 2-D M-Mode. Doppler. 2-D Echocardiogram - 1 2-D M-MODE: , ,1. Left atrial enlargement with left atrial diameter of 4.7 cm.,2. Normal size right and left ventricle.,3. Normal LV systolic function with left ventricular ejection fraction of 51%.,4. Normal LV diastolic function.,5. No pericardial effusion.,6. Normal morphology of aortic valve, mitral valve, tricuspid valve, and pulmonary valve.,7. PA systolic pressure is 36 mmHg.,DOPPLER: , ,1. Mild mitral and tricuspid regurgitation.,2. Trace aortic and pulmonary regurgitation. cardiovascular / pulmonary, 2-d m-mode, doppler, aortic valve, atrial enlargement, diastolic function, ejection fraction, mitral, mitral valve, pericardial effusion, pulmonary valve, regurgitation, systolic function, tricuspid, tricuspid valve, normal lv Cardiovascular / Pulmonary 2-D Echocardiogram 2-D Echocardiogram - 2 1. The left ventricular cavity size and wall thickness appear normal. The wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%. There is near-cavity obliteration seen. There also appears to be increased left ventricular outflow tract gradient at the mid cavity level consistent with hyperdynamic left ventricular systolic function. There is abnormal left ventricular relaxation pattern seen as well as elevated left atrial pressures seen by Doppler examination.,2. The left atrium appears mildly dilated.,3. The right atrium and right ventricle appear normal.,4. The aortic root appears normal.,5. The aortic valve appears calcified with mild aortic valve stenosis, calculated aortic valve area is 1.3 cm square with a maximum instantaneous gradient of 34 and a mean gradient of 19 mm.,6. There is mitral annular calcification extending to leaflets and supportive structures with thickening of mitral valve leaflets with mild mitral regurgitation.,7. The tricuspid valve appears normal with trace tricuspid regurgitation with moderate pulmonary artery hypertension. Estimated pulmonary artery systolic pressure is 49 mmHg. Estimated right atrial pressure of 10 mmHg.,8. The pulmonary valve appears normal with trace pulmonary insufficiency.,9. There is no pericardial effusion or intracardiac mass seen.,10. There is a color Doppler suggestive of a patent foramen ovale with lipomatous hypertrophy of the interatrial septum.,11. The study was somewhat technically limited and hence subtle abnormalities could be missed from the study., cardiovascular / pulmonary, 2-d, doppler, echocardiogram, annular, aortic root, aortic valve, atrial, atrium, calcification, cavity, ejection fraction, mitral, obliteration, outflow, regurgitation, relaxation pattern, stenosis, systolic function, tricuspid, valve, ventricular, ventricular cavity, wall motion, pulmonary artery Cardiovascular / Pulmonary 2-D Echocardiogram 2-D Echocardiogram - 3 2-D ECHOCARDIOGRAM,Multiple views of the heart and great vessels reveal normal intracardiac and great vessel relationships. Cardiac function is normal. There is no significant chamber enlargement or hypertrophy. There is no pericardial effusion or vegetations seen. Doppler interrogation, including color flow imaging, reveals systemic venous return to the right atrium with normal tricuspid inflow. Pulmonary outflow is normal at the valve. Pulmonary venous return is to the left atrium. The interatrial septum is intact. Mitral inflow and ascending aorta flow are normal. The aortic valve is trileaflet. The coronary arteries appear to be normal in their origins. The aortic arch is left-sided and patent with normal descending aorta pulsatility. cardiovascular / pulmonary, 2-d echocardiogram, cardiac function, doppler, echocardiogram, multiple views, aortic valve, coronary arteries, descending aorta, great vessels, heart, hypertrophy, interatrial septum, intracardiac, pericardial effusion, tricuspid, vegetation, venous, pulmonaryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., Cardiovascular / Pulmonary Echocardiogram and Doppler 2-D Echocardiogram - 4 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%., cardiovascular / pulmonary, ejection fraction, lv systolic function, cardiac chambers, regurgitation, tricuspid, normal lv systolic function, normal lv systolic, ejection fraction estimated, normal lv, lv systolic, systolic function, function ejection, echocardiogram, doppler, lv, systolic, ejection, mitral, valve Cardiovascular / Pulmonary Normal left ventricle, moderate biatrial enlargement, and mild tricuspid regurgitation, but only mild increase in right heart pressures. 2-D Doppler 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. cardiovascular / pulmonary, 2-d study, doppler, tricuspid regurgitation, heart pressures, stenosis, ventricular, heart, ventricle, tricuspid, regurgitation, Cardiovascular / Pulmonary Cerebral Angiogram - moyamoya disease. Moyamoya Disease "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." Neurology Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube. Tracheostomy PREOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,POSTOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,OPERATION PERFORMED,Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube.,INDICATIONS FOR SURGERY,The patient is a 50-year-old white male with history of progressive tracheomalacia treated in the National Tennessee, and several years ago he had a tracheal metallic stent placed with some temporary improvement. However developed progressive problems and he had two additional stents placed with some initial improvement. Subsequently, he developed progressive airway obstruction and came into the ABC Hospital critical airway service for further evaluation and was admitted on Month DD, YYYY. He underwent bronchoscopy by Dr. W and found to have an extensive subglottic upper tracheal and distal tracheal stenosis secondary to metallic stent extensive granulation and inflammatory tissue changes. The patient had some debridement and then was hospitalized and Laryngology and Thoracic Surgery services were consulted for further management. Exploration of trachea, removal of foreign body stents constricting his airway, dilation and stabilization of his trachea were offered to the patient. Nature of the proposed procedure including risks and complications of bleeding, infection, alteration of voice, speech, swallowing, voice changes permanently, possibility of tracheotomy temporarily or permanently to maintain his airway, loss of voice, cardiac risk factors, anesthetic risks, recurrence of problems, upon surgical intervention were all discussed at length. The patient stated that he understood and wished to proceed.,DESCRIPTION OF PROCEDURE,The patient was taken to the operating room, placed in the supine position. Following adequate monitoring by Anesthesia Service to maintain sedation, the patient's neck was prepped and draped in the sterile fashion. The neck was then infiltrated with 1% Xylocaine and 1000 epinephrine. A collar incision approximately 1 fingerbreadth above the clavicle, this was an outline incision, was carried out. The skin, subcutaneous tissue, platysma, subplatysmal flaps elevated superiorly and inferiorly. Strap muscles were separated in the midline, dissection carried down to visceral fascia. Beneath the strap muscles, there was dense inflammation scarring obscuring palpable landmarks. There appeared to be significant scarring fusion of soft tissue at the perichondrium and cartilage of the cricoid making the cricoid easily definable. There was a markedly enlarged thyroid isthmus. Thyroid isthmus was divided and dense inflammation, attachment of the thyroid isthmus, fusion of the thyroid gland to the capsule to the pretracheal fascia requiring extensive blunt sharp dissection. Trachea was exposed from the cricoid to the fourth ring which entered down into the chest. The trachea was incised between the second and third ring inferior limb in the midline and excision of small ridge of cartilage on each side sent for pathologic evaluation. The tracheal cartilage externally had marked thickening and significant stiffness calcification, and the tracheal wall from the outside of the trachea to the mucosa measured 3 to 4 mm in thickness. The trachea was entered and visualized with thickening of the mucosa and submucosa was noted. The patient, however, was able to ventilate at this point a #6 Endo Tube was inserted and general anesthesia administered. Once the airway was secured, we then proceeded working around the #6 Endo Tube as well as with the tube intake and out to explore the trachea with ridged fiberoptic scopes as well as flexible fiberoptic bronchoscopy to the trach site. Examination revealed extrusion of metallic fragments from stent and multiple metallic fragments were removed from the stent in the upper trachea. A careful examination of the subglottic area showed inflamed and thickened mucosa but patent subglottis. After removal of the stents and granulation tissue, the upper trachea was widely patent. The mid trachea had some marked narrowing secondary to granulation. Stent material was removed from this area as well. In the distal third of the trachea, a third stent was embedded within the mucosa, not encroaching on the lumen without significant obstruction distally and this was not disturbed at this time. All visible stent material in the upper and mid trachea were removed. Initial attempt to place a #16 Montgomery T tube showed the distal lumen of the T tube to be too short to stent the granulation narrowing of the trachea at the junction of the anterior two thirds and the distal third. Also, this was removed and a #8 Shiley single cannula tracheostomy tube was placed after removal of the endotracheal tube. A good ventilation was confirmed and the position of the tube confirmed it to be at the level just above the metallic stent which was embedded in the mucosa. The distal trachea and mainstem bronchi were widely patent. This secured his airway and no further manipulation felt to be needed at this time. Neck wound was thoroughly irrigated and strap muscles were closed with interrupted 3-0 Vicryl. The skin laterally to the trach site was closed with running 2-0 Prolene. Tracheostomy tube was secured with interrupted 2-0 silk sutures and the patient was taken back to the Intensive Care Unit in satisfactory condition. The patient tolerated the procedure well without complication. cardiovascular / pulmonary, airway, laryngology, shiley, alteration of voice, bronchi, bronchoscopy, cannula, cartilage, cricoid, flexible, foreign body, mainstem, obstruction, perichondrium, stenosis, stent, subglottic, swallowing, trachea, tracheal, tracheal stenosis, tracheostomy, shiley single cannula tracheostomy, shiley single cannula, single cannula tracheostomy, thyroid isthmus, stent material, tracheostomy tube, tube, thyroid, Cardiovascular / Pulmonary Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot. Youngswick Osteotomy 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. orthopedic, hallux limitus deformity, metatarsophalangeal joint, plantar cut, youngswick osteotomy, dorsal cuts, ankle tourniquet, proximal phalanx, anesthesia, tourniquet, youngswick, phalanx, metatarsophalangeal, proximal, metatarsal, dorsal, osteotomy Orthopedic Austin & Youngswick bunionectomy with Biopro implant. Screw fixation, left foot. Youngswick Bunionectomy PREOPERATIVE DIAGNOSES:,1. Hallux rigidus, left foot.,2. Elevated first metatarsal, left foot.,POSTOPERATIVE DIAGNOSES:,1. Hallux rigidus, left foot.,2. Elevated first metatarsal, left foot.,PROCEDURE PERFORMED:,1. Austin/Youngswick bunionectomy with Biopro implant.,2. Screw fixation, left foot.,HISTORY: , This 51-year-old male presents to ABCD General Hospital with the above chief complaint. The patient states that he has had degenerative joint disease in his left first MPJ for many years that has been progressively getting worse and more painful over time. The patient desires surgical treatment.,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 7 cc of 0.5% Marcaine plain was injected in a Mayo-type block. 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 then inflated to 250 mmHg. The foot was lowered to the operating table, the stockinet was reflected, and the foot was cleansed with wet and dry sponge.,Attention was then directed to the left first metatarsophalangeal joint. Approximately a 6 cm dorsomedial incision was created over the first metatarsophalangeal joint, just medial to the extensor hallucis longus tendon. The incision was then deepened with a #15 blade. All vessels encountered were ligated for hemostasis. The skin and subcutaneous tissue was undermined medially, off of the joint capsule. A dorsal linear capsular incision was then made. Care was taken to identify and preserve the extensor hallucis longus tendon. The capsule and periosteum were then reflected off of the head of the first metatarsal as well as the base of the proximal phalanx. There was noted to be a significant degenerative joint disease. There was little to no remaining healthy articular cartilage left on the head of the first metatarsal. There was significant osteophytic formation medially, dorsally, and laterally in the first metatarsal head as well as at the base of the proximal phalanx. A sagittal saw was then used to resect the base of the proximal phalanx. Care was taken to ensure that the resection was parallel to the nail. After the bone was removed in toto, the area was inspected and the flexor tendon was noted to be intact. The sagittal saw was then used to resect the osteophytic formation medially, dorsally, and laterally on the first metatarsal. The first metatarsal was then re-modelled and smoothed in a more rounded position with a reciprocating rasp. The sizers were then inserted for the Biopro implant. A large was noted to be of the best size. There was noted to be some hypertrophic bone laterally in the base of the proximal phalanx. Following inspection, the sagittal saw was used to clean both the medial and lateral sides of the base. A small bar drill was then used to pre-drill for the Biopro sizer. The bone was noted to be significantly hardened. The sizer was placed and a large Biopro was deemed to be the correct size implant. The sizer was removed and bar drill was then again used to ream the medullary canal. The hand reamer with a Biopro set was then used to complete the process. The Biopro implant was then inserted and tamped with a hammer and rubber mallet to ensure tight fit. There was noted to be distally increased range of motion after insertion of the implant.,Attention was then directed to the first metatarsal. A long dorsal arm Austin osteotomy was then created. A second osteotomy was then created just plantar and parallel to the first osteotomy site. The wedge was then removed in toto. The area was feathered to ensure high compression of the osteotomy site. The head was noted to be in a more plantar flexed position. The capital fragment was then temporarily fixated with two 0.45 K-wires. A 2.7 x 16 mm screw was then inserted in the standard AO fashion. A second more proximal 2.7 x 60 mm screw was also inserted in a standard AO fashion. With both screws, there was noted to be tight compression at the osteotomy sites.,The K-wires were removed and the areas were then smoothed with reciprocating rash. A screw driver was then used to check and ensure screw tightness. The area was then flushed with copious amounts of sterile saline. Subchondral drilling was performed with a 1.5 drill bit. The area was then flushed with copious amounts of sterile saline. Closure consisted of capsular closure with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl, followed by running subcuticular stitch of #5-0 Vicryl. Dressings consisted of Steri-Strips, Owen silk, 4x4s, Kling, Kerlix, and Coban. A total of 10 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain was injected intraoperatively for further anesthesia. 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. The patient was transported to PACU with vital signs stable and vascular status intact to the right foot. The patient was given postoperative pain prescription for Vicodin ES and instructed to take 1 q. 4-6h. p.o. p.r.n. pain. The patient was instructed to ice and elevate his left lower extremity as much as possible to help decrease postoperative edema. The patient is to follow up with Dr. X in his office as directed. orthopedic, hallux rigidus, metatarsal, youngswick, bunionectomy, screw fixation, ankle tourniquet, metatarsophalangeal joint, biopro implant, proximal phalanx, foot, austin, anesthesia, osteotomy, screw, Orthopedic Consultation for wrist pain. Wrist Pain CHIEF COMPLAINT:, Left wrist pain.,HISTORY OF PRESENT PROBLEM:, orthopedic, wrist pain, scapholunate, tenderness to palpation, three views, traumatic wrist injury, ulnar styloid nonunion, ulnar styloid, wrist, union, soreness, styloid, ulnar, Orthopedic Excision of dorsal wrist ganglion. Made a transverse incision directly over the ganglion. Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them. Wrist Ganglion Excision PREOPERATIVE DIAGNOSIS: , Wrist ganglion.,POSTOPERATIVE DIAGNOSIS: , Wrist ganglion.,TITLE OF PROCEDURE: , Excision of dorsal wrist ganglion.,PROCEDURE: , After administering appropriate antibiotics and general anesthesia, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with an Esmarch and tourniquet inflated to 250 mmHg. I made a transverse incision directly over the ganglion. Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them. I then excised the ganglion and its stalk. In addition, approximately a square centimeter of the dorsal capsule was removed at the origin of stalk, leaving enough of a defect to prevent formation of a one-way valve. We then identified the scapholunate ligament, which was uninjured. I irrigated and closed in layers and injected Marcaine with epinephrine. I dressed and splinted the wound. The patient was sent to the recovery room in good condition, having tolerated the procedure well. orthopedic, origin of stalk, extensor retinaculum, wrist ganglion, incision, excision, dorsal, tourniquet, wrist, ganglion Orthopedic Unilateral transpedicular T11 vertebroplasty. Vertebroplasty PREOPERATIVE DIAGNOSIS:, T11 compression fracture with intractable pain.,POSTOPERATIVE DIAGNOSIS:, T11 compression fracture with intractable pain.,OPERATION PERFORMED:, Unilateral transpedicular T11 vertebroplasty.,ANESTHESIA:, Local with 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. Using AP and lateral fluoroscopic projections the T11 compression fracture was identified. Starting from the left side local anesthetic was used for skin wheal just lateral superior to the 10 o'clock position of the lateral aspect of the T11 pedicle on the left. The 13-gauge needle and trocar were then taken and placed to 10 o'clock position on the pedicle. At this point using AP and lateral fluoroscopic views, the needle and trocar were advanced into the vertebral body using the fluoroscopic images and making sure that the needle was lateral to the medial wall of the pedicle of the pedicle at all times. Once the vertebral body was entered then using lateral fluoroscopic views, the needle was advanced to the junction of the anterior one third and posterior two thirds of the body. At this point polymethylmethacrylate was mixed for 60 seconds. Once the consistency had hardened and the __________ was gone, incremental dose of the cement were injected into the vertebral body. It was immediately seen that the cement was going cephalad into the vertebral body and was exiting through the crack in the vertebra. A total 1.2 cc of cement was injected. On lateral view, the cement crushed to the right side as well. There was some dye infiltration into the disk space. There was no dye taken whatsoever into the posterior aspect of the epidural space or intrathecal canal.,At this point, as the needle was slowly withdrawn under lateral fluoroscopic images, visualization was maintained to ensure that none of the cement was withdrawn posteriorly into the epidural space. Once the needle was withdrawn safely pressure was held over the site for three minutes. There were no complications. The patient was taken back to the recovery area in stable condition and kept flat for one hour. Should be followed up the next morning. orthopedic, transpedicular, vertebroplasty, fluoroscopic views, fluoroscopic images, epidural space, compression fracture, vertebral body, compression, pedicle, fluoroscopic, vertebral, needle Orthopedic Trigger thumb release. Right trigger thumb. The A-1 pulley was divided along its radial border, completely freeing the stenosing tenosynovitis (trigger release). Trigger Thumb Release - 1 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:, orthopedic, trigger thumb, trigger thumb release, tenosynovitis trigger, tenosynovitis, release, thumb, tourniquet, trigger, Orthopedic Right ulnar nerve transposition, right carpal tunnel release, and right excision of olecranon bursa. Right cubital tunnel syndrom, carpal tunnel syndrome, and olecranon bursitis. Ulnar Nerve Transposition & Olecranon Bursa Excision PREOPERATIVE DIAGNOSIS: ,1. Right cubital tunnel syndrome.,2. Right carpal tunnel syndrome.,3. Right olecranon bursitis.,POSTOPERATIVE DIAGNOSIS:, ,1. Right cubital tunnel syndrome.,2. Right carpal tunnel syndrome.,3. Right olecranon bursitis.,PROCEDURES:, ,1. Right ulnar nerve transposition.,2. Right carpal tunnel release.,3. Right excision of olecranon bursa.,ANESTHESIA:, General.,BLOOD LOSS:, Minimal.,COMPLICATIONS:, None.,FINDINGS: , Thickened transverse carpal ligament and partially subluxed ulnar nerve.,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, his right arm was sterilely prepped and draped in normal fashion. After elevation and exsanguination with an Esmarch, the tourniquet was inflated. The carpal tunnel was performed first with longitudinal incision in the palm carried down through the skin and subcutaneous tissues. The palmar fascia was divided exposing the transverse carpal ligament, which was incised longitudinally. A Freer was then inserted beneath the ligament, and dissection was carried out proximally and distally.,After adequate release has been formed, the wound was irrigated and closed with nylon. The medial approach to the elbow was then performed and the skin was opened and subcutaneous tissues were dissected. A medial antebrachial cutaneous nerve was identified and protected throughout the case. The ulnar nerve was noted to be subluxing over the superior aspect of the medial epicondyle and flattened and inflamed. The ulnar nerve was freed proximally and distally. The medial intramuscular septum was excised and the flexor carpi ulnaris fascia was divided. The intraarticular branch and the first branch to the SCU were transected; and then the nerve was transposed, it did not appear to have any significant tension or sharp turns. The fascial sling was made from the medial epicondyle and sewn to the subcutaneous tissues and the nerve had good translation with flexion and extension of the elbow and not too tight. The wound was irrigated. The tourniquet was deflated and the wound had excellent hemostasis. The subcutaneous tissues were closed with #2-0 Vicryl and the skin was closed with staples. Prior to the tourniquet being deflated, the subcutaneous dissection was carried out over to the olecranon bursa, where the loose fragments were excised with a rongeurs as well as abrading the ulnar cortex and excision of hypertrophic bursa. A posterior splint was applied. Marcaine was injected into the incisions and the splint was reinforced with tape. He was awakened from the anesthesia and taken to recovery room in a stable condition. Final needle, instrument, and sponge counts were correct. orthopedic, cubital tunnel syndrome, carpal tunnel syndrome, olecranon bursitis, ulnar nerve transposition, carpal tunnel release, excision of olecranon bursa, transposition, ligament, tourniquet, excision, bursa, syndrome, subcutaneous, ulnar, olecranon, carpal, nerve, tunnel, Orthopedic Subcutaneous ulnar nerve transposition. 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. Ulnar Nerve Transposition 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. orthopedic, neurolysis, ulnar, periosteal, flexor-pronator mass, ulnar nerve transposition, medial intermuscular septum, nerve transposition, intermuscular septum, flexor pronator, ulnar nerve, nerve Orthopedic Trigger finger release. A longitudinal incision was made over the digit's A1 pulley. Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles. The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease. Trigger Finger Release PROCEDURE: , Trigger finger release.,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 longitudinal incision was made over the digit's A1 pulley. Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles. The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease. Meticulous hemostasis was maintained with bipolar electrocautery.,The tendons were identified and atraumatically pulled to ensure that no triggering remained. The patient then actively moved the digit, and no triggering was noted.,After irrigating out the wound with copious amounts of sterile saline, the skin was closed with 5-0 nylon simple interrupted sutures.,The wound was dressed and the patient was sent to the recovery room in good condition, having tolerated the procedure well. orthopedic, a1 pulley, neurovascular bundles, trigger finger release, proximal digital, digital crease, trigger finger, trigger, finger, sheath, incision Orthopedic Decompression of the ulnar nerve, left elbow. Left cubital tunnel syndrome and ulnar nerve entrapment. Ulnar Nerve Decompression PREOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,POSTOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,PROCEDURE PERFORMED: , Decompression of the ulnar nerve, left elbow.,ANESTHESIA: , General.,FINDINGS OF THE OPERATION:, The ulnar nerve appeared to be significantly constricted as it passed through the cubital tunnel. There was presence of hourglass constriction of the ulnar nerve.,PROCEDURE: , The patient was brought to the operating room and once an adequate general anesthesia was achieved, his left upper extremity was prepped and draped in standard sterile fashion. A sterile tourniquet was positioned and tourniquet was inflated at 250 mmHg. Perioperative antibiotics were infused. Time-out procedure was called. The medial epicondyle and the olecranon tip were well palpated. The incision was initiated at equidistant between the olecranon and the medial epicondyle extending 3-4 cm proximally and 6-8 cm distally. The ulnar nerve was identified proximally. It was mobilized with a blunt and a sharp dissection proximally to the arcade of Struthers, which was released sharply. The roof of the cubital tunnel was then incised and the nerve was mobilized distally to its motor branches. The ulnar nerve was well-isolated before it entered the cubital tunnel. The arch of the FCU was well defined. The fascia was elevated from the nerve and both the FCU fascia and the Osborne fascia were divided protecting the nerve under direct visualization. Distally, the dissection was carried between the 2 heads of the FCU. Decompression of the nerve was performed between the heads of the FCU. The muscular branches were well protected. Similarly, the cutaneous branches in the arm and forearm were well protected. The venous plexus proximally and distally were well protected. The nerve was well mobilized from the cubital tunnel preserving the small longitudinal vessels accompanying it. Proximally, multiple vascular leashes were defined near the incision of the septum into the medial epicondyle, which were also protected. Once the in situ decompression of the ulnar nerve was performed proximally and distally, the elbow was flexed and extended. There was no evidence of any subluxation. Satisfactory decompression was performed. Tourniquet was released. Hemostasis was achieved. Subcutaneous layer was closed with 2-0 Vicryl and skin was approximated with staples. A well-padded dressing was applied. The patient was then extubated and transferred to the recovery room in stable condition. There were no intraoperative complications noted. The patient tolerated the procedure very well. orthopedic, ulnar nerve entrapment, ulnar nerve, ulnar nerve decompression, cubital tunnel syndrome, ulnar, nerve, fascia, decompression, cubital, tunnel Orthopedic Total knee replacement. A midline incision was made, centered over the patella. Dissection was sharply carried down through the subcutaneous tissues. A median parapatellar arthrotomy was performed. Total Knee Replacement - 1 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. orthopedic, proximal medial tibia, total knee replacement, parapatellar arthrotomy, subcutaneous tissues, tibial plateau, incision, cutting, patella, femur, femoral, component, knee, Orthopedic Right total knee arthroplasty - Osteoarthritis, right knee. Total Knee Arthroplasty - Right 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. orthopedic, osteoarthritis, arthroplasty, knee, patella, retinacular parapatellar, total knee arthroplasty, total knee, knee arthroplasty, baseplate, femoral, tibia, Orthopedic Total left knee replacement. Degenerative arthritis of the left knee. Degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau. Total Knee Replacement PREOPERATIVE DIAGNOSIS: ,Degenerative arthritis of the left knee.,POSTOPERATIVE DIAGNOSIS:, Degenerative arthritis of the left knee.,PROCEDURE PERFORMED: , Total left knee replacement on 08/19/03. The patient also underwent a bilateral right total knee replacement in the same sitting and that will be dictated by Dr. X.,TOURNIQUET TIME: , 76 minutes.,BLOOD LOSS: , 150 cc.,ANESTHESIA: ,General.,IMPLANT USED FOR PROCEDURE:, NexGen size F femur on the left with #8 size peg tibial tray, a #12 mm polyethylene insert and this a cruciate retaining component. The patella on the left was not resurfaced.,GROSS INTRAOPERATIVE FINDINGS: , Degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau. The surface of the patella was with a minimal ware and minimal osteophytes and we decided not to resurface the patellar component.,HISTORY: ,This is a 69-year-old male with complaints of bilateral knee pain for several years and increased intensity in the past several months where it has affected his activities of daily living. He attempted conservative treatment, which includes anti-inflammatory medications as well as cortisone and Synvisc. This has only provided him with temporary relief. It is for that reason, he is elected to undergo the above-named procedure.,All risks as well as complications were discussed with the patient, which include, but are not limited to infection, deep vein thrombosis, pulmonary embolism, need for further surgery, and further pain. He has agreed to undergo this procedure and a consent was obtained preoperatively.,PROCEDURE: , The patient was wheeled back to operating room #2 at ABCD General Hospital on 08/19/03 and was placed supine on the operating room table. At this time, a nonsterile tourniquet was placed on the left upper thigh, but not inflated. An Esmarch was then used to exsanguinate the extremity and the left extremity was then prepped and draped in the usual sterile fashion for this procedure. The tourniquet was then inflated to 325 mmHg. At this time, a standard midline incision was made towards the total knee. We did discuss preoperatively for a possible unicompartmental knee replacement for this patient, but he did have radiographic evidence of chondrocalcinosis of the lateral meniscus. We did start off with a small midline skin incision in case we were going to do a unicompartmental. Once we exposed the medial parapatellar mini-arthrotomy and visualized the lateral femoral condyle, we decided that this patient would not be an optimal candidate for unicompartmental knee replacement. It is for this reason that we extended the incision and underwent with the total knee replacement. Once the full medial parapatellar arthrotomy was performed with the subperiosteal dissection of the proximal tibia in order to evert the patella. Once the patella was everted, we then used a drill to cannulate the distal femoral canal in order to place the intramedullary guide. A Charnley awl was then used to remove all the intramedullary contents and they were removed from the knee. At this time, a femoral sizer was then placed with reference to the posterior condyles and we measured a size F. Once this was performed, three degrees of external rotation was then drilled into the condyle in alignment with the epicondyles of the femur. At this time, the intramedullary guide was then inserted and placed in three degrees of external rotation. Our anterior cutting guide was then placed and an anterior cut was performed with careful protection of the soft tissues. Next, this was removed and the distal femoral cutting guide was then placed in five degrees of valgus. This was pinned to the distal femur and with careful protection of the collateral ligaments, a distal femoral cut was performed. At this time, the intramedullary guide was removed and a final cutting block was placed. This was placed in the center on the distal femur with 1 mm to 2 mm laterally translated for better patellar tracking. At this time, the block was pinned and screwed in place with spring pins with careful protection of the soft tissues. An oscillating saw was then used to resect the posterior and anterior cutting blocks with anterior and posterior chamfer as well as the notch cut. Peg holes were then drilled.,The block was then removed and an osteotome was then used to remove all the bony cut pieces. At this time with a better exposure of the proximal tibia, we placed external tibial guide. This was placed with longitudinal axis of the tibia and carefully positioned in order to obtain an optimal cut for the proximal tibia. At this time with careful soft tissue retraction and protection, an oscillating saw was used to make a proximal tibial osteotomy. Prior to the osteotomy, the cut was checked with a depth gauge in order to assure appropriate bony resection. At this time, a _blunt Kocher and Bovie cautery were used to remove the proximal tibial cut, which had soft tissue attachments. Once this was removed, we then implanted our trial components of size F to the femur and a size 8 mm tibial tray with 12 mm plastic articulating surface. The knee was taken through range of motion and revealed excellent femorotibial articulation. The patella did tend to sublux somewhat laterally with extremes of flexion and it was for this reason, we performed a minimal small incision lateral retinacular release. Distal lateral patella was tracked more uniformly within the patellar groove of the prosthesis. At this time, an intraoperative x-ray was performed, which revealed excellent alignment with no varus angulation especially of the whole femur and tibial alignment and tibial cut. At this time, the prosthesis was removed. A McGill retractor was then reinserted and replaced peg tibial tray in order to peg the proximal tibia. Once the drill holes were performed, we then copiously irrigated the wound and then suctioned it dry to get ready and prepped for cementation of the drilled components. At this time, polymethyl methacrylate cement was then mixed. The cement was placed on the tibial surface as well as the underneath surface of the component. The component was then placed and impacted with excess cement removed. In a similar fashion, the femoral component was also placed. A 12 mm plastic tray was then placed and the leg held in full extension and compression in order to obtain adequate bony cement content. Once the cement was fully hardened, the knee was flexed and a small osteotome was used to remove any extruding cement from around the prosthesis of the bone. Once this was performed, copious irrigation was used to irrigate the wound and the wound was then suctioned dry. The knee was again taken through range of motion with a 12 mm plastic as well as #14. The #14 appeared to be a bit too tight especially in extremes of flexion. We decided to go with a #12 mm polyethylene tray. At this time, this was placed to the tibial articulation and then left in place. This was rechecked with careful attention to detail with checking no soft tissue interpositioned between the polyethylene tray and the metal tray of the tibia. The knee was again taken through range of motion and revealed excellent tracking of the patella with good femur and tibial contact. A drain was placed and cut to length.,At this time, the knee was irrigated and copiously suction dried. #1-0 Ethibond suture was then used to approximate the medial parapatellar arthrotomy in figure-of-eight fashion. A tight capsular closure was performed. This was reinforced with a #1-0 running Vicryl suture. At this time, the knee was again taken through range of motion to assure tight capsular closure. At this time, copious irrigation was used to irrigate the superficial wound. #2-0 Vicryl was used to approximate the wound with figure-of-eight inverted suture. The skin was then approximated with staples. The leg was then cleansed. Sterile dressing consisting of Adaptic, 4x4, ABDs, and Kerlix roll were then applied. At this time, the patient was extubated and transferred to recovery in stable condition. Prognosis is good for this patient. orthopedic, degenerative arthritis, nexgen, polyethylene, cruciate, total knee replacement, proximal tibia, knee replacement, femoral, cutting, tibial, knee, arthritis, femur, cementation, Orthopedic Trigger thumb release. A transverse incision was made over the MPJ crease of the thumb. Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles. Trigger Thumb Release PROCEDURE: ,Trigger thumb release.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual sterile fashion. The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A transverse incision was made over the MPJ crease of the thumb. Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles. The flexor sheath was opened under direct vision with a scalpel, and then a scissor was used to release the A1 pulley under direct vision on the radial side, from its proximal extent to its distal extent at the junction of the proximal and middle thirds of the proximal phalanx. Meticulous hemostasis was maintained with bipolar electrocautery.,The flexor pollicis longus tendon was identified and atraumatically pulled to ensure that no triggering remained. The patient then actively moved the thumb and no triggering was noted.,After irrigating out the wound with copious amounts of sterile saline, the skin was closed with 5-0 nylon simple interrupted sutures.,The wound was dressed and the patient was sent to the recovery room in good condition, having tolerated the procedure well. orthopedic, neurovascular, a1 pulley, trigger thumb release, mpj crease, trigger thumb, flexor sheath, triggering, sheath, proximal, incision Orthopedic Right knee total arthroplasty. Degenerative osteoarthritis, right knee. Total Knee Arthroplasty PREOPERATIVE DIAGNOSIS:, Degenerative osteoarthritis, right knee.,POSTOPERATIVE DIAGNOSIS: , Degenerative osteoarthritis, right knee.,PROCEDURE PERFORMED: ,Right knee total arthroplasty.,ANESTHESIA: , The procedure was done under a subarachnoid block anesthetic in the supine position with a tourniquet utilized.,TOTAL TOURNIQUET TIME: , Approximately 90 minutes.,SPECIFICATIONS: , The entire procedure is done in the inpatient operating suite in the Room #1 at ABCD General Hospital. The following sizes of NexGen system were utilized: E on right femur, cemented; 5 tibial stem tray with a 10 mm polyethylene insert, and a 32 mm patellar button.,HISTORY AND GROSS FINDINGS: , This is a 58-year-old white female suffering increasing right knee pain for number of years prior to surgical intervention. She was completely refractory to conservative outpatient therapy. She had undergone two knee arthroscopies in the years preceding this. They were performed by myself. She ultimately failed this treatment and developed a collapsing-type valgus degenerative osteoarthritis with complete collapse and ware of the lateral compartment and degenerative changes noted to the femoral sulcus that were proved live. Medial compartment had minor changes present. There was no contracture of the lateral collateral ligament, but instead mild laxity on both sides. There was no significant flexion contracture preoperatively.,OPERATIVE PROCEDURE: ,The patient was laid supine upon the operating table after receiving a subarachnoid block anesthetic by the Anesthesia Department. Thigh tourniquet was placed upon the patient's right leg. She was prepped and draped in the usual sterile manner. The limb was elevated and exsanguinated and tourniquet placed 325 mmHg for the above noted time. A straight incision was carried down through the skin and subcutaneous tissue. Hemostasis was controlled with electrocoagulation. Medial parapatellar arthrotomy was created and the knee cap was everted. The ligaments were balanced. A portion of the fat pad was removed and the ACL was completely removed. Drill hole was made in the distal femur. The size to an E, right. Care was taken to make up for the severe loss of articular cartilage on the posterior condyle in the lateral side. This was checked with the epicondylar abscess and with three degrees of external rotation, drill holes were made. Intramedullary guide was then placed, pegged, and anterior cut carried out. There was excellent resection. It was flat. Distal cutting guide was then placed in five degrees of valgus. Appropriate cuts were carried out. The standard cut was utilized.,The finishing guide for E was held with pins as well as screws. Cutting was carried out posterior to anterior, then posterior chamfer and anterior chamfer, femoral sulcus cut was carried out and drill holes for pegs were made. The cutting guide was then removed. The bone was removed. Excess bone was taken out posteriorly. The posterior capsule was loosened up. There were two different fabellas in the posterolateral compartment and they were loosened. Posterolateral corner was then anchored with osteotome and was taken around the posterolateral corner. An extramedullary tibial cutting guide was then placed, pinned, and held. A cut was carried out parallel to the foot. Hard copy ________ was obtained, deemed to be satisfactory after evening up the edges. Trial range of motion was satisfactory. It was necessary to perform a lateral retinacular release to the patella. The patella was isolated. Approximately 10 mm to 11 mm were reamed off. The size to 32 mm button and drill hole guide was placed, impacted, and drilled. Trial range of motion was satisfactory. The tibial guide was then pinned. Drill hole was placed, broached, and utilized. Copious irrigation was carried out. Methylmethacrylate was mixed and was sequentially placed from the femur to the tibia to the patella. The implants were sequentially placed in tibia to femur to patella. Once excess methylmethacrylate was removed and cured, 10 mm Poly was placed. There was excellent ligament balancing. A separate portal was utilized for subcutaneous drain. Tourniquet was deflated and hemostasis was controlled with electrocoagulation. Interrupted #1 Ethibond suture was utilized for parapatellar closure, running #1 Vicryl suture was utilized for overstitch.,Trial range of motion was satisfactory. Interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed to the skin. Adaptic, 4x4s, ABDs, and Webril were placed for compression dressing. Digits were pink and warm with brawny pulses distally at the end of the case. The patient was then transferred to PACU in apparent satisfactory condition. Expected surgical prognosis on this patient is fair. orthopedic, arthroplasty, knee, degenerative osteoarthritis, subcutaneous, osteoarthritis, degenerative, tourniquet, drill, Orthopedic Foraminal disc herniation of left L3-L4. Enlarged dorsal root ganglia of the left L3 nerve root. Transpedicular decompression of the left L3-L4 with discectomy. Transpedicular Decompression PREOPERATIVE DIAGNOSIS: , Foraminal disc herniation of left L3-L4.,POSTOPERATIVE DIAGNOSES:,1. Foraminal disc herniation of left L3-L4.,2. Enlarged dorsal root ganglia of the left L3 nerve root.,PROCEDURE PERFORMED:, Transpedicular decompression of the left L3-L4 with discectomy.,ANESTHESIA:, General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , None.,HISTORY: , This is a 55-year-old female with a four-month history of left thigh pain. An MRI of the lumbar spine has demonstrated a mass in the left L3 foramen displacing the nerve root, which appears to be a foraminal disc herniation effacing the L3 nerve root. Upon exploration of the nerve root, it appears that there was a small disc herniation in the foramen, but more impressive was the abnormal size of the dorsal root ganglia that was enlarged more medially than laterally. There was no erosion into the bone surrounding the area rather in the pedicle above or below or into the vertebral body, so otherwise the surrounding anatomy is normal. I was prepared to do a discectomy and had not consented the patient for a biopsy of the nerve root. But because of the sequela of cutting into a nerve root with residual weakness and persistent pain that the patient would suffer, at this point I was not able to perform this biopsy without prior consent from the patient. So, surgery ended decompressing the L3 foramen and providing a discectomy with idea that we will obtain contrasted MRIs in the near future and I will discuss the findings with the patient and make further recommendations.,OPERATIVE PROCEDURE: , The patient was taken to OR #5 at ABCD General Hospital in a gurney. Department of Anesthesia administered general anesthetic. Endotracheal intubation followed. The patient received the Foley catheter. She was then placed in a prone position on a Jackson table. Bony prominences were well padded. Localizing x-rays were obtained at this time and the back was prepped and draped in the usual sterile fashion. A midline incision was made over the L3-L4 disc space taking through subcutaneous tissues sharply, dissection was then carried out to the left of the midline with lumbodorsal fascia incised and the musculature was elevated in a supraperiosteal fashion from the level of L3. Retractors were placed into the wound to retract the musculature. At this point, the pars interarticularis was identified and the facet joint of L2-L3 was identified. A marker was placed over the pedicle of L3 and confirmed radiographically. Next, a microscope was brought onto the field. The remainder of the procedure was noted with microscopic visualization. A high-speed drill was used to remove the small portions of the lateral aspects of the pars interarticularis. At this point, soft tissue was removed with a Kerrison rongeur and the nerve root was clearly identified in the foramen. As the disc space of L3-L4 is identified, there is a small prominence of the disc, but not as impressive as I would expect on the MRI. A discectomy was performed at this time removing only small portions of the lateral aspect of the disc. Next, the nerve root was clearly dissected out and visualized, the lateral aspect of the nerve root appears to be normal in structural appearance. The medial aspect with the axilla of the nerve root appears to be enlarged. The color of the tissue was consistent with a nerve root tissue. There was no identifiable plane and this is a gentle enlargement of the nerve root. There are no circumscribed lesions or masses that can easily be separated from the nerve root. As I described in the initial paragraph, since I was not prepared to perform a biopsy on the nerve and the patient had not been consented, I do not think it is reasonable to take the patient to this procedure, because she will have persistent weakness and pain in the leg following this procedure. So, at this point there is no further decompression. A nerve fork was passed both ventral and dorsal to the nerve root and there was no compression for lateral. The pedicle was palpated inferiorly and medially and there was no compression, as the nerve root can be easily moved medially. The wound was then irrigated copiously and suctioned dry. A concoction of Duramorph and ______ was then placed over the nerve root for pain control. The retractors were removed at this point. The fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissues with #2 Vicryl sutures, and Steri-Strips covering the incision. The patient transferred to the hospital gurney, extubated by Anesthesia, and subsequently transferred to Postanesthesia Care Unit in stable condition. orthopedic, dorsal root ganglia, nerve root, discectomy, foraminal disc herniation, transpedicular decompression, lateral aspects, disc herniation, nerve, anesthesia, foraminal Orthopedic Total hip arthroplasty on the left. Left hip degenerative arthritis. Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes. Total Hip Arthroplasty 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. orthopedic, degenerative arthritis, total hip arthroplasty, tensor fascia lata, vastus lateralis, gluteus medius, femoral neck, femoral head, head, femoral, acetabulum, hip, attachment, arthroplasty, Orthopedic Total hip replacement. An incision was made, centered over the greater trochanter. Dissection was sharply carried down through the subcutaneous tissues. Total Hip Replacement - 1 PROCEDURE:, Total hip replacement.,PROCEDURE DESCRIPTION:, The patient was bought to the operating room and placed in the supine position. After induction of anesthesia, the patient was turned on the side and secured in the hip table. An incision was made, centered over the greater trochanter. Dissection was sharply carried down through the subcutaneous tissues. The gluteus maximus was incised and split proximally. The piriformis and external rotators were identified. These were removed from their insertions on the greater trochanter as a sleeve with the hip capsule. The hip was dislocated. A femoral neck cut was made using the guidance of preoperative templating. The femoral head was removed. Extensive degenerative disease was found on the femoral head as well as in the acetabulum.,Baseline leg-length measurements were taken. The femur was retracted anteriorly and a complete labrectomy was performed. Reaming of the acetabulum was then performed until adequate bleeding subchondral bone was identified in the key areas. The trial shell was placed and found to have an excellent fit. The real shell was opened and impacted into position in the appropriate amount of anteversion and abduction. Screws were placed by drilling into the pelvis, measuring, and placing the appropriate length screw. Excellent purchase was obtained. The trial liner was placed.,The femur was then flexed and internally rotated. The extra trochanteric bone was removed, as was any leftover lateral soft tissue at the piriformis insertion. An intramedullary hole was drilled into the femur to define the canal. Reaming was performed until the appropriate size was reached. The broaches were then used to prepare the femur with the appropriate amount of version. Once the appropriate size broach was reached, it was used as a trial with head and neck placement. Hip range-of-motion was checked in all planes, including flexion-internal rotation, the position of sleep, and extension-external rotation. The hip was found to have excellent stability with the final chosen head-neck combination. Leg length measurements were taken and found to be within acceptable range, given the necessity for stability.,The real stem was opened and impacted into position. The real head was impacted atop the stem. If cement was used, the canal was thoroughly washed and dried and plugged with a restrictor, and then the cement was injected and pressurized and the stem was implanted in the appropriate version. Excess cement was removed from the edges of the component. Range of motion and stability were once again checked and found to be excellent. Adequate hemostasis was obtained. Vigorous power irrigation was used to remove all debris from the joint prior to final reduction.,The arthrotomy and rotators were closed using #1 Ethibond through drill holes in the bone, recreating the posterior hip structural anatomy. The gluteus maximus was repaired using 0 Ethibond and 0 Vicryl. The subcutaneous tissues were closed after further irrigation with 2-0 Vicryl and Monocryl sutures. The skin was closed with nylon. Xeroform and a sterile dressing were applied followed by a cold pack and Ace wrap. The patient was transferred to the recovery room in stable condition, having tolerated the procedure well. orthopedic, range-of-motion, hip, total hip replacement, gluteus maximus, femoral head, subcutaneous tissues, incision, ethibond, trochanter, subcutaneous, acetabulum, femur Orthopedic 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. Total Knee Arthoplasty - Right - 1 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. orthopedic, degenerative joint disease, knee, total knee arthroplasty, biomet, cemented, cobalt g, arthoplasty, osteoarthritis, polyethylene, cruciate, ligament, patella, femoral, tibial, Orthopedic Right hip osteoarthritis. Total hip replacement on the right side. Total Hip Replacement PREOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,POSTOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,PROCEDURES PERFORMED: , Total hip replacement on the right side using the following components:,1. Zimmer trilogy acetabular system 10-degree elevated rim located at the 12 o'clock position.,2. Trabecular metal modular acetabular system 48 mm in diameter.,3. Femoral head 32 mm diameter +0 mm neck length.,4. Alloclassic SL offset stem uncemented for taper.,ANESTHESIA: , Spinal.,DESCRIPTION OF PROCEDURE IN DETAIL:, The patient was brought into the operating room and was placed on the operative table in a lateral decubitus position with the right side up. After review of allergies, antibiotics were administered and time out was performed. The right lower extremity was prepped and draped in a sterile fashion. A 15 cm to 25 cm in length, an incision was made over the greater trochanter. This was angled posteriorly. Access to the tensor fascia lata was performed. This was incised with the use of scissors. Gluteus maximus was separated. The bursa around the hip was identified, and the bleeders were coagulated with the use of Bovie. Hemostasis was achieved. The piriformis fossa was identified, and the piriformis fossa tendon was elevated with the use of a Cobb. It was detached from the piriformis fossa and tagged with 2-0 Vicryl. Access to the capsule was performed. The capsule was excised from the posterior and superior aspects. It was released also in the front with the use of a Mayo scissors. The hip was then dislocated. With the use of an oscillating saw, the femoral neck cut was performed. The acetabulum was then visualized and debrided from soft tissues and osteophytes. Reaming was initiated and completed for a 48 mm diameter cap without complications. The trial component was put in place and was found to be stable in an anatomic position. The actual component was then impacted in the acetabulum. A 10-degree lip polyethylene was also placed in the acetabular cap. Our attention was then focused to the femur. With the use of a cookie cutter, the femoral canal was accessed. The broaching process was initiated for No.4 trial component. Trialing of the hip with the hip flexed at 90 degrees and internally rotated to 30 degrees did not demonstrate any obvious instability or dislocation. In addition, in full extension and external rotation, there was no dislocation. The actual component was inserted in place and hemostasis was achieved again. The wound was irrigated with normal saline. The wound was then closed in layers. Before performing that the medium-sized Hemovac drain was placed in the wound. The tensor fascia lata was closed with 0 PDS and the wound was closed with 2-0 Monocryl. Staples were used for the skin. The patient recovered from anesthesia without complications.,EBL: , 50 mL.,IV FLUIDS: , 2 liters.,DRAINS: , One medium-sized Hemovac.,COMPLICATIONS: , None.,DISPOSITION: , The patient was transferred to the PACU in stable condition. She will be weightbearing as tolerated to the right lower extremity with posterior hip precautions. We will start the DVT prophylaxis after the removal of the epidural catheter. orthopedic, total hip replacement, epidural catheter, tensor fascia lata, hemostasis was achieved, medium sized hemovac, tensor fascia, fascia lata, trial component, medium sized, sized hemovac, total hip, hip replacement, hip osteoarthritis, piriformis fossa, total, hip, acetabular, extremity, tensor, fascia, hemostasis, acetabulum, dislocation, hemovac, replacement, osteoarthritis, femoral, piriformis, fossa, components, anesthesia, Orthopedic NexGen left total knee replacement. Degenerative arthritis of left knee. The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs. Total Knee Replacement - NexGen PREOPERATIVE DIAGNOSIS: , Degenerative arthritis of left knee.,POSTOPERATIVE DIAGNOSIS:, Degenerative arthritis of left knee.,PROCEDURE PERFORMED: , NexGen left total knee replacement.,ANESTHESIA: , Spinal.,TOURNIQUET TIME: Approximately 66 minutes.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Approximately 50 cc.,COMPONENTS: , A NexGen stemmed tibial component size 5 was used, 10 mm cruciate retaining polyethylene surface, a NexGen cruciate retaining size E femoral component, and a size 38 9.5 mm thickness All-Poly Patella.,BRIEF HISTORY:, The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs. She wishes to proceed with arthroplasty at this time.,PROCEDURE: ,The patient was taken to the Operative Suite at ABCD General Hospital on 09/11/03. She was placed on the operating table. Department of Anesthesia administered a spinal anesthetic. Once adequately anesthetized, the left lower extremity was prepped and draped in the usual sterile fashion. An Esmarch was applied and a tourniquet was inflated to 325 mmHg on the left thigh. A longitudinal incision was made over the anterior portion of the knee and this was taken down through the subcutaneous tissue to the level of the patella retinaculum. A medial peripatellar arthrotomy was then made and taken down to the level of the tibial tubercle. Care was then ensured that the patellar tendon was not violated. The proximal tibia was then skeletonized both medially and laterally to the level of the axis through the joint line. Again care was ensured that the patellar tendon was not avulsed from the insertion on the tibia. The intramedullary canal was then opened using a drill and the anterior sizing guide was then placed. Rongeur was used to take out any osteophytes and the size of approximately size E. At this point, the epicondyle axis guide was then inserted and aligned in a proper orientation. The anterior cutting guide was then placed. Care was checked for the amount of resection that the femur would be notched and the oscillating saw was used to cut the anterior portion of the femur. After this was performed, this was removed and the distal femoral cutting guide was then placed. The left knee placed in 5 degrees of valgus, guide was then placed, and a standard distal cut was then taken. After the cuts were ensured further to be leveled and they were, and we proceeded to place the finishing guide size E and distal femur. This was placed slightly in lateral position and secured in position with spring tense and head lift tense. Once adequately secured and placed in the appropriate orientation, the alignment was again verified with the epicondyle axis and appeared to be externally rotated appropriately. The chamfer cuts and anterior and posterior cuts were then made as well as the notch cut using the reciprocating and oscillating saws. After this was performed, the guide was removed and all bony fragments were then removed. Attention was then directed to the tibia. The external tibial alignment guide was then placed and pinned to the proximal tibia in a proper position. Care was ensured if it is was a varus or valgus and the appropriate. The femur gauge was then used to provide us appropriate amount of bony resection. This was then pinned and secured into place. Ligament retractors were used to protect the collateral ligaments and the tip proximal tibial cut was then made. This bony portion was then removed and remaining meniscal fragments were removed as well as the ACL till adequate exposure was obtained. Trial components were then inserted into position and taken the range of motion and found to have good and full excellent range of motion stability. The trial components were then removed. The tibia was then stemmed in standard fashion after the tibial plate was placed in some degree of external rotation with appropriate alignment. After it was stemmed and broached, these were removed and the patella was then incised, a size 41 patella reamer blade was then used and was taken down, a size 38 patella button was then placed intact. Again the trial components were placed back into position. Patella button was placed and the tracking was evaluated. They tracked centrally with no touch technique. Again, all components were now removed and the knee was then copiously irrigated and suctioned dry. Once adequately suctioned dry, the tibial portion was cemented and packed into place. Also excess cement was removed. The femoral component was then cemented into position. All excess cement was removed. A size 12 poly was then inserted in trial to provide compression at cement adhered. The patella was then cemented and held into place. All components were held under compression until cement had adequately adhered all excess cement was then removed. The knee was then taken through range of motion and size 12 felt to be slightly too big, this was removed and the size 10 trial was replaced, and again had excellent varus and valgus stability with full range of motion and felt to be the articulate surface of choice. The knee was again copiously irrigated and suctioned dry. One last check in the posterior aspect of the knee for any loose bony fragments or osteophytes was performed, there were none found and a final articulating surface was impacted and locked into place. After this, the knee was taken again for final range of motion and found to have excellent position, stability, and good alignment of the components. The knee was once again copiously irrigated, and the tourniquet was deflated. Bovie cautery was used to cauterize the knee bleeding that was seen until good hemostasis obtained. A drain was then placed deep to the retinaculum and the retinaculum repair was performed using #2-0 Ethibond and oversewn with a #1 Vicryl. This was flexed and the repair was found held securely. At this point, the knee was again copiously irrigated and suctioned dry. The subcutaneous tissue was closed with #2-0 Vicryl, and the skin was approximated with skin staples. Sterile dressing with Adaptic, 4x4s, ABDs, and Kerlix rolls was then applied. The patient was then transferred back to the gurney in a supine position.,DISPOSITION: , The patient tolerated well with no complications, to PACU in satisfactory condition. orthopedic, degenerative arthritis, nexgen stemmed tibial component, all-poly patella, nexgen cruciate, total knee replacement, patellar tendon, proximal tibia, epicondyle axis, bony fragments, patella button, tibial, knee, arthritis, nexgen, patella Orthopedic Transforaminal lumbar interbody fusion, placement of intervertebral prosthetic device. TLIF "PREOPERATIVE DIAGNOSIS (ES):, L4-L5 and L5-S1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy.,POSTOPERATIVE DIAGNOSIS (ES):, L4-L5 and L5-S1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy.,PROCEDURE:,1. Left L4-L5 and L5-S1 Transforaminal Lumbar Interbody Fusion (TLIF).,2. L4 to S1 fixation (Danek M8 system).,3. Right posterolateral L4 to S1 fusion.,4. Placement of intervertebral prosthetic device (Danek Capstone spacers L4-L5 and L5-S1).,5. Vertebral autograft plus bone morphogenetic protein (BMP).,COMPLICATIONS:, None.,ANESTHESIA:, General endotracheal.,SPECIMENS:, Portions of excised L4-L5 and L5-S1 disks.,ESTIMATED BLOOD LOSS:, 300 mL.,FLUIDS GIVEN:, IV crystalloid.,OPERATIVE INDICATIONS:, The patient is a 37-year-old male presenting with a history of chronic, persistent low back pain as well as left lower extremity of radicular character were recalcitrant to conservative management. Preoperative imaging studies revealed the above-noted abnormalities. After a detailed review of management considerations with the patient and his wife, he was elected to proceed as noted above.,Operative indications, methods, potential benefits, risks and alternatives were reviewed. The patient and his wife expressed understanding and consented to proceed as above.,OPERATIVE FINDINGS:, L4-L5 and L5-S1 disk protrusion with configuration as anticipated from preoperative imaging studies. Pedicle screw placement appeared satisfactory with satisfactory purchase and positioning noted at all sites as well as satisfactory findings upon probing of the pedicular tracts at each site. In addition, all pedicle screws were stimulated with findings of above threshold noted at all sites. Spacer snugness and positioning appeared satisfactory. Electrophysiological monitoring was carried out throughout the procedure and remained stable with no undue changes reported.,DESCRIPTION OF THE OPERATION:, After obtaining proper patient identification and appropriate preoperative informed consent, the patient was taken to the operating room on a hospital stretcher in the supine position. After the induction of satisfactory general endotracheal anesthesia and placement of appropriate monitoring equipment by Anesthesiology as well as placement of electrophysiological monitoring equipment by the Neurology team, the patient was carefully turned to the prone position and placed upon the padded Jackson table with appropriate additional padding placed as needed. The patient's posterior lumbosacral region was thoroughly cleansed and shaved. The patient was then scrubbed, prepped and draped in the usual manner. After local infiltration with 1% lidocaine with 1: 200,000 epinephrine solution, a posterior midline skin incision was made extending from approximately L3 to the inferior aspect of the sacrum. Dissection was continued in the midline to the level of the posterior fascia. Self-retaining retractors were placed and subsequently readjusted as needed. The fascia was opened in the midline, and the standard subperiosteal dissection was then carried out to expose the posterior and posterolateral elements from L3-L4 to the sacrum bilaterally with lateral exposure carried out to the lateral aspect of the transverse processes of L4 and L5 as well as the sacral alae bilaterally. _____ by completing the exposure, pedicle screw fixation was carried out in the following manner. Screws were placed in systematic caudal in a cranial fashion. The pedicle screw entry sites were chosen using standard dorsal landmarks and fluoroscopic guidance as needed. Cortical openings were created at these sites using a small burr. The pedicular tracts were then preliminarily prepared using a Lenke pedicle finder. They were then probed and subsequently tapped employing fluoroscopic guidance as needed. Each site was ""under tapped"" and reprobed with satisfactory findings noted as above. Screws in the following dimensions were placed. 6.5-mm diameter screws were placed at all sites. At S1, 40-mm length screws were placed bilaterally. At L5, 40-mm length screws were placed bilaterally, and at L4, 40-mm length screws were placed bilaterally with findings as noted above. The rod was then contoured to span from the L4 to the S1 screws on the right. The distraction was placed across the L4-L5 interspace, and the connections were temporarily secured. Using a matchstick burr, a trough was then carefully created slightly off the midline of the left lamina extending from its caudal aspect to its more cranial aspect at the foraminal level. This was longitudinally oriented. A transverse trough was similarly carefully created from the cranial point of the longitudinal trough out to the lateral aspect of the pars against the foraminal level that is slightly caudal to the L4 pedicle. This trough was completed to the level of the ligamentum flavum using small angled curettes and Kerrison rongeurs, and this portion of the lamina along with the inferior L4 articular process was then removed as a unit using rongeurs and curettes. The cranial aspect of the left L5 superior articular process was then removed using a small burr and angled curettes and Kerrison rongeurs. A superior laminotomy was performed from the left L5 lamina and flavectomy was then carried out across this region of decompression, working from caudally to cranially and medially to laterally, again using curettes and Kerrison rongeurs under direct visualization. In this manner, the left lateral aspect of the thecal sac passing left L5 spinal nerve and exiting left L4 spinal nerve along with posterolateral aspect of disk space was exposed. Local epidural veins were coagulated with bipolar and divided. Gelfoam was then placed in this area. This process was then repeated in similar fashion; thereby, exposing the posterolateral aspect of the left L5-S1 disk space. As noted, distraction had previously been placed at L4-L5, this was released. Distraction was placed across the L5-S1 interspace. After completing satisfactory exposure as noted, a annulotomy was made in the posterolateral left aspect of the L5-S1 disk space. Intermittent neural retraction was employed with due caution afforded to the neural elements throughout the procedure. The disk space was entered, and diskectomy was carried out in routine fashion using pituitary rongeurs followed by the incremental sized disk space shavers as well as straight and then angled TLIF curettes to prepare the front plate. Herniated portions of the disk were also removed in routine fashion. The diskectomy and endplate preparation were carried out working progressively from the left towards the right aspect of the disk across the midline in routine fashion. After completing this disk space preparation, Gelfoam was again placed. The decompression was assessed and appeared to be satisfactory. The distraction was released, and attention was redirected at L4-L5, where again, distraction was placed and diskectomy and endplate preparation was carried out at this interspace again in similar fashion. After completing the disk space preparation, attention was redirected to L5-S1. Distraction was released at L4-L5 and again, reapplied at L5-S1, incrementally increasing size. Trial spaces were used, and a 10-mm height by 26-mm length spacer was chosen. A medium BMP kit was appropriately reconstituted. A BMP sponge containing morcellated vertebral autograft was then placed into the anterior aspect of the disk space. The spacer was then carefully impacted into position. The distraction was released. The spacer was checked with satisfactory snugness and positioning noted. This process was then repeated in similar fashion at L4-L5, again with placement of a 10-mm height by 26-mm length Capstone spacer, again containing BMP and again with initial placement of a BMP sponge with vertebral autograft anteriorly within the interspace. This spacer was also checked again with satisfactory snugness and positioning noted. The prior placement of the spacers and BMP, the wound was thoroughly irrigated and dried with satisfactory hemostasis noted. Surgicel was placed over the exposed dura and disk space. The distraction was released on the right and compression plates across the L5-S1 and L4-L5 interspaces and the connections fully tightened in routine fashion. The posterolateral elements on the right from L4 to S1 were prepared for fusion in routine fashion, and BMP sponges with supplemental vertebral autograft was placed in the posterolateral fusion bed as well as the vertebral autograft in the dorsal aspect of the L4-L5 and L5-S1 facets on the right in a routine fashion. A left-sided rod was appropriated contoured and placed to span between the L4 to S1 screws. Again compression was placed across the L4-L5 and L5-S1 segments, and these connections were fully secured. Thorough hemostasis was ascertained after checking the construct closely and fluoroscopically. The wound was closed using multiple simple interrupted 0-Vicryl sutures to reapproximate the deep paraspinal musculature in the midline. The superficial paraspinal musculature in posterior fashion was closed in the midline using multiple simple interrupted 0-Vicryl sutures. The suprafascial subcutaneous layers were closed using multiple simple interrupted #0 and 2-0 Vicryl sutures. The skin was then closed using staples. Sterile dressings were then applied and secured in place. The patient tolerated the procedure well and was to the recovery room in satisfactory condition." orthopedic, degenerative disk disease, disk protrusions, spondylosis, radiculopathy, tlif, transforaminal lumbar interbody fusio, danek m8, intervertebral prosthetic device, danek capstone, matchstick burr, capstone, bmp, vertebral autograft, screws were placed bilaterally, pedicle screw, kerrison rongeurs, disk space, disk, spacers, kerrison, interbody, rongeurs, pedicle, lumbar, screws, Orthopedic Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer. Removal of antibiotic spacer and revision total hip arthroplasty. Total Hip Arthroplasty - Revision 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. orthopedic, infected, bipolar arthroplasty, antibiotic spacer, revision, placement of antibiotic spacer, total hip arthroplasty, scar tissue, soft tissue, antibiotic, spacer, femoral, hip, arthroplasty, total, acetabulum, femur, Orthopedic History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy. Wound debridement x2, including skin, subcutaneous, and muscle. Insertion of tissue expander to the medial and lateral wound. Tissue Expander Insertion PREOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,POSTOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,OPERATIONS:,1. Wound debridement x2, including skin, subcutaneous, and muscle.,2. Insertion of tissue expander to the medial wound.,3. Insertion of tissue expander to the lateral wound.,COMPLICATIONS: , None.,TOURNIQUET: , None.,ANESTHESIA: ,General.,INDICATIONS: , This patient developed a compartment syndrome. She underwent 4 compartment fasciotomy with dual incision on medial and lateral aspect of the right lower leg. She was doing very well and was obviously improving.,The swelling was reduced. A compartment pressure had obviously improved based on examination. She was therefore indicated for placement of tissue expander for ventral wound closure. The risks of procedure as well as alternatives of this procedure were discussed at length with the patient and he understood them well. Risks and benefits were all discussed, risk of bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgery, chronic pain with range of motion, risk of continued discomfort, risk of need for further reconstructive procedures, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed. She understood them well. All questions were answered, and she signed the consent for the procedure as described.,DESCRIPTION OF THE PROCEDURE:, The patient was placed on the operating table and general anesthesia was achieved. The medial wound was noted to be approximately 10.5 cm in length x 4 cm. The lateral wound was noted in approximately 14 cm in length x 5 x 5 cm in width. Both wounds were then thoroughly debrided. The debridement of both wounds included skin and subcutaneous tissue and nonviable muscle portion. This involve very small portion of muscle as well as skin edge and the subcutaneous tissue did require debridement on both sides. At this point adequate debridement was performed and healthy tissue did appear to be present. Initially on the medial wound I did place the DermaClose RC continuous external tissue expander. On the medial wound the 5 skin anchors were placed on each side of the wound and separated appropriately. I then did place the line loop from the tension controller in a lace like manner through the skin anchors and the tension controller was attached to the middle anchor. I then did place adequate tension on the sutures. Continued tension will be noted after engaging the tension controller. At this point I performed the similar procedure to the lateral wound. The skin anchors were placed separately and appropriately on either side of the skin margin. The line loop from the tension controller was placed in lace like manner through the skin anchors. The tension controller was then attached to the mid anchor and appropriate tension was applied.,It must be noted I did undermine the skin edges both sides of flap from both incision site prior to placement of the skin anchor and adequate mobilization was obtained. Adequate tension was placed in this region. A non thick dressing was then applied to the open-wound region and sterile dressing was then applied. No complications were encountered throughout the procedure and the patient tolerated the procedure well. The patient was taken to recovery room in stable condition. orthopedic, fasciotomy, subcutaneous, muscle, wound debridement, insertion of tissue expander, compartment syndrome, compartment fasciotomy, lateral wound, medial wound, tension controller, tissue expander, wound, tissue, compartment, Orthopedic Pain. Three views of the right ankle. Three views of the right ankle are obtained. Three Views - Ankle 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. orthopedic, three views, calcaneal, plantar, spur, osseous, ankle Orthopedic Right foot trauma. Three views of the right foot. Three views of the right foot were obtained. Three Views - Foot EXAM: ,Three views of the right foot.,REASON FOR EXAM: , Right foot trauma.,FINDINGS: , Three views of the right foot were obtained. There are no comparison studies. There is no evidence of fractures or dislocations. No significant degenerative changes or obstructive osseous lesions were identified. There are no radiopaque foreign bodies.,IMPRESSION: , Negative right foot. orthopedic, three views, radiopaque, fractures, foot trauma Orthopedic Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm. Tenosynovectomy & Cortisone Injection 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. orthopedic, carpal tunnel syndrome, pulley, dupuytren's, tenosynovitis, tenosynovectomy, carpal tunnel release, flexor tenosynovectomy, cortisone injection, dupuytren's nodule, injection, cortisone, Orthopedic Painful enlarged navicula, right foot. Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot. Tarsectomy 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. orthopedic, navicula, metatarsal, osteochondroma, tarsectomy, metatarsectomy, painful enlarged navicula, navicular bone, foot, bony, capsule, periosteum, navicular, incision, bone Orthopedic Tailor bunionectomy, right foot, Weil-type with screw fixation. Hallux abductovalgus deformity and tailor bunion deformity, right foot. Tailor Bunionectomy with Screw Fixation 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. orthopedic, tailor bunionectomy, weil-type, screw fixation, hallux, abductovalgus, bunion, tailor, deformity, metatarsal, phalangeal, capsulotomy, abductor, hallucis, Orthopedic Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy. Mass, left second toe. Tumor. Left hallux bone invasion of the distal phalanx. Symes Amputation - Hallux 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. orthopedic, distal phalanx, mass, tumor., hallux bone, phalanx, symes amputation, excisional biopsy, distal, amputation, invasion, toe, symes, incision, flushed, excision, tissue, hallux Orthopedic Arthroscopic irrigation and debridement of same with partial synovectomy. Septic left total knee arthroplasty. Synovectomy - Partial PREOPERATIVE DIAGNOSIS: , Septic left total knee arthroplasty.,POSTOPERATIVE DIAGNOSIS: , Septic left total knee arthroplasty.,OPERATION PERFORMED: , Arthroscopic irrigation and debridement of same with partial synovectomy.,ANESTHESIA:, LMA.,ESTIMATED BLOOD LOSS:, Minimal.,COMPLICATIONS: , None.,DRAINS:, None.,INDICATIONS:, The patient is an 81-year-old female, who is approximately 10 years status post total knee replacement performed in another state, who presented a couple of days ago to the office with worsening pain without injury and whose symptoms have been present for approximately a month following a possible urinary tract infection. The patient' knee was aspirated in the office and cultures were positive for Escherichia coli. She presents for operative therapy.,DESCRIPTION OF OPERATION: , After obtaining informed consent and the administration of antibiotics since her cultures had already been obtained, the patient was taken to the operating room and following satisfactory induction and the patient was placed on the table in supine position. The left upper extremity was prepped and draped without a tourniquet. The knee was injected with 30 mL of normal saline and standard arthroscopy portals were created. The arthroscopy was inserted and a complete diagnostic was performed. Arthroscopic pictures were taken throughout the procedure. The knee was copiously irrigated with 9 L of irrigant. A partial synovectomy was performed in all compartments. Minimal amount of polyethylene wear was noted. The total knee components were identified arthroscopically for future revision surgery. The knee was then drained and the arthroscopic instruments were removed. The portals were closed with 4-0 nylon and local anesthetic was injected. A sterile dressing was applied and the patient was placed in a knee immobilizer, awakened from anesthesia and transported to the recovery room in stable condition and tolerated the procedure well. orthopedic, total knee arthroplasty, arthroscopic irrigation, debridement, partial synovectomy, knee, arthroscopic, irrigation, arthroscopy, synovectomy, Orthopedic Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist. Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion. Styloidectomy PREOPERATIVE DIAGNOSIS: , Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.,POSTOPERATIVE DIAGNOSIS: , Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion; finding of volar radial wrist mass of bulging inflammatory tenosynovitis from the volar radial wrist joint rather than a true ganglion cyst; synovitis was debrided and removed.,PROCEDURE: , Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist.,ANESTHESIA:, Axillary block plus IV sedation.,ESTIMATED BLOOD LOSS:, Zero.,SPECIMENS,1. Inflammatory synovitis from the volar radial wrist area.,2. Inflammatory synovitis from the dorsal wrist area.,DRAINS:, None.,PROCEDURE DETAIL: , Patient brought to the operating room. After induction of IV sedation a right upper extremity axillary block anesthetic was performed by anesthesia staff. Routine prep and drape was employed. Patient received 1 gm of IV Ancef preoperatively. Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet. Tourniquet inflated to 250 mmHg pressure. Hand positioned palm up in a lead hand-holder. A longitudinal zigzag incision over the volar radial wrist mass was made. Skin was sharply incised. Careful blunt dissection was used in the subcutaneous tissue. Antebrachial fascia was bluntly dissected and incised to reveal the radial artery. Radial artery was mobilized preserving its dorsal and palmar branches. Small transverse concomitant vein branches were divided to facilitate mobilization of the radial artery. Wrist mass was exposed by blunt dissection. This appeared to be an inflammatory arthritic mass from the volar radial wrist capsule. This was debrided down to the wrist capsule with visualization of the joint through a small capsular window. After complete volar synovectomy the capsular window was closed with 4-0 Mersilene figure-of-eight suture. Subcutaneous tissue was closed with 4-0 PDS and the skin was closed with a running subcuticular 4-0 Prolene. Forearm was pronated and C-arm image intensifier was used to confirm localization of the radial styloid for marking of the skin incision. An oblique incision overlying the radial styloid centered on the second extensor compartment was made. Skin was sharply incised. Blunt dissection was used in the subcutaneous tissue. Care was taken to identify and protect the superficial radial nerve. Blunt dissection was carried out in the extensor retinaculum. This was incised longitudinally over the second extensor compartment. EPL tendon was identified, mobilized and released to facilitate retraction and prevent injury. The interval between the ECRL and the ECRB was developed down to bone. Dorsal capsulotomy was made and local synovitis was identified. This was debrided and sent as second pathologic specimen. Articular surface of the scaphoid was identified and seen to be completely devoid of articular cartilage with hard, eburnated subchondral bone consistent with a SLAC pattern arthritis. Radial styloid had extensive spurring and was exposed subperiosteally and osteotomized in a dorsal oblique fashion preserving the volar cortex as the attachment point of the deep volar carpal ligament layer. Dorsally the styloidectomy was beveled smooth and contoured with a rongeur. Final x-rays documenting the styloidectomy were obtained. Local synovitis beneath the joint capsule was debrided. Remnants of the scapholunate interosseous which was completely deteriorated were debrided. The joint capsule was closed anatomically with 4-0 PDS and extensor retinaculum was closed with 4-0 PDS. Subcutaneous tissues closed with 4-0 Vicryl. Skin was closed with running subcuticular 4-0 Prolene. Steri-Strips were applied to wound edge closure; 10 cc of 0.5% plain Marcaine was infiltrated into the areas of the surgical incisions and radial styloidectomy for postoperative analgesia. A bulky gently compressive wrist and forearm bandage incorporating an EBI cooling pad were applied. Tourniquet was deflated. Good vascular color and capillary refill were seen to return to the tips of all digits. Patient discharged to the ambulatory recovery area and from there discharged home.,DISCHARGE PRESCRIPTIONS:,1. Keflex 500 mg tablets, #20, one PO q.6h. x 5 days.,2. Vicodin, 40 tablets, one to two PO q.4h. p.r.n.,3. Percocet, #20 tablets, one to two PO q.3-4h. p.r.n. severe pain. orthopedic, osteophytic, spurring, ganglion, synovitis, volar radial wrist mass, excision, inflammatory synovitis, radial styloidectomy, inflammatory, styloidectomy, volar, wrist, radial, mass Orthopedic Posterior spinal fusion and spinal instrumentation. Posterior osteotomy; posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots. Spinal Fusion & Instrumentation PREOPERATIVE DIAGNOSIS: , Severe scoliosis.,ANESTHESIA: , General. Lines were placed by Anesthesia to include an A line.,PROCEDURES: ,1. Posterior spinal fusion from T2-L2.,2. Posterior spinal instrumentation from T2-L2.,3. A posterior osteotomy through T7-T8 and T8-T9. Posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots.,IMPLANT: , Sofamor Danek (Medtronic) Legacy 5.5 Titanium system.,MONITORING: , SSEPs, and the EPs were available.,INDICATIONS: , The patient is a 12-year-old female, who has had a very dysmorphic scoliosis. She had undergone a workup with an MRI, which showed no evidence of cord abnormalities. Therefore, the risks, benefits, and alternatives were discussed with Surgery with the mother, to include infections, bleeding, nerve injuries, vascular injuries, spinal cord injury with catastrophic loss of motor function and bowel and bladder control. I also discussed ___________ and need for revision surgery. The mom understood all this and wished to proceed.,PROCEDURE: , The patient was taken to the operating room and underwent general anesthetic. She then had lines placed, and was then placed in a prone position. Monitoring was then set up, and it was then noted that we could not obtain motor-evoked potentials. The SSEPs were clear and were compatible with the preoperative, but no preoperative motors had been done, and there was a concern that possibly this could be from the result of the positioning. It was then determined at that time, that we would go ahead and proceed to wake her up, and make sure she could move her feet. She was then lightened under anesthesia, and she could indeed dorsiflex and plantarflex her feet, so therefore, it was determined to go ahead and proceed with only monitoring with the SSEPs.,The patient after being prepped and draped sterilely, a midline incision was made, and dissection was carried down. The dissection utilized a combination of hand instruments and electrocautery and dissected out along the laminae and up to the transverse processes. This occurred from T2-L2. Fluoroscopy was brought in to verify positions and levels. Once this was done, and all bleeding was controlled, retractors were then placed. Attention was then turned towards placing screws first on the left side. Lumbar screws were placed at the junction of the transverse process and the facets under fluoroscopic guidance. The area was opened with a high speed burr, and then the track was defined with a blunt probe, and a ball-tipped feeler was then utilized to verify all walls were intact. They were then tapped, and then screws were then placed. This technique was used at L1 and L2, both the right and left. At T12, a direct straight-ahead technique was utilized, where the facet was removed, and then the position was chosen under the fluoroscopy, and then it was spurred, the track was defined and then probed and tapped, and it was felt to be in good position. Two screws, in the right and left were placed at T12 as well, reduction screws on the left. The same technique was used for T11, where right and left screws were placed as well as T10 on the left. At T9, a screw was placed on the left, and this was a reduction screw. On the left at T8, a screw could not be placed due to the dysmorphic nature of the pedicle. It was not felt to be intact; therefore, a screw was left out of this. On the right, a thoracic screw was placed as well as at 7 and 6. This was the dysmorphic portion of this. Screws were attempted to be placed up, they could not be placed, so attention was then turned towards placing pedicle hooks. Pedicle hooks were done by first making a box out of the pedicle, removing the complete pedicle, feeling the undersurface of the pedicle with a probe, and then seating the hook. Upgoing pedicle hooks were placed at T3, T4, and T5. A downgoing laminar hook was placed at the T7 level. Screws had been placed at T6 and T7 on the right. An upgoing pedicle hook was also placed at T3 on the right, and then, downgoing laminar hooks were placed at T2. This was done by first using a transverse process, lamina finders to go around the transverse process and then ___________ laminar hooks. Once all hooks were in place, spinal osteotomies were performed at T7-T8 and T8-T9. This was the level of the kyphosis, to bring her back out of her kyphoscoliosis. First the ligamentum flavum was resected using a large Kerrisons. Next, the laminotomy was performed, and then a Kerrison was used to remove the ligamentum flavum at the level of the facet. Once this was accomplished, a laminotomy was performed by removing more of the lamina, and to create a small wedge that could be closed down later to correct the kyphosis. This was then brought out with resection of bone out to the foramen, doing a foraminotomy to free up the foramen on both sides. This was done also between the T8-T9. Once this was completed, Gelfoam was then placed. Next, we observed, and measured and contoured. The rods were then seated on the left, and then a derotation maneuver was performed. Hooks had come loose, so the rod was removed on the left. The hooks were then replaced, and the rod was reseated. Again, it was derotated to give excellent correction. Hooks were then well seated underneath, and therefore, they were then locked. A second rod was then chosen on the right, and was measured, contoured, and then seated. Next, once this was done, the rods were locked in the midsubstance, and then the downgoing pedicle hook, which had been placed at T7 was then helped to compress T8 as was the pedicle screw, and then this compressed the osteotomy sites quite nicely. Next, distraction was then utilized to further correct at the spine, and to correct on the left, the left concave curve, which gave excellent correction. On the right, compression was used to bring it down, and then, in the lower lumbar areas, distraction and compression were used to level out L2. Once this was done, all screws were tightened. Fluoroscopy was then brought in to verify L1 was level, and the first ribs were also level, and it gave a nice balanced spine. Everything was copiously irrigated, ___________. Next, a wake-up test was performed, and the patient was then noted to flex and extend the knees as well as dorsiflex and plantar flex both the feet. The patient was then again sedated and brought back under general anesthesia. Next, a high-speed burr was used for decortication. After final tightening had been accomplished, and then allograft bone and autograft bone were mixed together with 10 mL of iliac crest aspirate and were placed into the wound. The open canal areas had been protected with Gelfoam. Once this was accomplished, the deep fascia was closed with multiple figure-of-eight #1's, oversewn with a running #1, _________ were then placed in the subcutaneous spaces which were then closed with 3-0 Vicryl, and then the skin was closed with 3-0 Monocryl and Dermabond. Sterile dressing was applied. Drains had been placed in the subcutaneous layer x2. The patient during the case had no changes in the SSEPs, had a normal wake-up test, and had received Ancef and clindamycin during the case. She was taken from the operating room in good condition. orthopedic, osteotomy, laminotomy-foraminotomy, sofamor danek, sseps, spinal fusion, transverse processes, pedicle hooks, pedicle, laminotomy, hooks, screws, instrumentation, decompression, scoliosis, sofamor, foraminotomy, spinal Orthopedic Thoracic right-sided discectomy at T8-T9. The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9. Thoracic Discectomy PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,OPERATION PERFORMED: , Thoracic right-sided discectomy at T8-T9.,BRIEF HISTORY AND INDICATION FOR OPERATION: , The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9. She has failed conservative measures and sought operative intervention for relief of her symptoms. For details of workup, please see the dictated operative report.,DESCRIPTION OF OPERATION: ,Appropriate informed consent was obtained and the patient was taken to the operating room and placed under general anesthetic. She was placed in a position of comfort on the operating table with all bony prominences and soft tissues well padded and protected. Second check was made prior to prepping and draping. Following this, we did needle localization with reviews of AP and lateral multiple times to make sure we had the T8-T9 level. We then made an approach through a midline incision and came out over the pars. We dissected down carefully to identify the pars. We then went on the outside of the pars and identified the foramen and then we took another series of x-rays to confirm the T8-T9 level. We did this under live fluoroscopy. We confirmed T8-T9 and then went ahead and took a Midas Rex and removed the superior portion of the pedicle overlying the outside of the disc and then worked our way downward removing portion of the transverse process as well. We found the edge of the disc and then worked our way and we were able to remove some of the disc material but then decided to go ahead and take down the pars. The pars was then drilled out. We identified the disc even further and found the disc herniation material that was under the spinal cord. We then took a combination of small pituitaries and removed the disc material without difficulty. Once we had disc material out, we went ahead and made a small cruciate incision in the disc space and entered the disc space in earnest removing more disc material making sure there is nothing free to herniate further. Once we had done that, we inspected up by the nerve root, found some more disc material there and removed that as well. We could trace the nerve root out freely and easily. We made sure there was no evidence of further disc material. We used an Epstein curette and placed a nerve hook under the nerve root. The Epstein curette removed some more disc material. Once we had done this, we were satisfied with the decompression. We irrigated the wound copiously to make sure there is no further disc material and then ready for closure. We did place some steroid over the nerve root and readied for closure. Hemostasis was meticulous. The wound was closed with #1 Vicryl suture for the fascial layer, 2 Vicryl suture for the skin, and Monocryl and Steri-Strips applied. Dressing was applied. The patient was awoken from anesthesia and taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:, 150 mL.,COMPLICATIONS: , None.,DISPOSITION:, To PACU in stable condition having tolerated the procedure well, to mobilize routinely when she is comfortable to go to her home. orthopedic, thoracic right-sided discectomy, herniated nucleus pulposus, discectomy, thoracic, herniated, Orthopedic Repeat irrigation and debridement of Right distal femoral subperiosteal abscess. Subperiosteal Abscess Debridement PREOPERATIVE DIAGNOSIS: , Right distal femoral, subperiosteal abscess.,POSTOPERATIVE DIAGNOSIS: , Right distal femoral, subperiosteal abscess.,OPERATION:, Repeat irrigation and debridement of above.,ANESTHESIA: , General.,BLOOD LOSS:, Minimal.,FLUID: , Per anesthesia.,DRAINS: , Hemovac times two.,COMPLICATIONS: , None apparent.,SPECIMENS:, To microbiology.,INDICATIONS: , She is a 10-year-old girl who has history of burns and has developed a subperiosteal abscess at her right distal femur. I am bringing her back to the operating room for another exploration of this area and washout. This will be the third procedure for this. At the last time, there was gross purulence that was encountered. Since that time, the patient has defervesced. Her white count is slowly coming down. Her C-reactive protein is slowly coming down.,PROCEDURE IN DETAIL:, After informed consent was obtained, operative site marked, and after preoperative antibiotics were given, the patient was brought back to the operating room and placed supine on the operating table, where Anesthesia induced general anesthesia. The patient's right lower extremity was prepped and draped in normal sterile fashion. Surgical timeout occurred verifying the patient's identification, surgical site, surgical procedure, and administration of antibiotics. The patient's previous incision sites had the sutures removed. We bluntly dissected down through to the IT band. These deep stitches were then removed. We exposed the area of the subperiosteal abscess. The tissue looked much better than at the last surgery. We irrigated this area with three liters of saline containing bacitracin. Next, we made our small medial window to assist with washout of the joint itself. We put another three liters of saline containing bacitracin through the knee joint. Lastly, we did another three liters into the area of the distal femur with three liters of plain saline. We then placed two Hemovac drains, one in the metaphysis and one superficially. We closed the deep fascia with #1 PDS. Subcutaneous layers with 2-0 Monocryl and closed the skin with 2-0 nylon. We placed a sterile dressing. We then turned the case over to Dr. Petty for dressing change and skin graft.,PLAN: ,Our plan will be to pull the drains in 48 hours. We will then continue to watch the patient's fever curve and follow her white count to see how she is responding to the operative and medical therapies., orthopedic, repeat irrigation and debridement, repeat irrigation, distal femur, distal femoral, femoral subperiosteal, subperiosteal abscess, hemovac, femur, debridement, irrigation, saline, anesthesia, distal, subperiosteal, abscess, Orthopedic Subcutaneous transposition of the right ulnar nerve. Right carpal tunnel syndrome and right cubital tunnel syndrome. Subcutaneous Transposition of Ulnar Nerve PREOPERATIVE DIAGNOSIS: ,1. Right carpal tunnel syndrome.,2. orthopedic, subcutaneous transposition, ulnar nerve, carpal tunnel syndrome, cubital tunnel syndrome, tourniquet, subcutaneous, epicondyle, antebrachial, syndrome, cubital, ulnar, nerve, tunnel Orthopedic Anterior spine fusion from T11-L3. Posterior spine fusion from T3-L5. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft. Spine Fusion 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. orthopedic, anterior spine fusion, posterior spine fusion, spine segmental instrumentation, dry sterile dressings, autograft and allograft, pds sutures, spinous processes, spine fusion, spine, instrumentation, morcellized, allograft, fusion, autograft, Orthopedic Superior labrum anterior and posterior lesion repair. Superior Labrum Lesions Repair PROCEDURE IN DETAIL:, After written consent was obtained from the patient, the patient was brought back into the operating room and identified. The patient was placed on the operating room table in supine position and given anesthetic.,Once adequate anesthesia had been achieved, a careful examination of the shoulder was performed. It revealed no patholigamentous laxity. We then placed the patient into a beach-chair position, maintaining a neutral alignment of the head, neck, and thorax. The shoulder was then prepped and draped in the usual sterile fashion. We then injected the glenohumeral joint with 60 cc of sterile saline solution. A small stab incision was made 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion. Through this incision, a blunt trocar was placed.,We then placed the camera through this cannula and the shoulder was insufflated with sterile saline solution. An anterior portal was made just below the subscapularis and then we began to inspect the shoulder joint.,We found that the articular surface was in good condition. The biceps was found to be intact. There was a SLAP tear noted just posterior to the biceps. Pictures were taken. No Bankart or Hill-Sachs lesions were noted. The rotator cuff was examined and there were no undersurface tears. Pictures were again taken.,We then made a lateral portal going through the muscle belly of the rotator cuff. A drill hole was made and then knotless suture anchor was placed to repair this. Pictures were taken. We then washed out the joint with copious amounts of sterile saline solution. It was drained. Our 3 incisions were closed using 3-0 nylon suture. A pain pump catheter was introduced into the shoulder joint. Xeroform, 4 x 4s, ABDs, tape, and sling were placed.,The patient was successfully taken out of the beach-chair position, extubated and brought to the recovery room in stable condition. I then went out and spoke with the patient's family, going over the case, postoperative instructions, and followup care. orthopedic, laxity, patholigamentous, superior labrum, saline solution, anterior, superior, lesions, repair, sterile, joint, shoulder, Orthopedic Spinal Manipulation under Anesthesia - Sacro-iliitis, lumbo-sacral segmental dysfunction, thoraco-lumbar segmental dysfunction, associated with myalgia/fibromyositis. Spinal Manipulation PREOPERATIVE DIAGNOSIS: , Sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (739.2), associated with myalgia/fibromyositis (729.1).,POSTOPERATIVE DIAGNOSIS: , Sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (739.2), associated with myalgia/fibromyositis (729.1).,ANESTHESIA: , Conscious Sedation.,INFORMED CONSENT: , After adequate explanation of the medical surgical and procedural options, this patient has decided to proceed with the recommended spinal Manipulation under Anesthesia (MUA). The patient has been informed that more than one procedure may be necessary to achieve the satisfactory results.,INDICATION:, This patient has failed extended conservative care of condition/dysfunction by means of aggressive physical medical and pharmacological intervention.,COMMENTS: , This patient understands the essence of the diagnosis and the reasons for the MUA- The associated risks of the procedure, including anesthesia complications, fracture, vascular accidents, disc herniation and post-procedure discomfort, were thoroughly discussed with the patient. Alternatives to the procedure, including the course of the condition without MUA, were discussed. The patient understands the chances of success from undergoing MUA and that no guarantees are made or implied regarding outcome. The patient has given both verbal and written informed consent for the listed procedure.,PROCEDURE IN DETAIL: , The patient was draped in the appropriate gowning and accompanied to the operative area. Following their sacral block injection, they were asked to lie supine on the operative table and they were placed on the appropriate monitors for this procedure. When the patient and I were ready, the anesthesiologist administered the appropriate medications to assist the patient into the twilight sedation using medication which allows the stretching, mobilization, and adjustments necessary for the completion of the outcome I desired.,THORACIC SPINE: , With the patient in the supine position on the operative table, the upper extremities were flexed at the elbow and crossed over the patient's chest to achieve maximum traction to the patient's thoracic spine. The first assistant held the patient's arms in the proper position and assisted in rolling the patient for the adjusting procedure. With the help of the first assist, the patient was rolled to their right side, selection was made for the contact point and the patient was rolled back over the doctor's hand. The elastic barrier of resistance was found, and a low velocity thrust was achieved using a specific closed reduction anterior to posterior/superior manipulative procedure. The procedure was completed at the level of TI-TI2. Cavitation was achieved.,LUMBAR SPINE/SACRO-ILIAC JOINTS:, With the patient supine on the procedure table, the primary physician addressed the patient's lower extremities which were elevated alternatively in a straight leg raising manner to approximately 90 degrees from the horizontal. Linear force was used to increase the hip flexion gradually during this maneuver. Simultaneously, the first assist physician applied a myofascial release technique to the calf and posterior thigh musculature. Each lower extremity was independently bent at the knee and tractioned cephalad in a neutral sagittal plane, lateral oblique cephalad traction, and medial oblique cephalad traction maneuver. The primary physician then approximated the opposite single knee from his position from neutral to medial slightly beyond the elastic barrier of resistance. (a piriformis myofascial release was accomplished at this time). This was repeated with the opposite lower extremity. Following this, a Patrick-Fabere maneuver was performed up to and slightly beyond the elastic barrier of resistance.,With the assisting physician stabling the pelvis and femoral head (as necessary), the primary physician extended the right lower extremity in the sagittal plane, and while applying controlled traction gradually stretched the para-articular holding elements of the right hip by means gradually describing an approximately 30-35 degree horizontal arc. The lower extremity was then tractioned, and straight caudal and internal rotation was accomplished. Using traction, the lower extremity was gradually stretched into a horizontal arch to approximately 30 degrees. This procedure was then repeated using external rotation to stretch the para-articular holding elements of the hips bilaterally. These procedures were then repeated on the opposite lower extremity.,By approximating the patient's knees to the abdomen in a knee-chest fashion (ankles crossed), the lumbo-pelvic musculature was stretched in the sagittal plane, by both the primary and first assist, contacting the base of the sacrum and raising the lower torso cephalad, resulting in passive flexion of the entire lumbar spine and its holding elements beyond the elastic barrier of resistance orthopedic, fibromyositis, myalgia, segmental dysfunction, sacro-iliitis, spinal manipulation under anesthesia, lumbar segmental dysfunction, informed consent, iliac joints, spinal manipulation, sacro iliitis, lower extremity, spinal, mua, cephalad, dysfunction, segmental, lumbar, Orthopedic Frontal and lateral views of the hip and pelvis. Slipped Capital Femoral Epiphysis (SCFE) EXAM: , Two views of the pelvis.,HISTORY:, This is a patient post-surgery, 2-1/2 months. The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.,TECHNIQUE: , Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM/DD/YYYY. Lateral view of the right hip was evaluated.,FINDINGS:, Frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient's most recent priors dated MM/DD/YYYY. Current films reveal stable appearing post-surgical changes. Again demonstrated is a single intramedullary screw across the left femoral neck and head. There are 2 intramedullary screws through the greater trochanter of the right femur. There is a lucency along the previous screw track extending into the right femoral head and neck. There has been interval removal of cutaneous staples and/or surgical clips. These were previously seen along the lateral aspect of the right hip joint.,Deformity related to the previously described slipped capital femoral epiphysis is again seen.,IMPRESSION:,1. Stable-appearing right hip joint status-post pinning.,2. Interval removal of skin staples as described above. orthopedic, scfe, frontal and lateral views, slipped capital femoral epiphysis, lateral views, slipped, capital, epiphysis, frontal, pelvis, femoral, hip Orthopedic Arthroscopic subacromial decompression and repair of rotator cuff through mini-arthrotomy. Rotator Cuff Repair PREOPERATIVE DIAGNOSIS: , Rotator cuff tear, left.,POSTOPERATIVE DIAGNOSES:,1. Sixty-percent rotator cuff tear, joint side.,2. Impingement syndrome.,ANESTHESIA: , General,NAME OF OPERATION:,1. Arthroscopic subacromial decompression.,2. Repair of rotator cuff through mini-arthrotomy.,FINDINGS AT OPERATION: , The patient's glenohumeral joint was completely clear, other than obvious tear of the rotator cuff. The midportion of this appeared to be complete, but for the most part, this was about a 60% rupture of the tendon. This was confirmed later when the bursal side was opened up. Note, the patient also had abrasion of the coracoacromial ligament under the anterolateral edge of the acromion. He did not have any acromioclavicular joint pain or acromioclavicular joint disease noted.,PROCEDURE:, He was given an anesthetic, examined, prepped, and draped in a sterile fashion in a beach-chair position. The shoulder was instilled with fluid from posteriorly, followed by the arthroscope. The shoulder was instilled with fluid from posteriorly, followed by the arthroscope. Arthroscopy was then carried out in standard fashion using a 30-degree Dionic scope. With the scope in the posterior portal, the above findings were noted, and an anterior portal was established. A curved shaver was placed for debridement of the tear. I established this was about a 60-70% tear with a probable complete area of tear which was very small. There were no problems at the biceps or the rest of the joint. The subacromial space showed findings, as noted above, and a thorough subacromial decompression was carried out with a Bovie, rotary shaver, and bur. I did not debride the acromioclavicular joint. The lateral portal was then extended to a mini-arthrotomy, and subacromial space was entered by blunt dissection through the deltoid. The area of weakness of the tendon was found, and was transversely cut, and findings were confirmed. The diseased tissue was removed, and the greater tuberosity was abraded with a rongeur. Tendon-to-tendon repair was then carried out with buried sutures of 2-0 Ethibond, giving a very nice repair. The shoulder was carried through a range of motion. I could see no evidence of impingement. Copious irrigation was carried out. The deltoid deep fascia was anatomically closed, as was the superficial fascia. The subcutaneous tissue and skin were closed in layers. A sterile dressing was applied. The patient appeared to tolerate the procedure well. orthopedic, rotator cuff tear, mini-arthrotomy, repair of rotator cuff, arthroscopic subacromial decompression, arthroscopic subacromial, cuff tear, subacromial space, subacromial decompression, mini arthrotomy, acromioclavicular joint, rotator cuff, arthroscopic, decompression, acromioclavicular, impingement, rotator, cuff, Orthopedic Left shoulder injury. A 41-year-old male presenting for initial evaluation of his left shoulder. Shoulder Contusion CHIEF COMPLAINT: , orthopedic, shoulder, injury, two views, shoulder contusion, Orthopedic Consultation for right shoulder pain. Shoulder Pain Consult CHIEF COMPLAINT:, Right shoulder pain.,HISTORY OF PRESENT PROBLEM: orthopedic, shoulder pain, history of present problem:, cortisone shot, no numbness or tingling, rhomboids, scapula, shoulder impingement, focal findings, shoulder, Orthopedic Followup left-sided rotator cuff tear and cervical spinal stenosis. Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis. Rotator Cuff Tear REASON FOR VISIT: , Followup left-sided rotator cuff tear and cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS: , Ms. ABC returns today for followup regarding her left shoulder pain and left upper extremity C6 radiculopathy. I had last seen her on 06/21/07.,At that time, she had been referred to me Dr. X and Dr. Y for evaluation of her left-sided C6 radiculopathy. She also had a significant rotator cuff tear and is currently being evaluated for left-sided rotator cuff repair surgery, I believe on, approximately 07/20/07. At our last visit, I only had a report of her prior cervical spine MRI. I did not have any recent images. I referred her for cervical spine MRI and she returns today.,She states that her symptoms are unchanged. She continues to have significant left-sided shoulder pain for which she is being evaluated and is scheduled for surgery with Dr. Y.,She also has a second component of pain, which radiates down the left arm in a C6 distribution to the level of the wrist. She has some associated minimal weakness described in detail in our prior office note. No significant right upper extremity symptoms. No bowel, bladder dysfunction. No difficulty with ambulation.,FINDINGS: , On examination, she has 4 plus over 5 strength in the left biceps and triceps muscle groups, 4 out of 5 left deltoid, 5 out of 5 otherwise in both muscle groups and all muscle groups of upper extremities. Light touch sensation is minimally decreased in the left C6 distribution; otherwise, intact. Biceps and brachioradialis reflexes are 1 plus. Hoffmann sign normal bilaterally. Motor strength is 5 out of 5 in all muscle groups in lower extremities. Hawkins and Neer impingement signs are positive at the left shoulder.,An EMG study performed on 06/08/07 demonstrates no evidence of radiculopathy or plexopathy or nerve entrapment to the left upper extremity.,Cervical spine MRI dated 06/28/07 is reviewed. It is relatively limited study due to artifact. He does demonstrate evidence of minimal-to-moderate stenosis at the C5-C6 level but without evidence of cord impingement or cord signal change. There appears to be left paracentral disc herniation at the C5-C6 level, although axial T2-weighted images are quite limited.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.,I agree with the plan to go ahead and continue with rotator cuff surgery. With regard to the radiculopathy, I believe this can be treated non-operatively to begin with. I am referring her for consideration of cervical epidural steroid injections. The improvement in her pain may help her recover better from the shoulder surgery.,I will see her back in followup in 3 months, at which time she will be recovering from a shoulder surgery and we will see if she needs any further intervention with regard to the cervical spine.,I will also be in touch with Dr. Y to let him know this information prior to the surgery in several weeks. orthopedic, upper extremity, radiculopathy, rotator cuff repair, cervical spinal stenosis, rotator cuff tear, physical examination, cuff, impingement, stenosis, extremity, surgery, tear, shoulder, rotator, cervical, Orthopedic Scarf bunionectomy procedure of the first metatarsal of the left foot. Hallux abductovalgus deformity with bunion of the left foot. Scarf Bunionectomy PREOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,POSTOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,PROCEDURE PERFORMED: , Scarf bunionectomy procedure of the first metatarsal of the left foot.,ANESTHESIA:, IV sedation with local.,HISTORY: , This patient is a 55-year-old female who presents to ABCD preoperative holding area after keeping herself n.p.o., since mid night for surgery for her painful left bunion. The patient has had increasing pain over time and is having difficulty ambulating and wearing shoes. The patient has failed to conservative treatment and desires surgical correction at this time. Risks versus benefits of the procedure have been explained in detail by Dr. X, and consent is available on the chart for review.,PROCEDURE IN DETAIL:, After an IV established by the Department of Anesthesia, the patient was given preoperatively 600 mg of clindamycin intravenously. The patient was then taken to the Operating Suite via cart and was placed on the operating table in a supine position and a safety strap was placed across her waist for protection. Next, a pneumatic ankle tourniquet was applied over her left ankle with copious amounts of Webril for the patient's protection. After adequate IV sedation was applied, the patient was given a local injection consisting of 17 cc of 4.5 cc 1% lidocaine plain, 4.5 cc of 0.5% Marcaine plain, and 1.0 cc of Solu-Medrol mixture in the standard Mayo block to the left foot. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was then elevated, the Esmarch was applied and the tourniquet was inflated to 250 mmHg. The foot was then lowered to the operating field.,A sterile stockinet was reflected and the attention was directed to the first metatarsophalangeal joint of the left foot. After sufficient anesthesia, using a #10 blade a linear incision was made approximately 5 to 6 cm in length over the first metatarsophalangeal joint dorsally, just near to the extensor hallucis longus tendon. Then using a fresh #15 blade, this incision was deepened through the skin into the subcutaneous layer after all small traversing veins were ligated and cauterized with electrocautery. A neurovascular bundle was identified and reflected medially. Laterally the extensor hallucis longus tendon was identified and protected with retraction as well. Care was then taken to undermine the medial and lateral margins of the first metatarsophalangeal joint carefully. The first metatarsophalangeal joint capsule was then identified and using a #15 blade, a linear incision made down to the bone through the joint capsule. The periosteum was reflected and elevated off of its bone and the metatarsal head as well as the base of the proximal phalanx to a small degree. Noted was a large hypertrophic bone spur on the dorsal medial aspect of the first metatarsal head as well as some small osteophytes along the medial portion of the proximal phalanx. Care was then taken to reflect and dissect the periosteum off of the shaft of the first metatarsal proximally into the proximal portion of the metatarsal close to the first metatarsocuneiform joint. The bone cortex was noted to be intact and in good condition. Following this, using a sagittal saw with a #138 blade, the attention was directed to the medial hypertrophic bone of the first metatarsal head. In the sagittal plane with the blade angulated from dorsolateral to proximal medial, the medial eminence of bone was resected. Plantarly it was noted that the tibial sesamoid groove was intact and the sesamoid apparatus was intact as well. Following this bone cut, 0.45 K-wire was inserted from medial to lateral through the medial portion of the first metatarsal head directed in the dorsal third of the metatarsal head. Then using the Reese osteotomy guide, the guide was directed from the distal portion of the metatarsal head proximally to the proximal portion of the first metatarsal. A second 0.45 K-wire was inserted proximally as well. Following this, using the sagittal saw with the #138 blade a transverse linear osteotomy cut was made through the first metatarsal from medial to lateral. After reaching the distal as well as the proximal portions of the bone and ensuring that cortex was cut on both the medial as well as lateral side, the Reese osteotomy guide was removed and the dorsal and plantar incision cuts were made. This began with the dorsal distal cut, which extended from medial to lateral with the dorsal portion of the blade angled proximally about five degrees through the dorsal third of the distal first metatarsal. Following this, attention was directed proximally and an incision osteotomy cut through the bone was made, directed medially to laterally with the inferior portion of the blade angled distally to transect the cortex of the bone. Following this, the distal portion of the osteotomy cut was freely movable and was able to be translocated medially. The head was then slit medially several millimeters until it was noted to be in good position and no chopping was present in the medullary canal of the bone. Following this, the bone was stabilized using a 0.45 K-wire distally as well as proximally directed from dorsal to planar direction. Next using the normal AO manner, the distal cortex was drilled from dorsal to plantar with a 2.0 mm drill bit and then over drilled proximally with the cortex using a 2.7 mm drill bit. The proximal cortex was then _________ and then the drill hole was measured and it was determined to be 18 mm in length from dorsal to plantar cortex. Then using 2.7 mm tap, the thread holes were placed and using an 18 x 2.7 mm screw ___________ was achieved and good apposition of the bone and tightness were achieved. Intramedullary sludge was noted to exit from the osteotomy cut. Following this, attention was directed proximally and the 0.45 K-wire was removed and the holes were predrilled using a 2.0 mm screw then over-drilled using 2.7 mm screw and counter sucked. Following this, the holes were measured, found to 20 mm in length and the drill hole was tapped using a 2.7 mm tap. Following this, a 20 mm full threaded screw was inserted and tightened. Good intramedullary sludge was noted and compression was achieved. Attention was then directed to the distal screw where it was once again tightened and found to be in good position with good bite. Following this, range of motion was performed on the first metatarsophalangeal joint and some lateral deviation of the hallux was noted. Based on this, a lateral release was performed. The extensor hallucis longus tendon was identified and was transected medially and a linear incision was placed down using a #15 blade into the first interspace. The incision was then deepened with sharp and blunt dissection and using a curved hemostat, the transverse as well as the oblique fibers of the abductor hallucis tendon were identified and transected. Care was taken to perform lateral release around the fibular sesamoid through these suspensory ligaments as well as the transverse metatarsal ligament and the collateral ligament. Upon completion of this, the hallux was noted to be in a rectus position with good alignment. The area was then flushed and irrigated with copious amounts of sterile saline. After this, attention was directed back to the medial capsule and a medial capsulorrhaphy was performed and the capsule was closed using #3-0 Vicryl suture. Subcutaneous tissues were closed using #3-0 and #4-0 Vicryl sutures to close in layers. The skin was then reapproximated and closed using #5-0 Monocryl suture. Following this, the incisions were dressed and bandaged in the normal manner using Owen silk, 4x4s, Kling, and Kerlix as well as Coban dressing. The tourniquet was then dropped with a total tourniquet time of 99 minutes at 250 mmHg. The patient followed the procedure and the anesthesia well and vascular status was intact as noted by immediate hyperemia to digits one through five of the left foot. The patient was then transferred back to the cart and escorted on the cart to the Postanesthesia Care Unit. Following this, the patient was given prescription for Vicoprofen total #20 to be taken one every six hours as necessary for moderate to severe pain. The patient was also given prescription for clindamycin to be taken 300 mg four times a day. The patient was given surgical shoe and was placed in a posterior sling. The patient was given crutches and instructed to use them for ambulation. The patient was instructed to keep her foot iced and elevated and to remain nonweightbearing over the weekend. The patient will follow up with Dr. X on Tuesday morning at 11'o clock in his Livonia office. The patient was concerned about any possible allergic reaction to medication and was placed on codeine and antibiotics due to that. The patient has Dr. X's pager and will contact him over this weekend if she has any problems or complaints or return to Emergency Department if any difficulty should arise. X-rays were taken and the patient was discharged home upon completion of this. orthopedic, hallux abductovalgus deformity, scarf bunionectomy, metatarsal, bunion, hallux abductovalgus, metatarsophalangeal joint, dorsally, foot, bone, abductovalgus Orthopedic Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented. Severe degenerative joint disease of the right shoulder. Shoulder Hemi-resurfacing PREOPERATIVE DIAGNOSIS: , Severe degenerative joint disease of the right shoulder.,POSTOPERATIVE DIAGNOSIS:, Severe degenerative joint disease of the right shoulder.,PROCEDURE: , Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,COMPLICATIONS:, None. The patient was taken to Postanesthesia Care Unit in stable condition. The patient tolerated the procedure well.,INDICATIONS: , The patient is a 55-year-old female who has had increased pain in to her right shoulder. X-rays as well as an MRI showed a severe arthritic presentation of the humeral head with mild arthrosis of the glenoid. She had an intact rotator cuff being at a young age and with potential of glenoid thus it was felt that a hemi-resurfacing was appropriate for her right shoulder focusing in the humeral head. All risks, benefits, expectations and complications of surgery were explained to her in detail including nerve and vessel damage, infection, potential for hardware failure, the need for revision surgery with potential of some problems even with surgical intervention. The patient still wanted to proceed forward with surgical intervention. The patient did receive 1 g of Ancef preoperatively.,PROCEDURE: , The patient was taken to the operating suite, placed in supine position on the operating table. The Department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well. The patient was moved to a beach chair position. All extremities were well padded. Her head was well padded to the table. Her right upper extremity was draped in sterile fashion. A saber incision was made from the coracoid down to the axilla. Skin was incised down to the subcutaneous tissue, the cephalic vein was retracted as well as all neurovascular structures were retracted in the case. Dissecting through the deltopectoral groove, the subscapularis tendon was found as well as the bicipital tendon, 1 finger breadth medial to the bicipital tendon an incision was made. Subscapularis tendon was released. The humeral head was brought in to; there were large osteophytes that were removed with an osteotome. The glenoid then was evaluated and noted to just have mild arthrosis, but there was no need for surgical intervention in this region. A sizer was placed. It was felt that size 5 was appropriate for this patient, after which the guide was used to place the stem and pin. This was placed, after which a reamer was placed along the humeral head and reamed to a size 5. All extra osteophytes were excised. The supraspinatus and infraspinatus tendons were intact. Next, the excess bone was removed and irrigated after which reaming of the central portion of the humeral head was performed of which a trial was placed and showed that there was adequate fit and appropriate fixation. The arm had excellent range of motion. There are no signs of gross dislocation. Drill holes were made into the humeral head after which a size 5 Copeland hemi-resurfacing component was placed into the humeral head, kept down in appropriate position, had excellent fixation into the humeral head. Excess bone that had been reamed was placed into the Copeland metal component, after which this was tapped into position. After which the wound site was copiously irrigated with saline and antibiotics and the humeral head was reduced and taken through range of motion; had adequate range of motion, full internal and external rotation as well as forward flexion and abduction. There was no gross sign of dislocation. Wound site once again it was copiously irrigated with saline antibiotics. The subscapularis tendon was approximated back into position with #2 Ethibond after which the bicipital tendon did have significant tear to it; therefore it was tenodesed in to the pectoralis major tendon. After which, the wound site again was irrigated with saline antibiotics after which subcutaneous tissue was approximated with 2-0 Vicryl. The skin was closed with staples. A sterile dressing was placed. The patient was awakened from general anesthetic and transferred to hospital gurney to the postanesthesia care unit in stable condition. orthopedic, degenerative joint disease, hemi-resurfacing, biomet copeland, shoulder hemi resurfacing, humeral, head, degenerative, glenoid, subscapularis, antibiotics, resurfacing, tendon, shoulder, Orthopedic Right shoulder hemiarthroplasty. Right shoulder rotator cuff tear. Glenohumeral rotator cuff arthroscopy. Degenerative joint disease. Right Shoulder Hemiarthroplasty PREOPERATIVE DIAGNOSES:,1. Right shoulder rotator cuff tear.,2. Glenohumeral rotator cuff arthroscopy.,3. Degenerative joint disease.,POSTOPERATIVE DIAGNOSES:,1. Right shoulder rotator cuff tear.,2. Glenohumeral rotator cuff arthroscopy.,3. Degenerative joint disease.,PROCEDURE PERFORMED: ,Right shoulder hemiarthroplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Approximately 125 cc.,COMPLICATIONS:, None.,COMPONENTS: , A DePuy 10 mm global shoulder system stem was used cemented and a DePuy 44 x 21 mm articulating head was used.,BRIEF HISTORY: ,The patient is an 82-year-old right-hand dominant female who presents for shoulder pain for many years now and affecting her daily living and function and pain is becoming unbearable failing conservative treatment.,PROCEDURE: , The patient was taken to the operative suite, placed on the operative field. Department of Anesthesia administered general anesthetic. Once adequately sedated, the patient was placed in the beach chair position. Care was ensured that she was well positioned, adequately secured and padded. At this point, the right upper extremity was then prepped and draped in the usual sterile fashion. A deltopectoral approach was used and taken down to the skin with a #15 blade scalpel.,At this point, blunt dissection with Mayo scissors was used to come to the overlying subscapular tendon and bursal tissue. Any perforating bleeders were cauterized with Bovie to obtain hemostasis. Once the bursa was seen, it was removed with a Rongeur and subscapular tendon could be easily visualized. At this point, the rotator cuff in the subacromial region was evaluated. There was noted to be a large rotator cuff, which was irreparable. There was eburnated bone on the greater tuberosity noted. The articular surface could be visualized. The biceps tendon was intact. There was noted to be diffuse discolored synovium around this as well as some fraying of the tendon in the intraarticular surface. The under surface of the acromion, it was felt there was mild ware on this as well. At this point, the subscapular tendon was then taken off using Bovie cautery and Metzenbaum scissors that was tied with Metzenbaum suture. It was separated from the capsule to have a two layered repair at closure. The capsule was also reflected posterior. At this point, the glenoid surface could be easily visualized. It was evaluated and had good cartilage contact and appeared to be intact. The humeral head was evaluated. There was noted to be ware of the cartilage and eburnated bone particularly in the central portion of the humeral head. At this point, decision was made to proceed with the arthroplasty, since the rotator cuff tear was irreparable and there was significant ware of the humoral head. The arm was adequately positioned. An oscillating saw was used to make the head articular cut. This was done at the margin of the articular surface with the anatomic neck. This was taken down to appropriate level until this articular surface was adequately removed. At this point, the intramedullary canal and cancellous bone could be easily visualized. The opening hand reamers were then used and this was advanced to a size #10. Under direct visualization, this was performed easily. At this point, the 10 x 10 proximal flange cutter was then inserted and impacted into place to cut grooves for the fins. This was then removed. A trial component was then impacted into place, which did fit well and trial heads were then sampled and it was felt that a size 44 x 21 mm head gave us the best fit and appeared adequately secured. It did not appear overstuffed with evidence of excellent range of motion and no impingement. At this point, the trial component was removed. Wound was copiously irrigated and suctioned dry. Cement was then placed with a cement gun into the canal and taken up to the level of the cut. The prosthesis was then inserted into place and held under direct visualization. All excess cement was removed and care was ensured that no cement was left in the posterior aspect of the joint itself. This _______ cement was adequately hard at this point. The final component of the head was impacted into place, secured on the Morris taper and checked, and this was reduced.,The final component was then taken through range of motion and found to have excellent stability and was satisfied with its position. The wound was again copiously irrigated and suctioned dry. At this point, the capsule was then reattached to its insertion site in the anterior portion. Once adequately sutured with #1-Vicryl, attention was directed to the subscapular. The subscapular was advanced superiorly and anchored not only to the biceps tendon region, but also to the top anterior portion of the greater tuberosity. This was opened to allow some type of coverage points of the massive rotator cuff tear. This was secured to the tissue and interosseous sutures with size #2 fiber wire. After this was adequately secured, the wound was again copiously irrigated and suctioned dry. The deltoid fascial split was then repaired using interrupted #2-0 Vicryl, subcutaneous tissue was then approximated using interrupted #24-0 Vicryl, skin was approximated using a running #4-0 Vicryl. Steri-Strips and Adaptic, 4 x 4s, and ABDs were then applied. The patient was then placed in a sling and transferred back to the gurney, reversed by Department of Anesthesia.,DISPOSITION: , The patient tolerated well and transferred to Postanesthesia Care Unit in satisfactory condition. orthopedic, glenohumeral rotator cuff, arthroscopy, degenerative joint disease, shoulder hemiarthroplasty, rotator, cuff, subscapular, shoulder, Orthopedic Shoulder pain, right shoulder diffusely - Rotator cuff syndrome, right. Rotator cuff syndrome - H&P CHIEF COMPLAINT: ,This 18 year old male presents today with shoulder pain right. Location: He indicates the problem location is the right shoulder diffusely. Quality: Quality of the pain is described by the patient as aching, throbbing and tolerable. Patient relates pain on a scale from 0 to 10 as 5/10. Severity: The severity has worsened over the past 3 months. Timing (onset/frequency): Onset was gradual and after pitching a baseball game. Modifying Factors: Patient's condition is aggravated by throwing. He participates with difficulty in basketball. Past conservative treatments include NSAID and muscle relaxant medications.,ALLERGIES: , No known medical allergies.,MEDICATION HISTORY:, None.,PAST MEDICAL HISTORY: ,Childhood Illnesses: (+) strep throat (+) mumps (+) chickenpox,PAST SURGICAL HISTORY:, No previous surgeries.,FAMILY HISTORY:, Patient admits a family history of arthritis associated with mother.,SOCIAL HISTORY: , Patient denies smoking, alcohol abuse, illicit drug use and STDs.,REVIEW OF SYSTEMS:,Musculoskeletal: (+) joint or musculoskeletal symptoms (+) stiffness in AM.,Psychiatric: (-) psychiatric or emotional difficulties.,Eyes: (-) visual disturbance or change.,Neurological: (-) neurological symptoms or problems Endocrine: (-) endocrine-related symptoms.,Allergic / Immunologic: (-) allergic or immunologic symptoms.,Ears, Nose, Mouth, Throat: (-) symptoms involving ear, nose, mouth, or throat.,Gastrointestinal: (-) GI symptoms.,Genitourinary: (-) GU symptoms.,Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,Cardiovascular: (-) cardiovascular problems or chest symptoms.,Respiratory: (-)breathing difficulties, respiratory symptoms.,Physical Exam: BP Standing: 116/68 Resp: 16 HR: 68 Temp: 98.1 Height: 5 ft. 11 in. Weight: 165 lbs. Patient is a 18 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus. Oriented to person, place and time. Right shoulder shows evidence of swelling and tenderness. Radial pulses are 2 /4, bilateral. Brachial pulses are 2 /4, bilateral.,Appearance: Normal.,Tenderness: Anterior - moderate, Biceps - none, Posterior - moderate and Subacromial - moderate right.,Range of Motion: Right shoulder ROM shows decreased flexion, decreased extension, decreased adduction, decreased abduction, decreased internal rotation, decreased external rotation. L shoulder normal.,Strength: External rotation - fair. Internal rotation - poor right.,AC Joint: Pain with ABD and cross-chest - mild right.,Rotator Cuff: Impingement - moderate. Painful arc - moderate right.,Instability: None.,TEST & X-RAY RESULTS:, X-rays of the shoulder were performed. X-ray of right shoulder reveals cuff arthropathy present.,IMPRESSION: , Rotator cuff syndrome, right.,PLAN: , Diagnosis of a rotator cuff tendinitis and shoulder impingement were discussed. I noted that this is a very common condition resulting in significant difficulties with use of the arm. Several treatment options and their potential benefits were described. Nonsteroidal anti-inflammatories can be helpful but typically are slow acting. Cortisone shots can be very effective and are quite safe. Often more than one injection may be required. Physical therapy can also be helpful, particularly if there is any loss of shoulder mobility or strength. If these treatments fail to resolve symptoms, an MRI or shoulder arthrogram may be required to rule out a rotator cuff tear. Injected shoulder joint and with Celestone Soluspan 1.0 cc . Ordered x-rays of shoulder right.,PRESCRIPTIONS:, Vioxx Dosage: 25 mg tablet Sig: TID Dispense: 60 Refills: 0 Allow Generic: Yes,PATIENT INSTRUCTIONS:, Patient was instructed to restrict activity. Patient was given instructions on RICE therapy. Orthopedic Release of A1 pulley, right thumb. Stenosing tendinosis, right thumb (trigger finger). There was noted to be thickening of the A1 pulley. There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb. Release of A1 Pulley - 1 PREOPERATIVE DIAGNOSIS: , Stenosing tendinosis, right thumb (trigger finger).,POSTOPERATIVE DIAGNOSIS: , Stenosing tendinosis, right thumb (trigger finger).,PROCEDURE PERFORMED:, Release of A1 pulley, right thumb.,ANESTHESIA:, IV regional with sedation.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , Approximately 20 minutes at 250 mmHg.,INTRAOPERATIVE FINDINGS: , There was noted to be thickening of the A1 pulley. There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.,HISTORY: ,This is a 51-year-old right hand dominant female with a longstanding history of pain as well as locking sensation to her right thumb. She was actually able to spontaneously trigger the thumb. She was diagnosed with stenosing tendinosis and wishes to proceed with release of A1 pulley. All risks and benefits of the surgery was discussed with her at length. She was in agreement with the above treatment plan.,PROCEDURE: ,On 08/21/03, she was taken to operating room at ABCD General Hospital and placed supine on the operating table. A regional anesthetic was applied by the Anesthesia Department. Tourniquet was placed on her proximal arm. The upper extremity was sterilely prepped and draped in the usual fashion.,An incision was made over the proximal crease of the thumb. Subcuticular tissues were carefully dissected. Hemostasis was controlled with electrocautery. The nerves were identified and retracted throughout the entire procedure. The fibers of the A1 pulley were identified. They were sharply dissected to release the tendon. The tendon was then pulled up into the wound and inspected. There was no evidence of gross tear noted. Fibrous nodule was noted within the tendon itself. There was no evidence of continuous locking. Once release of the pulley had been performed, the wound was copiously irrigated. It was then reapproximated using #5-0 nylon simple interrupted and horizontal mattress sutures. Sterile dressing was applied to the upper extremity. Tourniquet was deflated. It was noted that the thumb was warm and pink with good capillary refill. The patient was transferred to Recovery in apparent stable and satisfactory condition. Prognosis is fair. orthopedic, release of a1 pulley, tendinosis, thumb, flexor tendon, trigger finger, fibrous nodule, stenosing tendinosis, tourniquet, stenosing, tendon, release, pulley Orthopedic Epicondylitis. history of lupus. Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine. Rheumatology Progress Note SUBJECTIVE:, The patient is here for a follow-up. The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d. Eye report was noted and appreciated. The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago. She denied having any trauma. She states that the pain is bothering her. She denies having any fevers, chills, or any joint effusion or swelling at this point. She noted also that there is some increase in her hair loss in the recent times.,OBJECTIVE:, The patient is alert and oriented. General physical exam is unremarkable. Musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows, no effusion. Hand examination is unremarkable today. The rest of the musculoskeletal exam is unremarkable.,ASSESSMENT:, Epicondylitis, both elbows, possibly secondary to lupus flare-up.,PLAN:, We will inject both elbows with 40-mg of Kenalog mixed with 1 cc of lidocaine. The posterior approach was chosen under sterile conditions. The patient tolerated both procedures well. I will obtain CBC and urinalysis today. If the patient's pain does not improve, I will consider adding methotrexate to her therapy.,Sample Doctor M.D. orthopedic, rheumatology, 1 cc of lidocaine, epicondylitis, kenalog, kenalog mixed with 1 cc of lidocaine, progress note, aches and pains, history of lupus, lidocaine, lupus, methotrexate, kenalog mixed, injected, Orthopedic The patient was found to have limitations to extension at the IP joint to the right thumb and he had full extension after release of A1 pulley. Release of A1 Pulley PREOPERATIVE DIAGNOSIS: , Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:, Right trigger thumb.,SURGERY: , Release of A1 pulley, CPT code 26055.,ANESTHESIA:, General LMA.,TOURNIQUET TIME: ,9 minutes at 200 torr.,FINDINGS:, The patient was found to have limitations to extension at the IP joint to the right thumb. He was found to have full extension after release of A1 pulley.,INDICATIONS:, The patient is 2-1/2-year-old. He has a history of a trigger thumb. This was evaluated in the office. He was indicated for release of A1 pulley to allow for full excursion. Risks and benefits including recurrence, infection, and problems with anesthesia were discussed at length with the family. They wanted to proceed.,PROCEDURE:, The patient was brought into the operating room and placed on the operating table in supine position. General anesthesia was induced without incident. He was given a weight-adjusted dose of antibiotics. The right upper extremity was then prepped and draped in a standard fashion. Limb was exsanguinated with an Esmarch bandage. Tourniquet was raised to 200 torr. Transverse incision was then made at the base of thumb. The underlying soft tissues were carefully spread in line longitudinally. The underlying tendon was then identified. The accompanied A1 pulley was also identified. This was incised longitudinally using #11 blade. Inspection of the entire tendon then demonstrated good motion both in flexion and extension. The leaflets of the pulley were easily identified.,The wound was then irrigated and closed. The skin was closed using interrupted #4-0 Monocryl simple sutures. The area was injected with 5 mL of 0.25% Marcaine. The wound was dressed with Xeroform, dry sterile dressings, hand dressing, Kerlix, and Coban. The patient was awakened from anesthesia and taken to the recovery room in good condition. There were no complications. All instrument, sponge, needle counts were correct at the end of case.,PLAN: , The patient will be discharged home. He will return in 1-1/2 weeks for wound inspection. orthopedic, a1 pulley, release of a1 pulley, trigger thumb, limitations to extension, ip joint Orthopedic Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion. PMT Halo Crown & Vest PREOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.,POSTOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion, and potentially unstable cervical spine.,OPERATIVE PROCEDURE: ,Application of PMT large halo crown and vest.,ESTIMATED BLOOD LOSS: , None.,ANESTHESIA: ,Local, conscious sedation with Morphine and Versed.,COMPLICATIONS: , None. Post-fixation x-rays, nonalignment, no new changes. Post-fixation neurologic examination normal.,CLINICAL HISTORY: ,The patient is a 41-year-old female who presented to me with severe cervical spondylosis and myelopathy. She was referred to me by Dr. X. The patient underwent a complicated anterior cervical discectomy, 2-level corpectomy, spinal cord decompression and fusion with fibular strut and machine allograft in the large cervical plate. Surgery had gone well, and the patient has done well in the last 2 days. She is neurologically improved and is moving all four extremities. No airway issues. It was felt that the patient was now a candidate for a halo vest placement given that chance of going to the OR were much smaller. She was consented for the procedure, and I sought the help of ABC and felt that a PMT halo would be preferable to a Bremer halo vest. The patient had this procedure done at the bedside, in the SICU room #1. I used a combination of some morphine 1 mg and Versed 2 mg for this procedure. I also used local anesthetic, with 1% Xylocaine and epinephrine a total of 15 to 20 cc.,PROCEDURE DETAILS:, The patient's head was positioned on some towels, the retroauricular region was shaved, and the forehead and the posterolateral periauricular regions were prepped with Betadine. A large PMT crown was brought in and fixed to the skull with pins under local anesthetic. Excellent fixation achieved. It was lateral to the supraorbital nerves and 1 fingerbreadth above the brows and the ear pinnae.,I then put the vest on, by sitting the patient up, stabilizing her neck. The vest was brought in from the front as well and connected. Head was tilted appropriately, slightly extended, and in the midline. All connections were secured and pins were torqued and tightened.,During the procedure, the patient did fine with no significant pain.,Post-procedure, she is neurologically intact and she remained intact throughout. X-rays of the cervical spine AP, lateral, and swimmer views showed excellent alignment of the hardware construct in the graft with no new changes.,The patient will be subjected to a CT scan to further define the alignment, and barring any problems, she will be ambulating with the halo on.,The patient will undergo pin site care as per protocol, and likely she will go in the next 2 to 3 days. Her prognosis indeed is excellent, and she is already about 90% or so better from her surgery. She is also on a short course of Decadron, which we will wean off in due course.,The matter was discussed with the patient and the patient's family. orthopedic, cervical spondylosis, anterior cervical discectomy, corpectomy, decompression, fusion, pmt, crown, vest, pmt halo, cervical, Orthopedic A sample note on RICE Therapy RICE Therapy RICE, stands for the most important elements of treatment for many injuries---rest, ice, compression, and elevation.,REST:,Stop using the injured part as soon as you realize that an injury has taken place. Use crutches to avoid bearing weight on injuries of the foot, ankle, knee, or leg. Use splints for injuries of the hand, wrist, elbow, or arm. Continued exercise or activity could cause further injury, increased pain, or a delay in healing.,ICE:,Ice helps stop bleeding from injured blood vessels and capillaries. Sudden cold causes the small blood vessels to contract. This contraction decreases the amount of blood that can collect around the wound. The more blood that collects, the longer the healing time. Ice can be safely applied in many ways:,* For injuries to small areas, such as a finger, toe, foot, or wrist, immerse the injured area for 15 to 35 minutes in a bucket of ice water. Use ice cubes to keep the water cold, adding more as the ice cubes dissolve.,* For injuries to larger areas, use ice packs. Avoid placing the ice directly on the skin. Before applying the ice, place a towel, cloth, or one or two layers of an elasticized compression bandage on the skin to be iced. To make the ice pack, put ice chips or ice cubes in a plastic bag or wrap them in a thin towel. Place the ice pack over the cloth. The pack may sit directly on the injured part, or it may be wrapped in place.,* Ice the injured area for about 30 minutes.,* Remove the ice to allow the skin to warm for 15 minutes.,* Reapply the ice.,* Repeat the icing and warming cycles for 3 hours. Follow the instructions below for compression and elevation. If pain and swelling persist after 3 hours call our office. You may need to change the icing schedule after the first 3 hours. Regular ice treatment is often discontinued after 24 to 48 hours. At that point, heat is sometimes more comfortable.,COMPRESSION:,Compression decreases swelling by slowing bleeding and limiting the accumulation of blood and plasma near the injured site. Without compression, fluid from adjacent normal tissue seeps into the injured area. To apply compression safely to an injury:,* Use an elasticized bandage (Ace bandage) for compression, if possible. If you do not have one available, any kind of cloth will suffice for a short time.,* Wrap the injured part firmly, wrapping over the ice. Begin wrapping below the injury site and extend above the injury site.,* Be careful not to compress the area so tightly that the blood supply is impaired. Signs of deprivation of the blood supply include pain, numbness, cramping, and blue or dusky nails. Remove the compression bandage immediately if any of theses symptoms appears. Leave the bandage off until all signs of impaired circulation disappear. Then rewrap the area--less tightly this time.,ELEVATION:,Elevating the injured part above the level of the heart is another way to decrease swelling and pain at the injury site. Elevate the iced, compressed area in whatever way is most convenient. Prop an injured leg on a solid object or pillows. Elevate an injured arm by lying down and placing pillows under the arm or on the chest with the arm folded across. orthopedic, rest, ice, compression, and elevation, foot, ankle, knee, leg, splints, hand, wrist, elbow, arm, ace bandage, compression and elevation, rice therapy, compression bandage, ice packs, rice, elevation, swelling, bandage, therapy Orthopedic Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain. Radiologic Exam - Spine EXAM: , Cervical, lumbosacral, thoracic spine flexion and extension.,HISTORY: , Back and neck pain.,CERVICAL SPINE,FINDINGS: ,AP, lateral with flexion and extension, and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable. orthopedic, radiologic exam, ap, back, cervical, oblique views, alignment, disc space, extension, fixation, flexion, foramina, intervertebral, lateral views, lumbosacral, neck, neck pain, oblique, odontoid view, pain, physiologic, projections, spine, subluxation, thoracic, flexion and extension, thoracic spine, vertebral Orthopedic Closed reduction and pinning of the right ulna with placement of a long-arm cast. Pinning - Ulna PREOPERATIVE DIAGNOSIS:, Right both bone forearm refracture.,POSTOPERATIVE DIAGNOSIS: , Right both bone forearm refracture.,PROCEDURE:, Closed reduction and pinning of the right ulna with placement of a long-arm cast.,ANESTHESIA: , Surgery performed under general anesthesia. Local anesthetic was 10 mL of 0.25% Marcaine plain.,COMPLICATIONS: , No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HARDWARE: ,Hardware was 0.79 K-wire.,HISTORY AND PHYSICAL: , The patient is a 5-year-old male who sustained refracture of his right forearm on 12/05/2007. The patient was seen in the emergency room. The patient had a complete fracture of both bones with shortening bayonet apposition. Treatment options were offered to the family including casting versus closed reduction and pinning. The parents opted for the latter. Risks and benefits of surgery were discussed. Risks of surgery included risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, and need for later hardware removal, cast tightness. All questions were answered, and the parents agreed to the above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was then administered. The patient received Ancef preoperatively. The right upper extremity was then prepped and draped in standard surgical fashion. A small incision was made at the tip of the olecranon. Initially, a 1.11 guidewire was placed, but this was noted to be too wide for this canal. This was changed for a 0.79 K-wire. This was driven up to the fracture site. The fracture was manually reduced and then the K-wire passed through the distal segment. This demonstrated adequate fixation and reduction of both bones. The pin was then cut short. The fracture site and pin site was infiltrated with 0.25% Marcaine. The incision was closed using 4-0 Monocryl. The wounds were cleaned and dried. Dressed with Xeroform, 4 x 4. The patient was then placed in a well-moulded long-arm cast. He tolerated the procedure well. He was subsequently taken to Recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will be maintain current pin, and long-arm cast for 4 weeks at which time he will return for cast removal. X-rays of the right forearm will be taken. The patient may need additional mobilization time. Once the fracture has healed, we will take the pin out, usually at the earliest 3 to 4 months. Intraoperative findings were relayed to the parents. All questions were answered. orthopedic, closed reduction, pinning, forearm refracture, fracture site, arm cast, Orthopedic Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose. Records Review - Orthopedic 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 Orthopedic Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine. Radiofrequency Ablation PROCEDURE: , Bilateral L5, S1, S2, and S3 radiofrequency ablation.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications. I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing. The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE: , Oxygen saturation and vital signs were monitored continuously throughout the procedure. The patient remained awake throughout the procedure in order to interact and give feedback. The x-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in a prone position on the treatment table with a pillow under the chest and head rotated. The skin over and surrounding the treatment area was cleaned with Betadine. The area was covered with sterile drapes, leaving a small window opening for needle placement. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 20 gauge 10-mm bent Teflon coated needle was gently guided into the groove between the SAP and the sacrum for the dorsal ramus of L5 and the lateral border of the posterior sacral foramen, for the lateral branches of S1, S2, and S3. Also, fluoroscopic views were used to ensure proper needle placement.,The following technique was used to confirm correct placement. Motor stimulation was applied at 2 Hz with 1 millisecond duration. No extremity movement was noted at less than 2 volts. Following this, the needle trocar was removed and a syringe containing 1% lidocaine was attached. At each level, after syringe aspiration with no blood return, 0.5 mL of 1% lidocaine was injected to anesthetize the lateral branch and the surrounding tissue. After completion, a lesion was created at that level with a temperature of 80 degrees for 90 seconds.,All injected medications were preservative free. Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS: ,None.,COMPLICATIONS: , None.,DISCUSSION: , Post-procedure vital signs and oximetry were stable. The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day. The patient was told to resume all medications. The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made at PM&R Spine Clinic in approximately one to two weeks. orthopedic, sacroiliac joint pain, sacroiliac, teflon coated needle, fluoroscopy, needle placement, radiofrequency ablation, ablation, tissue, lidocaine, needle, Orthopedic External fixation of left pilon fracture and closed reduction of left great toe, T1 fracture. 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. Pilon Fracture External Fixation 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. orthopedic, phalanx fracture, schantz pins, toe fracture, tibia fracture, pilon fracture, external fixation, proximal phalanx, fracture, toe, pilon, phalanx, reduction, tibia, proximal, fixation, Orthopedic Revision and in situ pinning of the right hip. Pinning - Hip PREOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,POSTOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,PROCEDURE: , Revision and in situ pinning of the right hip.,ANESTHESIA: , Surgery performed under general anesthesia.,COMPLICATIONS: ,There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,LOCAL: ,10 mL of 0.50% Marcaine local anesthetic.,HISTORY AND PHYSICAL: , The patient is a 13-year-old girl who presented in November with an acute on chronic right slipped capital femoral epiphysis. She underwent in situ pinning. The patient on followup; however, noted to have intraarticular protrusion of her screw. This was not noted intraoperatively on previous fluoroscopic views. Given this finding, I explained to the father and especially the mother that this can cause further joint damage and that the screw would need to be exchanged for a shorter one. Risks and benefits of surgery were discussed. Risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, failure to remove the screw, possible continued joint stiffness or damage. All questions were answered and parents agreed to above plan.,PROCEDURE IN DETAIL: , 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 small bump was placed underneath her right buttock. The right upper thigh was then prepped and draped in standard surgical fashion. The upper aspect of the incision was reincised. The dissection was carried down to the crew, which was easily found. A guidewire was placed inside the screw with subsequent removal of the previous screw. The previous screw measured 65 mm. A 60 mm screw was then placed under direct visualization with fluoroscopy. The hip was taken through full range of motion to check on the length of the screw, which demonstrated no intraarticular protrusion. The guidewire was removed. The wound was then irrigated and closed using 2-0 Vicryl in the fascial layer as well as the subcutaneous fat. The skin was closed with 4-0 Monocryl. The wound was cleaned and dried, dressed with Steri-Strips, Xeroform, 4 x 4s, and tape. The area was infiltrated with total 10 mL of 0.5% Marcaine local anesthetic.,POSTOPERATIVE PLAN: , The patient will be discharged on the day of surgery. She should continue toe touch weightbearing on her leg. The wound may be wet in approximately 5 days. The patient should follow up in clinic in about 10 days. The patient is given Vicodin for pain. Intraoperative findings were relayed to the mother. orthopedic, guidewire, capital femoral epiphysis, intraarticular protrusion, femoral epiphysis, pinning, screw, Orthopedic Amputation distal phalanx and partial proximal phalanx, right hallux. Osteomyelitis, right hallux. Phalanx Amputation PREOPERATIVE DIAGNOSIS:, Osteomyelitis, right hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, right hallux.,PROCEDURE PERFORMED:, Amputation distal phalanx and partial proximal phalanx, right hallux.,ANESTHESIA:, TIVA/local.,HISTORY:, This 44-year-old male patient was admitted to ABCD General Hospital on 09/02/2003 with a diagnosis of osteomyelitis of the right hallux and cellulitis of the right lower extremity. The patient has a history of diabetes and has had a chronic ulceration to the right hallux and has been on outpatient antibiotics, which he failed. The patient after a multiple conservative treatments such as wound care antibiotics, the patient was given the option of amputation as a treatment for the chronic resistant osteomyelitis. The patient desires to attempt a surgical correction. The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X. The consent was available on the chart for review.,PROCEDURE IN DETAIL: , After patient was taken to the operating room via cart and placed on the operating table in the supine position, a safety strap was placed across his waist. Adequate IV sedation was administered by the Department of Anesthesia and a total of 3.5 cc of 1:1 mixture 1% lidocaine and 0.5% Marcaine plain were injected into the right hallux as a digital block. The foot was prepped and draped in the usual aseptic fashion lowering the operative field.,Attention was directed to the hallux where there was a full-thickness ulceration to the distal tip of the hallux measuring 0.5 cm x 0.5 cm. There was a ________ tract, which probed through the distal phalanx and along the sides of the proximal phalanx laterally. The toe was 2.5 times to the normal size. There were superficial ulcerations in the medial arch of both feet secondary to history of a burn, which were not infected. The patient had dorsalis pedis and posterior tibial pulses that were found to be +2/4 bilaterally preoperatively. X-ray revealed complete distraction of the distal phalanx and questionable distraction of the lateral aspect of the proximal phalanx. A #10 blade was used to make an incision down the bone in a transverse fashion just proximal to the head of the proximal phalanx. The incision was carried mediolaterally and plantarly encompassing the toe leaving a large amount of plantar skin intact. Next, the distal phalanx was disarticulated at the interphalangeal joint and removed. The distal toe was amputated and sent to laboratory for bone culture and sensitivity as well as tissue pathology. Next, the head of the proximal phalanx was inspected and found to be soft on the distal lateral portion as suspected. Therefore, a sagittal saw was used to resect approximately 0.75 cm of the distal aspect of head of the proximal phalanx. This bone was also sent off for culture and was labeled proximal margin. Next, the flexor hallucis longus tendon was identified and retracted as far as possible distally and transected. The flexor tendon distally was gray discolored and was not viable. A hemostat was used to inspect the flexor sheath to ensure no infection tracking up the sheath proximally. None was found. No purulent drainage or abscess was found. The proximal margin of the surgical site tissue was viable and healthy. There was no malodor. Anaerobic and aerobic cultures were taken and passed this as a specimen to microbiology. Next, copious amounts of gentamicin and impregnated saline were instilled into the wound.,A #3-0 Vicryl was used to reapproximate the deep subcutaneous layer to release skin tension. The plantar flap was viable and was debulked with Metzenbaum scissors. The flap was folded dorsally and reapproximated carefully with #3-0 nylon with a combination of simple interrupted and vertical mattress sutures. Iris scissors were used to modify and remodel the plantar flap. An excellent cosmetic result was achieved. No tourniquet was used in this case. The patient tolerated the above anesthesia and surgery without apparent complications. A standard postoperative dressing was applied consisting of saline-soaked Owen silk, 4x4s, Kerlix, and Coban. The patient was transported via cart to Postanesthesia Care Unit with vital signs able and vascular status intact to right foot. He will be readmitted to Dr. Katzman where we will continue to monitor his blood pressure and regulate his medications. Plan is to continue the antibiotics until further IV recommendations.,He will be nonweightbearing to the right foot and use crutches. He will elevate his right foot and rest the foot, keep it clean and dry. He is to follow up with Dr. X on Monday or Tuesday of next week. orthopedic, osteomyelitis, phalanx, phalanx amputation, proximal margin, plantar flap, distal phalanx, proximal phalanx, proximal, hallux, amputation, foot, plantarly, distal Orthopedic Open repair of right pectoralis major tendon. Right pectoralis major tendon rupture. On MRI evaluation, a complete rupture of a portion of the pectoralis major tendon was noted. Pectoralis Tendon Repair PREOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,POSTOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,OPERATION PERFORMED: , Open repair of right pectoralis major tendon.,ANESTHESIA:, General with an interscalene block.,COMPLICATIONS:, None.,Needle and sponge counts were done and correct.,INDICATION FOR OPERATION: ,The patient is a 26-year-old right hand dominant male who works in sales, who was performing heavy bench press exercises when he felt a tearing burning pain severe in his right shoulder. The patient presented with mild bruising over the proximal arm of the right side with x-ray showing no fracture. Over concerns for pectoralis tendon tear, he was sent for MRI evaluation where a complete rupture of a portion of the pectoralis major tendon was noted. Due to the patient's young age and active lifestyle surgical treatment was recommended in order to obtain best result. The risks and benefits of the procedure were discussed in detail with the patient including, but not limited to scarring, infection, damage to blood vessels and nerves, re-rupture, need further surgery, loss of range of motion, inability to return to heavy activity such as weight lifting, complex usual pain syndrome, and deep vein thrombosis as well as anesthetic risks. Understanding all risks and benefits, the patient desires to proceed with surgery as planned.,FINDINGS:,1. Following deltopectoral approach to the right shoulder, the pectoralis major tendon was encountered. The clavicular head was noted to be intact. There was noted to be complete rupture of the sternal head of the pectoralis major tendon with an oblique-type tear having some remaining cuff on the humerus and some tendon attached to the retracted portion.,2. Following freeing of adhesions using tracks and sutures, the pectoralis major tendon was able to reapproximated to its insertion site on the humerus just lateral to the biceps.,3. A soft tissue repair was performed with #5 FiberWire suture and a single suture anchor of 5 x 5 bioabsorbable anchor was placed in order to decrease tension at the repair site. Following repair of soft tissue and using the bone anchor, there was noted to be good apposition of the tendon with edges and a solid repair.,OPERATIVE REPORT IN DETAIL: , The patient was identified in the preop holding area. His right shoulder was identified, marked his appropriate surgical site after verification with the patient. He was then taken to the operating room where he was transferred to the operative table in supine position and placed under general anesthesia by anesthesiology team. He then received prophylactic antibiotics. A time-out was then undertaken verifying the correct patient, extremity, surgery performed, administration of antibiotics, and the availability of equipment. At this point, the patient was placed to a modified beech chair position with care taken to ensure all appropriate pressure points were padded and there was no pressure over the eyes. The right upper extremity was then prepped and draped in the usual sterile fashion. Preoperative markings were still visible at this point. A deltopectoral incision was made utilizing the inferior portion. Dissection was carried down. The deltoid was retracted laterally. The clavicular head of the pectoralis major was noted to be intact with the absence of the sternal insertion. There was a small cuff of tissue left on the proximal humerus associated with the clavicular head. Gentle probing medially revealed the end of the sternal retracted portion, traction sutures of #5 Ethibond were used in this to allow for retraction and freeing from light adhesion. This allowed reapproximation of the retracted tendon to the tendon stump. At this point, a repair using #5 FiberWire was then performed of the pectoralis major tendon back to stump on the proximal humerus noting good apposition of the tendon edges and no gapping of the repair site. At this point, a single metal suture anchor was attempted to be implanted just lateral to the insertion of the pectoralis in order to remove tension off the repair site; however, the inserted device attached to the metal anchor broke during insertion due to significant hardness of the bone. For this reason, the starting hole was tapped and a 5x5 bioabsorbable anchor was placed, doubly loaded. The sutures were then weaved through the lateral aspect of the torn tendon and a modified Krackow type performed and sutured thereby relieving tension off the soft tissue repair. At this point, there was noted to be excellent apposition of the soft tissue ends and a solid repair to gentle manipulation. Aggressive external rotation was not performed. The wound was then copiously irrigated. The cephalic vein was not injured during the case. The skin was then closed using a 2-0 Vicryl followed by a 3-0 subcuticular Prolene suture with Steri-Strips. Sterile dressing was then placed. Anesthesia was then performed, interscalene block. The patient was then awakened from anesthesia and transported to postanesthesia care in stable condition in a shoulder immobilizer with the arm adducted and internally rotated.,Plan for this patient, the patient will remain in the shoulder immobilizer until followup visit in approximately 10 days. We will then start a gentle Codman type exercises and having limited motion until the 4-6 week point based on the patient's progression. orthopedic, tendon rupture, interscalene block, pectoralis major tendon rupture, pectoralis major tendon, repair, pectoralis, interscalene, tendon, rupture, sutures, Orthopedic Patient was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms. The patient would benefit from skilled physical therapy intervention. Physical Therapy - Back Pain DIAGNOSIS: , Low back pain and degenerative lumbar disk.,HISTORY:, The patient is a 59-year-old female, who was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms. The patient states that this occurred in October 2008 as well as November 2008. The patient has a history of low back pain, secondary to a fall that originally occurred in 2006. The patient states that she slipped on a newly waxed floor and fell on her tailbone and low back region. The patient then had her second fall in March 2006. The patient states that she was qualifying on the range with a handgun and lost her footing and states that she fell more due to weakness in her lower extremities rather than loss of balance.,PAST MEDICAL HISTORY:, Past medical history is significant for allergies and thyroid problems.,PAST SURGICAL HISTORY: , The patient has a past surgical history of appendectomy and hysterectomy.,MEDICATIONS:,1. TriCor.,2. Vytorin.,3. Estradiol.,4. Levothyroxine.,5. The patient is also taking ibuprofen 800 mg occasionally as needed for pain management. The patient states she rarely takes this and does not like to take pain medication if at all possible. The patient states that she has had uncomplicated pregnancies in the past.,SOCIAL HISTORY:, The patient states she lives in a single-level home with her husband, who is in good health and is able to assist with any tasks or activities the patient is having difficulty with. The patient rates her general health as excellent and denies any smoking and reports very occasional alcohol consumption. The patient does state that she has completed exercises on a daily basis of one to one and a half hours a day. However, has not been able to complete these exercise routine since approximately June 2008, secondary to back pain. The patient is working full-time as a project manager, and is required to do extensive walking at various periods during a workday.,MEDICAL IMAGING:, The patient states that she has had an MRI recently performed; however, the results are not available at the time of the evaluation. The patient states she is able to bring the report in upon next visit.,SUBJECTIVE: ,The patient rates her pain at 7/10 on a Pain Analog Scale, 0 to 10, 10 being worse. The patient describes her pain as a deep aching, primarily on the right lower back and gluteal region. Aggravating factors include stairs and prolonged driving, as well as general limitations with home tasks and projects. The patient states she is a very active individual and is noticing extreme limitations with ability to complete home tasks and projects she used to be able to complete.,NEUROLOGICAL SYMPTOMS:, The patient reports having occasional shooting pains into the lower extremities. However, these are occurring less frequently and is now occurring more frequently in the right versus the left lower extremity when they do occur.,FUNCTIONAL ACTIVITIES AND HOBBIES: , Include exercising and general activities.,PATIENT'S GOAL: , The patient would like to improve her overall body movements and return to daily exercise routine as able and well maintaining safety.,OBJECTIVE: , Upon observation, the patient ambulates independently without the use of assistive device. However, does present with mild limp and favoring the left lower extremity after extensive standing and walking activity. The patient does have mild difficulty transferring from the seated position to standing. However, once is upright, the patient denies any increased pain or symptoms.,ACTIVE RANGE OF MOTION OF LUMBAR SPINE: ,Forward flexion is 26 cm, fingertip to floor, lateral side bend, fingertip to floor is 52.5 cm bilaterally.,STRENGTH: , Strength is grossly 4/5. The patient denies any significant tenderness to palpation. However, does have mild increase in tenderness on the right versus left. A six-minute walk test revealed painful symptoms and achiness occurring after approximately 400 feet of walking. The patient was able to continue; however, stopped after 700 feet. There were two minutes remaining in the six-minute walk test. The patient does have tight hamstrings as well as a negative slump test.,ASSESSMENT: , The patient would benefit from skilled physical therapy intervention in order to address the following problem list.,PROBLEM LIST:,1. Increased pain.,2. Decreased ability to complete tasks and hobbies.,3 Orthopedic " Specimen labeled ""sesamoid bone left foot""." Pathology - Sesamoid Bone "GROSS DESCRIPTION: , Specimen labeled ""sesamoid bone left foot"" is received in formalin and consists of three irregular fragments of grey-brown, hard, bony tissue admixed with multiple fragments of brown-tan, rubbery, fibrocollagenous, soft tissue altogether measuring 3.1 x 1.5 x 0.9 cm. The specimen is entirely submitted, after decalcification.,DIAGNOSIS:, Acute Osteomyelitis, with foci of marrow fibrosis.,Focal acute and chronic inflammation of fascia and soft tissue. Arteriosclerosis, severely occlusive." orthopedic, marrow fibrosis, osteomyelitis, arteriosclerosis, inflammation of fascia, specimen, fragmentsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. Orthopedic Synovitis - anterior cruciate ligament tear of the left knee. The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient fell in a grocery store. He reports slipping on a grape that was on the floor. Physical Therapy - Synovitis DIAGNOSIS:, Synovitis/anterior cruciate ligament tear of the left knee.,HISTORY: , The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient states that on 10/02/08, the patient fell in a grocery store. He reports slipping on a grape that was on the floor. The patient states he went to the emergency room and then followed up with his primary care physician. The patient was then ultimately referred to Physical Therapy. After receiving a knee brace, history and information was received through a translator as the patient is Spanish speaking only.,PAST MEDICAL HISTORY: , Past medical history is unremarkable.,MEDICAL IMAGING: , Medical imaging is significant for x-rays and MRIs. The report was available at the time of the evaluation. The patient reports abnormal posterior horn of medial meniscus consistent with knee degenerative change and possibly tears.,MEDICATIONS:,1. Tramadol.,2. Diclofenac.,3. Advil.,4. Tylenol.,SUBJECTIVE: , The patient rates his pain at 6/10 on the Pain Analog Scale, primarily with ambulation. The patient does deny pain at night. The patient does present with his knee brace on the exterior of his __________ leg and appears to be on backboard.,FUNCTIONAL ACTIVITIES AND HOBBIES: ,Functional activities and hobbies that are currently limited include any work as the patient is currently unemployed and is looking for a job; however, his primary skills are of a laborer and a street broker for new homes.,OBJECTIVE: ,Upon observation, the patient is ambulating with a significant antalgic gait pattern. However, he is not using any assistive device. The knee brace was corrected and the patient and his wife demonstrated understanding and knowledge of how to place the knee brace on correctly.,ACTIVE RANGE OF MOTION: , Active range of motion of the left knee is 0 to 105 degrees with pain during range of motion. Right knee active range of motion is 0 to 126 degrees.,STRENGTH: ,Strength is 3/5 for left knee, 4+/5 for right knee. The patient denies any pain upon light and deep palpation at the knee joints. There is no evidence of temperature change, increased swelling or any discoloration at the left knee joint. The patient does not appear to have instability at this time with formal tests at the left knee joint.,SPECIAL TESTS: ,The patient performed a six-minute walk test. He was able to complete 600 feet; however, had to stop this test at approximately five minutes, secondary to significant increase in pain.,ASSESSMENT:, The patient would benefit from skilled physical therapy intervention in order to address the following problem list:,1. Increased pain.,2. Decreased range of motion.,3. Decreased strength.,4. Decreased ability to perform functional activities and work tasks.,5. Decreased ambulation tolerance.,SHORT-TERM GOALS TO BE COMPLETED IN THREE WEEKS:,1. Patient will demonstrate independence with the home exercise program.,2. Patient will report maximum pain of 2/10 on a Pain Analog Scale within a 24-hour period.,3. The patient will demonstrate left knee active range of motion, 0 to 120 degrees, without significant increase in pain during motion.,4. The patient will demonstrate 4/5 strength for the left knee.,5. The patient will complete 800 feet in a six-minute walk test without significant increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN SIX WEEKS:,1. The patient will demonstrate bilateral knee active range of motion, 0 to 130 degrees.,2. The patient will demonstrate 5/5 lower extremity strength bilaterally without significant increase in pain.,3. Patient will complete 1000 feet in a six-minute walk test without increase in pain and tolerate full completion of the six minutes.,4. The patient will improve confidence with ability to perform work activity, when the situation improves and resolves.,PROGNOSIS: ,Prognosis is good for above-stated goals, with compliance to a home exercise program and treatment.,SESSION PLAN: , The patient to be seen two to three times a week for six weeks for the following:,1. Therapeutic exercise with home exercise program. Orthopedic The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis. The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area. The patient was transferred from the hospital to a nursing home and lived there for 1 year. The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home. Physical Therapy - Osteoarthritis DIAGNOSIS: , Left knee osteoarthritis.,HISTORY: , The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis. The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area. The patient was transferred from the hospital to a nursing home and lived there for 1 year. Prior to this incident, the patient was ambulating independently with a pickup walker throughout her home. Since that time, the patient has only been performing transverse and has been unable to ambulate. The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.,PAST MEDICAL HISTORY: , High blood pressure, obesity, right patellar fracture with pin in 1990, and history of blood clots.,MEDICATIONS: ,Naproxen, Plavix, and stool softener.,MEDICAL DIAGNOSTICS: , The patient states that she had an x-ray of the knee in 2007 and was diagnosed with osteoarthritis.,SUBJECTIVE:, The patient reports that when seated and at rest, her knee pain is 0/10. The patient states that with active motion of the left knee, the pain in the anterior portion increases to 5/10.,PATIENT'S GOAL: , To transfer better and walk 5 feet from her bed to the couch.,INSPECTION: , The right knee has a large 8-inch long and very wide tight scar with adhesions to the underlying connective tissue due to her patellar fracture and surgery following an MVA in 1990, bilateral knees are very large due to obesity. There are no scars, bruising or increased temperature noted in the left knee.,RANGE OF MOTION: , Active and passive range of motion of the right knee is 0 to 90 degrees and the left knee, 0 to 85 degrees. Pain is elicited during active range of motion of the left knee.,PALPATION: , Palpation to the left knee elicits pain around the patellar tendon and to each side of this area.,FUNCTIONAL MOBILITY: ,The patient reports that she transfers with standby to contact-guard assist in the home from her bed to her wheelchair and return. The patient is able to stand modified independent from wheelchair level and tolerates at least 15 seconds of standing prior to needing to sit down due to the left knee pain.,ASSESSMENT: ,The patient is a 58-year-old female with left knee osteoarthritis. Examination indicates deficits in pain, muscle endurance, and functional mobility. The patient would benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN: ,The patient will be seen two times per week for an initial 4 weeks with re-assessment at that time for an additional 4 weeks if needed.,INTERVENTIONS INCLUDE:,1. Modalities including electrical stimulation, ultrasound, heat, and ice.,2. Therapeutic exercise.,3. Functional mobility training.,4. Gait training.,LONG-TERM GOALS TO BE ACHIEVED IN 4 WEEKS:,1. The patient is to have increased endurance in bilateral lower extremities as demonstrated by being able to perform 20 repetitions of all lower extremity exercises in seated and supine positions with minimum 2-pound weight.,2. The patient is to perform standby assist transfer using a pickup walker.,3. The patient is to demonstrate 4 steps of ambulation using forward and backward using a pickup walker or front-wheeled walker.,4. The patient is to report maximum 3/10 pain with weightbearing of 2 minutes in the left knee.,LONG-TERM GOALS TO BE ACHIEVED IN 8 WEEKS:,1. The patient is to be independent with the home exercise program.,2. The patient is to tolerate 20 reps of standing exercises with pain maximum of 3/10.,3. The patient is to ambulate 20 feet with the most appropriate assistive device.,PROGNOSIS TO THE ABOVE-STATED GOALS:, Fair to good.,The above treatment plan has been discussed with the patient. She is in agreement. Orthopedic A 7-year-old white male started to complain of pain in his fingers, elbows, and neck. This patient may have had reactive arthritis. Pediatric Rheumatology Consult 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. orthopedic, rheumatology, pediatric, reactive arthritis, psoriatic arthritis, psoriasis, joints, swelling, arthritis, Orthopedic The patient is a 26-year-old female, referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back. Physical Therapy - Low Back Pain HISTORY OF PRESENT ILLNESS: , The patient is a 26-year-old female, referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back. The patient stated initial injury occurred eight years ago, when she fell at a ABC Store. The patient stated she received physical therapy, one to two visits and received modality treatment only, specifically electrical stimulation and heat pack per patient recollection. The patient stated that she has had continuous low-back pain at varying degrees for the past eight years since that fall. The patient gave birth in August 2008 and since the childbirth, has experienced low back pain. The patient also states that she fell four to five days ago, while mopping her floor. The patient stated that she landed on her tailbone and symptoms have increased since that fall. The patient stated that her initial physician examination with Dr. X was on 01/10/09, and has a followup appointment on 02/10/09.,PAST MEDICAL HISTORY: , The patient denies high blood pressure, diabetes, heart disease, lung disease, thyroid, kidney, or bladder dysfunctions. The patient stated that she quit smoking prior to her past childbirth and is currently not pregnant. The patient has had a C-section and also an appendectomy. The patient was involved in a motor vehicle accident four to five years ago and at that time, the patient did not require any physical therapy nor did she report any complaints of increased back pain following that accident.,MEDICATIONS: , Patient currently states she is taking:,1. Vicodin 500 mg two times a day.,2. Risperdal.,3. Zoloft.,4. Stool softeners.,5. Prenatal pills.,DIAGNOSTIC IMAGERY: ,The patient states she has not had an MRI performed on her lumbar spine. The patient also states that Dr. X took x-rays two weeks ago, and no fractures were found at that time. Per physician note, dated 12/10/08, Dr. X dictated that the x-ray showed an anterior grade 1 spondylolisthesis of L5 over S1, and requested Physical Therapy to evaluate and treat.,SUBJECTIVE: ,The patient states that pain is constant in nature with a baseline of 6-7/10 with pain increasing to 10/10 during the night or in cold weather. The patient states that pain is dramatically less, when the weather is warmer. The patient also states that pain worsens as the day progresses, in that she also hard time getting out of bed in the morning. The patient states that she does not sleep at night well and sleeps less than one hour at a time.,Aggravating factors include, sitting for periods greater than 20 minutes or lying supine on her back. Easing factors include side lying position in she attempts to sleep.,OBJECTIVE: , AGE: 26 years old. HEIGHT: 5 feet 2 inches. WEIGHT: The patient is an obese 26-year-old female.,ACTIVE RANGE OF MOTION: , Lumbar spine, flexion, lateral flexion and rotation all within functional limits without complaints of pain or soreness while performing them during evaluation.,PALPATION: ,The patient complained of bilateral SI joint point tenderness. The patient also complained of left greater trochanter hip point tenderness. The patient also complained of bilateral paraspinal tenderness on cervical spine to lumbar spine.,STRENGTH: ,RIGHT LOWER EXTREMITY:,Knee extension 5/5, hip flexion 5/5, knee flexion 4/5, internal and external hip rotation was 4/5. With manual muscle testing of knee flexion, hip, internal and external rotation, the patient reports an increase in right SI joint pain to 8/10.,LEFT LOWER EXTREMITY:,Hip flexion 5/5, knee extension 5/5, knee flexion 4/5, hip internal and external rotation 4/5, with slight increase in pain level with manual muscle testing and resistance. It must be noted that PT did not apply as much resistance during manual muscle testing, secondary to the 8/10 pain elicited during the right lower extremity.,NEUROLOGICAL: ,The patient subjectively complains of numbness with tingling in her bilateral extremities when she sits longer than 25 minutes. However, they subside when she stands. The patient did complain of this numbness and tingling during the evaluation and the patient was seated for a period of 20 minutes. Upon standing, the patient stated that the numbness and tingling subsides almost immediately. The patient stated that Dr. X told her that he believes that during her past childbirth when the epidural was being administered that there was a possibility that a sensory nerve may have been also affected during the epidural less causing the numbness and tingling in her bilateral lower extremities. The patient does not demonstrate any sensation deficits with gentle pressure to the lumbar spine and during manual muscle testing.,GAIT: ,The patient ambulated out of the examination room, while carrying her baby in a car seat.,ASSESSMENT: ,The patient is a 26-year-old overweight female, referred to Physical Therapy for low back pain. The patient presents with lower extremity weakness, which may be contributing to her lumbosacral pain, in that she has poor lumbar stabilization with dynamic ADLs, transfers, and gait activity when fatigued. At this time, the patient may benefit from skilled physical therapy to address her decreased strength and core stability in order to improve her ADL, transfer, and mobility skills.,PROGNOSIS: , The patient's prognosis for physical therapy is good for dictated goals.,SHORT-TERM GOALS TO BE ACHIEVED IN TWO WEEKS:,1. The patient will be able to sit for greater than 25 minutes without complaints of paraesthesia or pain in her bilateral lower extremities or bilateral SI joints.,2. The patient will increase bilateral hip internal and external rotation to 4/5 with SI joint pain less than or equal to 5/10.,3. The patient will report 25% improvement in her functional and ADL activities.,4. Pain will be less than 4/10 while performing __________ while at PT session.,LONG-TERM GOALS TO BE ACCOMPLISHED IN ONE MONTH:,1. The patient will be independent with home exercise program.,2. Bilateral hamstring, bilateral hip internal and external rotation strength to be 4+/5 with SI joint pain less than or equal to 2/10, while performing manual muscle test.,3. The patient will report 60% improvement or greater in functional transfers in general ADL activity.,4. The patient will be able to sit greater than or equal to 45 minutes without complaint of lumbosacral pain.,5. The patient will be able to sleep greater than 2 hours without pain.,TREATMENT PLAN:,1. Therapeutic exercises to increase lower extremity strength and assist with lumbar sacral stability. Orthopedic Patellar tendon and medial and lateral retinaculum repair, right knee. Patellar tendon retinaculum ruptures, right knee. Patellar Tendon & Retinaculum Repair PREOPERATIVE DIAGNOSIS: , Patellar tendon retinaculum ruptures, right knee.,POSTOPERATIVE DIAGNOSIS: , Patellar tendon retinaculum ruptures, right knee.,PROCEDURE PERFORMED: , Patellar tendon and medial and lateral retinaculum repair, right knee.,SPECIFICATIONS: ,Intraoperative procedure done at Inpatient Operative Suite, room #2 of ABCD Hospital. This was done under subarachnoid block anesthetic in supine position.,HISTORY AND GROSS FINDINGS: , The patient is a 45-year-old African-American male who suffered acute rupture of his patellar tendon diagnosed both by exam as well as x-ray the evening before surgical intervention. He did this while playing basketball.,He had a massive deficit at the inferior pole of his patella on exam. Once opened, he had complete rupture of this patellar tendon as well as a complete rupture of his medial lateral retinaculum. Minimal cartilaginous pieces were at the patellar tendon. He had grade II changes to his femoral sulcus as well as grade I-II changes to the undersurface of the patella.,OPERATIVE PROCEDURE: , The patient was laid supine on the operative table receiving a subarachnoid block anesthetic by Anesthesia Department. A thigh high tourniquet was placed. He is prepped and draped in the usual sterile manner. Limb was elevated, exsanguinated and tourniquet placed at 325 mmHg for approximately 30 to 40 minutes. Straight incision is carried down through skin and subcutaneous tissue anteriorly. Hemostasis was controlled via electrocoagulation. Patellar tendon was isolated along with the patella itself.,A 6 mm Dacron tape x2 was placed with a modified Kessler tendon stitch with a single limb both medially and laterally and a central limb with subsequent shared tape. The inferior pole was freshened up. Drill bit was utilized to make holes x3 longitudinally across the patella and the limbs strutted up through the patella with a suture passer. This was tied over the bony bridge superiorly. There was excellent reduction of the tendon to the patella. Interrupted running #1-Vicryl suture was utilized for over silk. A running #2-0 Vicryl for synovial closure medial and laterally as well as #1-Vicryl medial and lateral retinaculum. There was excellent repair. Copious irrigation was carried out. Tourniquet was dropped and hemostasis controlled via electrocoagulation. Interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed through the skin. Adaptic, 4 x 4s, ABDs, and sterile Webril were placed for compression dressing. Digits were warm and no brawny pulses present at the end of the case. The patient's leg was placed in a Don-Joy brace 0 to 20 degrees of flexion. He will leave this until seen in the office.,Expected surgical prognosis on this patient is fair. orthopedic, subarachnoid, patellar tendon retinaculum, tendon, patellar, tourniquet, knee, ruptures, retinaculum Orthopedic Ankle sprain, left ankle. The patient 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. Physical Therapy - Ankle Sprain "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:" Orthopedic Pain management sample progress note. Pain Management Progress Note 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. orthopedic, progress note, management, muscle Orthopedic Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot. Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot. Osteotomy & Bunionectomy PREOPERATIVE DIAGNOSES:,1. Metatarsus primus varus with bunion deformity, right foot.,2. Hallux abductovalgus with angulation deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1. Metatarsus primus varus with bunion deformity, right foot.,2. Hallux abductovalgus with angulation deformity, right foot.,PROCEDURES:,1. Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot.,2. Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.,ANESTHESIA:,Local infiltrate with IV sedation.,INDICATION 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 treatment. The preoperative discussion with the patient included the alternative treatment options.,The procedure was explained in detail and risk factors such as infection, swelling, scarred tissue; numbness, continued pain, recurrence, and postoperative management were explained in detail. The patient has been advised, although no guaranty for success could be given, most patients have improved function and less pain. All questions were thoroughly answered. The patient requested surgical repair since the problem has reached a point that interferes with her normal daily activities. The purpose of the surgery is to alleviate the pain and discomfort.,DETAILS OF PROCEDURE: ,The patient was brought to the operating room and placed in a supine position. No tourniquet was utilized. IV sedation was administered and during that time local anesthetic consisting of approximately 10 mL total in a 1:1 mixture of 0.25% Marcaine and 1% lidocaine with epinephrine was locally infiltrated proximal to the operative site. The lower extremity was prepped and draped in the usual sterile manner. Balanced anesthesia was obtained.,PROCEDURE #1: , Distal metaphyseal osteotomy with internal screw fixation with bunionectomy, right foot. A dorsal curvilinear incision medial to the extensor hallucis longus tendon was made, extending from the distal third of the shaft of the first metatarsal to a point midway on the shaft of the proximal phalanx. Care was taken to identify and retract the vital structures and when necessary, vessels were ligated via electrocautery. Sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and then down to the capsular and periosteal layer, which was visualized. A linear periosteal capsular incision was made in line with the skin incision. The capsular tissue and periosteal layer were underscored, free from its underlying osseous attachments, and they refracted to expose the osseous surface. Inspection revealed increased first intermetatarsal angle and hypertrophic changes to the first metatarsal head. The head of the first metatarsal was dissected free from its attachment medially and dorsally, delivered dorsally and may be into the wound.,Inspection revealed the first metatarsophalangeal joint surface appeared to be in satisfactory condition. The sesamoid was in satisfactory condition. An oscillating saw was utilized to resect the hypertrophic portion of the first metatarsal head to remove the normal and functional configuration. Care was taken to preserve the sagittal groove. The rough edges were then smoothed with a rasp.,Attention was then focused on the medial mid portion of the first metatarsal head where a K-wire access guide was positioned to define the apex and direction of displacement for the capital fragment. The access guide was noted to be in good position. A horizontally placed, through-and-through osteotomy with the apex distal and the base proximal was completed. The short plantar arm was from the access guide to proximal plantar and the long dorsal arm was from the access guide to proximal dorsal. The capital fragment was distracted off the first metatarsal, moved laterally to decrease the intermetatarsal angle to create a more anatomical and functional position of the first metatarsal head. The capital fragment was impacted upon the metatarsal.,Inspection revealed satisfactory reduction of the intermetatarsal angle and good alignment of the capital fragment. It was then fixated with 1 screw. A guide pin was directed from the dorsal aspect of the capital fragment to the plantar aspect of the shaft and first metatarsal in a distal dorsal to proximal plantar direction. The length was measured, __________ mm cannulated cortical screw was placed over the guide pin and secured in position. Compression and fixation were noted to be satisfactory. Inspection revealed good fixation and alignment at the operative site. Attention was then directed to the medial portion of the distal third of the shaft of the first metatarsal where an oscillating saw was used to resect the small portion of the bone that was created by shifting the capital fragment laterally. All rough edges were rasped smooth. Examination revealed there was still lateral deviation of the hallux. A second procedure, the reposition osteotomy of the proximal phalanx with internal screw fixation to correct angulation deformity was indicated., ,PROCEDURE #2:, Reposition osteotomy with internal screw fixation to correct angulation deformity, proximal phalanx, right hallux. The original skin incision was extended from the point just distal to the interphalangeal joint. All vital structures were identified and retracted. Sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and down to the periosteal layer, which was underscored, free from its underlying osseous attachments and reflected to expose the osseous surface. The focus of the deformity was noted to be more distal on the hallux. Utilizing an oscillating saw, a more distal, wedge-shaped transverse oblique osteotomy was made with the apex being proximal and lateral and the base medial distal was affected. The proximal phalanx was then placed in appropriate alignment and stabilized with a guide pin, which was then measured, __________ 14 mm cannulated cortical screw was placed over the guide pin and secured into position.,Inspection revealed good fixation and alignment at the osteotomy site. The alignment and contour of the first way was now satisfactorily improved. The entire surgical wound was flushed with copious amounts of sterile normal saline irrigation. The periosteal and capsular layer was closed with running sutures of #3-0 Vicryl. The subcutaneous tissue was closed with #4-0 Vicryl and the skin edges coapted well with #4-0 nylon with running simples, reinforced with Steri-Strips.,Approximately 6 mL total in a 1:1 mixture of 0.25% Marcaine and 1% lidocaine plain was locally infiltrated proximal to the operative site for postoperative anesthesia. A dressing consisting of Adaptic and 4 x 4 was applied to the wound making sure the hallux was carefully splinted, followed by confirming 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 as evident by the normal capillary fill time.,A walker boot was dispensed and applied. The patient should wear it when walking or standing., ,The next office visit will be in 4 days. The patient was given prescriptions for Percocet 5 mg #40 one p.o. q.4-6h. p.r.n. pain, along with written and oral home instructions. The patient was discharged home with vital signs stable in no acute distress. Orthopedic Pain management for post-laminectomy low back syndrome and radiculopathy. Pain Management Consult - 1 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. orthopedic, pain management, opioid dependence, patrick's test, behavioral evaluation, cognitive impairment, low back syndrome, motor strength, pain control, physical therapy, radiculopathy, spinal cord stimulation, activities of daily living, neurological exam, laminectomy, hearing, diabetes, muscle, syndrome, Orthopedic Plantar flex third metatarsal and talus bunion, right foot. Third metatarsal osteotomy, talus bunionectomy, and application of short-leg cast, right foot. Patient has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief. At this time she desires to attempt a surgical correction. Osteotomy & Bunionectomy - 1 PREOPERATIVE DIAGNOSES:,1. Plantar flex third metatarsal, right foot.,2. Talus bunion, right foot.,POSTOPERATIVE DIAGNOSES:,1. Plantar flex third metatarsal, right foot.,2. Talus bunion, right foot.,PROCEDURE PERFORMED:,1. Third metatarsal osteotomy, right foot.,2. Talus bunionectomy, right foot.,3. Application of short-leg cast, right foot.,ANESTHESIA: , TIVA/local.,HISTORY: ,This 31-year-old female presents to ABCD Preoperative Holding Area after keeping herself n.p.o., since mid night for surgery on her painful right third plantar flex metatarsal. In addition, she complains of a painful right talus bunion to the right foot. She has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief. At this time she desires to attempt a surgical correction. The risks versus benefits of the procedure have been explained to the patient 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. She was placed on the operating table in supine position and a safety strap was placed across her waist for retraction. Next, copious amounts of Webril were applied around the right ankle and a pneumatic ankle tourniquet was applied.,Next, after adequate IV sedation was administered by the Department Of Anesthesia, a total of 10 cc mixture of 4.5 cc of 1% lidocaine/4.5 cc of 0.5% Marcaine/1 cc of Kenalog was injected into the right foot in an infiltrative type block. Next, the foot was prepped and draped in the usual aseptic fashion. An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg. Next, the foot was lowered in the operative field and attention was directed to the dorsal third metatarsal area. There was a plantar hyperkeratotic lesion and a plantar flex palpable third metatarsal head. A previous cicatrix was noted with slight hypertrophic scarring. Using a #10 blade, a lazy S-type incision was created over the dorsal aspect of the third metatarsal, approximately 3.5 cm in length. Two semi-elliptical converging incisions were made over the hypertrophic scar and it was removed and passed off as a specimen. Next, the #15 blade was used to deepen the incision down to the subcutaneous tissue. Any small traversing veins were ligated with electrocautery. Next, a combination of blunt and sharp dissection were used to undermine the long extensor tendon, which was tacked down with a moderate amount of fibrosis and fibrotic scar tissue. Next, the extensor tendon was retracted laterally and the deep fascia over the metatarsals was identified. A linear incision down to bone was made with a #15 blade to the capsuloperiosteal tissues. Next, the capsuloperiosteal tissues were elevated using a sharp dissection with a #15 blade, off of the third metatarsal. McGlamry elevator was carefully inserted around the head of the metatarsal and freed and all the plantar adhesions were freed. A moderate amount of plantar adhesions were encountered. The third toe was plantar flex and the third metatarsal was delivered into the wound. Next, a V-shaped osteotomy with an apex distally was created using a sagittal saw. The metatarsal head was allowed to float. The wound was flushed with copious amounts of sterile saline. #3-0 Vicryl was used to close the capsuloperiosteal tissues, which kept the metatarsal head contained. Next, #4-0 Vicryl was used to close the subcutaneous layer in a simple interrupted suture technique. Next, #4-0 nylon was used to close the skin in a simple interrupted technique.,Attention was directed to the right fifth metatarsal. There was a large palpable hypertrophic prominence, which is the area of maximal pain, which the patient complained of preoperatively. A #10 blade was used to make a 3 cm incision through the skin. Next, a #15 blade was used to deepen the incision through the subcutaneous tissue. Next, the medial and lateral aspects were undermined. The abductor tendon was identified and retracted. A capsuloperiosteal incision was made with a #15 blade in a linear fashion down to the bone. The capsuloperiosteal tissues were elevated off the bone with a Freer elevator and a #15 blade.,Next, the sagittal saw was used to resect the large hypertrophic dorsal exostosis. A reciprocating rasp was used to smooth all bony prominences. The wound was flushed with copious amount of sterile saline. #3-0 Vicryl was used to close the capsuloperiosteal tissues. #4-0 Vicryl was used to close subcutaneous layer with a simple interrupted suture. Next, #4-0 nylon was used to close the skin in a simple interrupted technique. Next, attention was directed to the plantar aspect of the third metatarsal where a bursal sac was felt to be palpated under the plantar flex third metatarsal head. A #15 blade was used to make a small linear incision under the third metatarsal head. The incision was deepened through the dermal layer and curved hemostats and Metzenbaum scissors were used to undermine the skin from the underlying bursa. The wound was flushed and two simple interrupted sutures with #4-0 nylon were applied.,Standard postoperative dressing was applied consisting of Xeroform, 4x4s, Kerlix, Kling, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.,A sterile stockinet was placed on the toes just below the knee. Copious amounts of Webril were placed on all bony prominences. 3 inch and 4 inch fiberglass cast tape was used to create a below the knee well-padded, well-moulded cast. One was able to insert two fingers to the distal and proximal aspects of the _cast. The capillary refill time to the digits was less than three seconds after cast application. The patient tolerated the above anesthesia and procedures 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 was given standard postoperative instructions to rest, ice and elevate her right foot. She was counseled on smoking cessation. She was given Vicoprofen #30 1 p.o. q.4-6h p.r.n., pain. She was given Keflex #30 1 p.o. t.i.d. She is to follow up with Dr. X on Monday. She is to be full weightbearing with a cast boot. She was given emergency contact numbers to call us if problem arises. orthopedic, plantar flex, talus bunion, talus bunionectomy, metatarsal osteotomy, osteotomy, short-leg cast, hypertrophic scarring, subcutaneous tissue, sharp dissection, linear incision, foot talus, pneumatic ankle, capsuloperiosteal tissues, plantar, foot, metatarsal, capsuloperiosteal, bunionectomy Orthopedic Orthopedic progress note for follow up of osteoarthritis, knees. Osteoarthritis - Progress Note CHIEF COMPLAINT: , Right knee. ,HISTORY OF THE PRESENT ILLNESS: , The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great. Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left.,Pain: Localized to the bilateral knees right worse than left.,Quality: There is no swelling, no redness, or warmth. The pain is described as aching occasionally. There is no burning. ,Duration: Months.,Associated symptoms: Includes stiffness and weakness. There is no sleep loss and no instability. ,Hip Pain: None. ,Back pain: None. ,Radicular type pain: None. ,Modifying factors: Includes weight bearing pain and pain with ambulation. There is no sitting, and no night pain. There is no pain with weather change.,VISCOSUPPLEMENTATION IN PAST:, No Synvisc.,VAS PAIN SCORE: , 10 bilaterally.,WOMAC SCORE: , 8,A-1 WOMAC SCORE: , 0,See the enclosed WOMAC osteoarthritis index, which accompanies the patient's chart, for complete details of the patient's limitations to activities of daily living. ,REVIEW OF SYSTEMS:, No change.,Constitutional: Good appetite and energy. No fever. No general complaints.,HEENT: No headaches, no difficulty swallowing, no change in vision, no change in hearing.,CV - RESP: No shortness of breath at rest or with exertion. No paroxysmal nocturnal dyspnea, orthopnea, and without significant cough, hemoptysis, or sputum. No chest pain on exertion.,GI: Orthopedic OssaTron extracorporeal shockwave therapy to right lateral epicondyle. Right lateral epicondylitis. OssaTron Extracorporeal Shockwave Therapy PREOPERATIVE DIAGNOSIS:, Right lateral epicondylitis.,POSTOPERATIVE DIAGNOSIS:, Right lateral epicondylitis.,OPERATION PERFORMED:, OssaTron extracorporeal shockwave therapy to right lateral epicondyle.,ANESTHESIA:, Bier block.,DESCRIPTION OF PROCEDURE: , With the patient under adequate Bier block anesthesia, the patient was positioned for extracorporeal shockwave therapy. The OssaTron equipment was brought into the field and the nose piece for treatment was placed against the lateral epicondyle targeting the area previously determined with the patient's input of maximum pain. Then using standard extracorporeal shockwave protocol, the OssaTron treatment was applied to the lateral epicondyle of the elbow. After completion of the treatment, the tourniquet was deflated, and the patient was returned to the holding area in satisfactory condition having tolerated the procedure well. orthopedic, epicondylitis, ossatron extracorporeal shockwave therapy, bier block, epicondyle, ossatron, extracorporeal, shockwave, Orthopedic Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip. Osteosynthesis of acetabular fracture on the left, complex variety and total hip replacement. Osteosynthesis 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. orthopedic, hip replacement, osteosynthesis, intertrochanteric variety, femoral insertion, acetabular fracture, fracture, acetabular, intertrochanteric, femoral Orthopedic Patient with back and hip pain. Orthopedic Consult - 5 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: Orthopedic Patient with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints. Orthopedic Consult - 4 CHIEF COMPLAINT: , Chronic low back, left buttock and leg pain.,HISTORY OF PRESENT ILLNESS: , This is a pleasant 49-year-old gentleman post lumbar disc replacement from January 2005. Unfortunately, the surgery and interventional procedures have not been helpful in alleviating his pain. He has also tried acupuncture, TENS unit, physical therapy, chiropractic treatment and multiple neuropathic medications including Elavil, Topamax, Cymbalta, Neurontin, and Lexapro, which he discontinued either due to side effects or lack of effectiveness in decreasing his pain. Most recently, he has had piriformis injections, which did give him a brief period of relief; however, he reports that the Botox procedure that was done on March 8, 2006 has not given him any relief from his buttock pain. He states that approximately 75% of his pain is in his buttock and leg and 25% in his back. He has tried to increase in his activity with walking and does note increased spasm with greater activity in the low back. He rated his pain today as 6/10, describing it is shooting, sharp and aching. It is increased with lifting, prolonged standing or walking and squatting, decreased with ice, reclining and pain medication. It is constant but variable in degree. It continues to affect activities and sleep at night as well as mood at times. He is currently not satisfied completely with his level of pain relief.,MEDICATIONS: , Kadian 30 mg b.i.d., Zanaflex one-half to one tablet p.r.n. spasm, and Advil p.r.n.,ALLERGIES:, No known drug allergies.,REVIEW OF SYSTEMS:, Complete multisystem review was noted and signed in the chart.,SOCIAL HISTORY:, Unchanged from prior visit.,PHYSICAL EXAMINATION: , Blood pressure 123/87, pulse 89, respirations 18, and weight 220 lbs. He is a well-developed obese male in no acute distress. He is alert and oriented x3, and displays normal mood and affect with no evidence of acute anxiety or depression. He ambulates with normal gait and has normal station. He is able to heel and toe walk. He denies any sensory changes.,ASSESSMENT & PLAN: , This is a pleasant 49-year-old with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints. We discussed treatment options at length and he is willing to undergo a trial of Lyrica.,He is sensitive to medications based on his past efforts and is given a prescription for 150 mg that he will start at bedtime. We discussed the up taper schedule and he understands that he will have to be on this for some time before we can decide whether or not it is helpful to him. We also briefly touched on the possibility of a spinal cord stimulator trial if this medication is not helpful to him. He will call me if there are any issues with the new prescription and follow in four weeks for reevaluation. orthopedic, radiculitis, myofascial, acupuncture, tens unit, physical therapy, chiropractic treatment, lumbar disk replacement, lumbar disk, disk replacement Orthopedic Back pain and right leg pain. Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs Orthopedic Consult - 3 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. Orthopedic Degenerative disk disease of the right hip, low back pain with lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, facet and sacroiliac joint syndrome, and post left hip arthroplasty. Orthopedic Consult - 2 SUBJECTIVE:, The patient comes back to see me today. She is a pleasant 77-year-old Caucasian female who had seen Dr. XYZ with right leg pain. She has a history of prior laminectomy for spinal stenosis. She has seen Dr. XYZ with low back pain and lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, and clinical right L2 radiculopathy, which is symptomatic. Dr. XYZ had performed two right L2-L3 transforaminal epidural injections, last one in March 2005. She was subsequently seen and Dr. XYZ found most of her remaining symptoms are probably coming from her right hip. An x-ray of the hip showed marked degenerative changes with significant progression of disease compared to 08/04/2004 study. Dr. XYZ had performed right intraarticular hip injection on 04/07/2005. She was last seen on 04/15/2005. At that time, she had the hip injection that helped her briefly with her pain. She is not sure whether or not she wants to proceed with hip replacement. We recommend she start using a cane and had continued her on some pain medicines.,The patient comes back to see me today. She continues to complain of significant pain in her right hip, especially with weightbearing or with movement. She said she had made an appointment to see an orthopedic surgeon in Newton as it is closer and more convenient for her. She is taking Ultracet or other the generic it sounds like, up to four times daily. She states she can take this much more frequently as she still has significant pain symptoms. She is using a cane to help her ambulate.,PAST MEDICAL HISTORY:, Essentially unchanged from her visit of 04/15/2005.,PHYSICAL EXAMINATION:,General: Reveals a pleasant Caucasian female.,Vital Signs: Height is 5 feet 4 inches. Weight is 149 pounds. She is afebrile.,HEENT: Benign.,Neck: Shows functional range of movements with a negative Spurling's.,Musculoskeletal: Examination shows some mild degenerative joint disease of both knees with grade weakness of her right hip flexors and half-grade weakness of her right hip adductors and right quadriceps, as compared to the left. 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 lumbar scoliosis with surgical scar with no 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. Sensations are intact to pinprick.,FUNCTIONAL EXAMINATION:, Gait has a normal stance and swing phase with no antalgic component to it.,IMPRESSION:,1. Degenerative disk disease of the right hip, symptomatic.,2. Low back syndrome, lumbar spinal stenosis, clinically right L2 radiculopathy, stable.,3. Low back pain with lumbar scoliosis post laminectomy syndrome, stable.,4. Facet and sacroiliac joint syndrome on the right, stable.,5. Post left hip arthroplasty.,6. Chronic pain syndrome.,RECOMMENDATIONS:, The patient is symptomatic primarily on her right hip and is planning on seeing an orthopedic surgeon for possible right hip replacement. In the interim, her Ultracet is not quite taking care of her pain. I have asked her to discontinue it and we will start her on Tylenol #3, up to four times a day. I have written a prescription for this for 120 tablets and two refills. The patient will call for the refills when she needs them. I will plan further follow up in six months, sooner if needed. She voiced understanding and is in agreement with this plan. Physical exam findings, history of present illness and recommendations were performed with and in agreement with Dr. Goel's findings. orthopedic, scoliosis, lumbar, laminectomy, spinal stenosis, radiculopathy, chronic pain syndrome, low back pain, facet and sacroiliac joint, degenerative disk disease, sacroiliac joint syndrome, lumbar spinal stenosis, disk disease, sacroiliac joint, hip arthroplasty, hip injection, hip replacement, lumbar scoliosis, injections, hip, Orthopedic Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left. Pain Management Consult - 2 HPI - WORKERS COMP:, The current problem began on or about 2/10/2000. The symptoms were sudden in onset. According to the patient, the current problem is a result of a work injury involving lifting approximately 40 pounds. Pain location (lower body): left hip. The patient describes the pain as dull, aching and stabbing. The severity of the pain ranges from mild to severe. The pain is severe occasionally. It is present constantly. The pain is made worse by sitting, riding in a car, twisting and lifting. The pain is made better by rest. The patient's symptoms appear to be soft tissue (spine), myofascial (spine) and musculoskeletal (spine) in origin. Sleep alteration because of pain: positive and wakes up after getting to sleep nightly. Systemic signs/symptoms relevant or potentially relevant to the spine: none. Patient reports the following symptoms: depressed mood, loss of interest or pleasure in all or most activities, insomnia, inability to concentrate, fatigue and loss of energy.,WORK STATUS:, Orthopedic Medical management, status post left total knee arthroplasty. Orthopedic Consult REASON FOR CONSULT: , Medical management, status post left total knee arthroplasty.,PAST MEDICAL HISTORY:,1. Polyarthritis.,2. Acromegaly.,3. Hypothyroidism.,4. Borderline hypertension.,5. Obesity.,PAST SURGICAL HISTORY: , Hernia repair, resection of tumor, right thumb arthrodesis, carpal tunnel decompression, bilateral hip replacement, right total knee replacement about 2 months ago, open reduction of left elbow fracture.,REVIEW OF SYSTEMS:,CONSTITUTIONAL SYMPTOMS: No fever or recent general malaise.,ENT: Not remarkable.,RESPIRATORY: No cough or shortness of breath.,CARDIOVASCULAR: The patient denies any heart problems. No orthopnea. No palpitations. No syncopal episodes.,GASTROINTESTINAL: No nausea. No vomiting. No history of GI bleed.,GENITOURINARY: No dysuria, no hematuria.,ENDOCRINE: The patient is status post pituitary tumor resection and is on supplemental hormone.,MEDICATIONS: Depo-Testosterone 200 mg IM q.3 weekly, prednisone 1 tablet p.o. daily, octreotide IM on a monthly basis, morphine extended release 50 mg p.o. b.i.d., Synthroid 100 mcg p.o. daily, desmopressin 1 tablet p.o. every bedtime, aspirin/oxycodone on a p.r.n. basis, aspirin on p.r.n. basis.,ALLERGIES: , IBUPROFEN AND TYLENOL.,SOCIAL HISTORY: , The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION,GENERAL: Obese, 57-year-old gentleman, not in acute distress.,VITAL SIGNS: Blood pressure of 105/55, pulse is 90. He is afebrile. O2 saturation is 95% on room air.,HEAD AND NECK: Face 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 was appreciated.,ABDOMEN: Benign.,EXTREMITIES: The left knee is in closed dressing. The lower extremities are still numb from spinal anesthesia.,ASSESSMENT AND PLAN:,1. Polyarthritis, status post left total knee replacement. The patient tolerated the procedure well.,2. Acromegaly, status post pituitary resection. Continue supplemental hormones.,3. Borderline hypertension, blood pressure is under control with monitoring.,4. Deep venous thrombosis prophylaxis as per surgeon.,5. Anemia due to repeated blood loss with monitor hemoglobin and hematocrit. Orthopedic 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. Orthopedic Consult - 1 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. orthopedic, low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet, sacroiliac joint syndrome, lumbar spinal stenosis, intermittent lower extremity radiculopathy, djd of both knees, bilateral pes anserinus bursitis, chronic pain syndrome, degenerative disc disease, pes anserinus bursitis, pes anserine bursa, sacroiliac joint, joint syndrome, degenerative disc, lumbar spinal, bilateral recess, lumbar, joint, intermittent, djd, pes, spinal, spondylosis, sacroiliac, syndrome, Orthopedic A 19-year-old right-handed male injured in a motor vehicle accident. Ortho - Letter - 1 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,, orthopedic, numbness paraesthesia and tingling, paraesthesia and tingling, cervical and lumbar, motor vehicle accident, mri scan, disc protrusion, paraspinal musculature, letter, musculature, radiculopathy, nerve, trigger, vehicle, accident, cervical, lumbar, evaluation, disc, ortho, Orthopedic Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate. Closed displaced angulated fracture of the right distal radius. ORIF Wrist - Acumed Locking Plate PREOPERATIVE DIAGNOSIS: ,Closed displaced angulated fracture of the right distal radius.,POSTOPERATIVE DIAGNOSIS: , Closed displaced angulated fracture of the right distal radius.,PROCEDURE: , Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate.,ANESTHESIA: , General laryngeal mask airway.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , 40 minutes.,COMPLICATIONS: , None.,The patient was taken to the postanesthesia care unit in stable condition. The patient tolerated the procedure well.,INDICATIONS: ,The patient is a 23-year-old gentleman who was involved in a crush injury to his right wrist. He was placed into a well-molded splint after reduction was performed in the emergency department. Further x-rays showed further distal fragment dorsal angulation that progressively worsened and it was felt that surgical intervention was warranted. All risks, benefits, expectations, and complications of the surgery were explained to the patient in detail, and he signed the informed consent for ORIF of the right wrist.,PROCEDURE: , The patient was taken to the operating suite, placed in supine position on the operative table. The Department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well. The right upper extremity had a well-padded tourniquet placed on the right arm, which was insufflated and maintained for 40 minutes at 250 mmHg pressure. The right upper extremity was prepped and draped in a sterile fashion. A 5-cm incision was made over the flexor carpi radialis of the right wrist. The skin was incised down to the subcutaneous tissue, the deep tissue was retracted, blunt dissection was performed down to the pronator quadratus. Sharp dissection was performed through the pronator quadratus after which a tissue elevator was used to elevate this tissue. Next, a reduction was performed placing the distal fragment into appropriate alignment. This was checked under fluoroscopy, and was noted to be adequately reduced and in appropriate position. An Acumed Accu-lock plate was placed along the volar aspect of the distal radius. This was checked under AP and lateral views with C-arm, noted to be in appropriate alignment. A 3.5-mm cortical screw was placed through the proximal aspect of the plate, positioned it into position. Two distal locking screws were placed along the plate itself. The screws were checked under AP and lateral views noting the fracture fragment was well aligned and appropriately reduced with the 2 screws being placed into appropriate position with the appropriate length as well as not being intraarticular. Four more screws were placed along the distal aspect of the plate and 2 more proximal along the plate. All locking screws placed into position and had excellent purchase into the bone or had excellent fixation into the plate and maintained the alignment of the fracture. AP and lateral views were taken of these screw placements again. None of these screws were into the joint and all had appropriate length into the dorsal cortex. Two more 3.5 fully threaded cortical screws were placed along the proximal aspect of the plate and had excellent bicortical purchase. AP and lateral views were taken of the wrist once again showing that this was appropriate reduction of the fracture as well as appropriate placement of the screws. Bicortical purchase was appreciated and no screws were placed into the joint. The wound itself was copiously irrigated with saline and Kantrex after which the subcutaneous tissue was approximated with 2-0 Vicryl, and the skin was closed with running 4-0 nylon stitch; 10 mL of 0.5% Marcaine plain was injected into the wound site after which sterile dressing was placed as well as the volar splint. The patient was awakened from general anesthetic, transferred to the hospital gurney and taken to the postanesthesia care unit in stable condition. The patient tolerated the procedure well. orthopedic, open reduction, angulated fracture, distal radius, acumed locking plate, internal fixation, tourniquet, acumed, orif, reduction, fracture, wrist Orthopedic The patient continues to suffer from ongoing neck and lower back pain with no recent radicular complaints. Ortho Office Visit Her evaluation today reveals restriction in the range of motion of the cervical and lumbar region with tenderness and spasms of the paraspinal musculature. Motor strength was 5/5 on the MRC scale. Reflexes were 2+ and symmetrical. Palpable trigger points were noted bilaterally in the trapezius and lumbar paraspinal musculature bilaterally.,Palpable trigger points were noted on today's evaluation. She is suffering from ongoing myofascitis. Her treatment plan will consist of a series of trigger point injections, which were performed today. She tolerated the procedure well. I have asked her to ice the region intermittently for 15 minutes off and on x 3. She will be followed in four weeks' time for repeat trigger point injections if indicated., orthopedic, back pain, trigger point injections, paraspinal musculature, lumbar, paraspinal, musculature, palpable, injections, evaluation, triggerNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. Orthopedic Open reduction and internal fixation (ORIF) of comminuted C2 fracture. Posterior spinal instrumentation C1-C3, using Synthes system. Posterior cervical fusion C1-C3. Insertion of morselized allograft at C1to C3. ORIF & Cervical Fusion PREOPERATIVE DIAGNOSIS: , Fracture dislocation, C2.,POSTOPERATIVE DIAGNOSIS: ,Fracture dislocation, C2.,OPERATION PERFORMED,1. Open reduction and internal fixation (ORIF) of comminuted C2 fracture.,2. Posterior spinal instrumentation C1-C3, using Synthes system.,3. Posterior cervical fusion C1-C3.,4. Insertion of morselized allograft at C1to C3.,ANESTHESIA:, GETA.,ESTIMATED BLOOD LOSS:, 100 mL.,COMPLICATIONS: , None.,DRAINS: , Hemovac x1.,Spinal cord monitoring is stable throughout the entire case.,DISPOSITION:, Vital signs are stable, extubated and taken back to the ICU in a satisfactory and stable condition.,INDICATIONS FOR OPERATION:, The patient is a middle-aged female, who has had a significantly displaced C2 comminuted fracture. This is secondary to a motor vehicle accident and it was translated appropriately 1 cm. Risks and benefits have been conferred with the patient as well as the family, they wish to proceed. The patient was taken to the operating room for a C1-C3 posterior cervical fusion, instrumentation, open reduction and internal fixation.,OPERATION IN DETAIL: , After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #5. The patient was placed in the usual supine position and intubated and under general anesthesia without any difficulties. Spinal cord monitoring was induced. No changes were seen from the beginning to the end of the case.,Mayfield tongues were placed appropriately. This was placed in line with the pinna of the ear as well as a cm above the tip of the earlobes. The patient was subsequently rolled onto the fluoroscopic OSI table in the usual prone position with chest rolls. The patient's Mayfield tongue was fixated in the usual standard fashion. The patient was subsequently prepped and draped in the usual sterile fashion. Midline incision was extended from the base of the skull down to the C4 spinous process. Full thickness skin fascia developed. The fascia was incised at midline and the posterior elements at C1, C2, C3, as well as the inferior aspect of the occiput was exposed. Intraoperative x-ray confirmed the level to be C2.,Translaminar screws were placed at C2 bilaterally. Trajectory was completed with a hand drill and sounded in all four quadrants to make sure there was no violation of pedicles and once this was done, two 3.5 mm translaminar screws were placed bilaterally at C2. Good placement was seen both in the AP and lateral planes using fluoroscopy. Facet screws were then placed at C3. Using standard technique of Magerl, starting in the inferomedial quadrant 14 mm trajectories in the 25-degree caudad-cephalad direction as well as 25 degrees in the medial lateral direction was made. This was subsequently sounded in all four quadrants to make sure that there is no elevation of the trajectory. A 14 x 3.5 mm screws were then placed appropriately. Lateral masteries at C1 endplate were placed appropriately. The medial and lateral borders were demarcated with a Penfield. The great occipital nerve was retracted out the way. Starting point was made with a high-speed power bur and midline and lateral mass bilaterally. Using a 20-degree caudad-cephalad trajectory as well as 10-degree lateral-to-medial direction, the trajectory was completed in 8 mm increments, this was subsequently sounded in all four quadrants to make sure that there was no violation of the pedicle wall of the trajectory. Once this was done, 24 x 3.5 mm smooth Schanz screws were placed appropriately. Precontoured titanium rods were then placed between the screws at the C1, C2, C3 and casts were placed appropriately. Once this was done, all end caps were appropriately torqued. This completed the open reduction and internal fixation of the C2 fracture, which showed perfect alignment. It must be noted that the reduction was partially performed on the table using lateral fluoroscopy prior to the instrumentation, almost reducing the posterior vertebral margin of the odontoid fracture with the base of the C2 access. Once the screws were torqued bilaterally, good alignment was seen both in the AP and lateral planes using fluoroscopy, this completed instrumentation as well as open reduction and internal fixation of C2. The cervical fusion was completed by decorticating the posterior elements of C1, C2, and C3. Once this was done, the morselized allograft 30 mL of cortical cancellous bone chips with 10 mL of demineralized bone matrix was placed over the decorticated elements. The fascia was closed using interrupted #1 Vicryl suture figure-of-8. Superficial drain was placed appropriately. Good alignment of the instrumentation as well as of the fracture was seen both in the AP and lateral planes. The subcutaneous tissues were closed using a #2-0 Vicryl suture. The dermal edges were approximated using staples. The wound was then dressed sterilely using Bacitracin ointment, Xeroform, 4x4s, and tape, and the drain was connected appropriately. The patient was subsequently released with a Mayfield contraption and rolled on to the stretcher in the usual supine position. Mayfield tongues were subsequently released. No significant bleeding was appreciated. The patient was subsequently extubated uneventfully and taken back to the recovery room in satisfactory and stable condition. No complications arose. orthopedic, fracture dislocation, spinal instrumentatio, comminuted, fracture, morselized, allograft, vicryl suture, mayfield tongues, cervical fusion, internal fixation, orif, cervical, fusion, fixation, spinal, reduction, instrumentation, Orthopedic Open reduction and internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint and closed reduction casting of the right forearm. ORIF & Closed Reduction PREOPERATIVE DIAGNOSES: , Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,POSTOPERATIVE DIAGNOSES:, Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,PROCEDURES: ,1. Open reduction internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint.,2. Closed reduction casting of the right forearm.,ANESTHESIA: , Surgery performed under general anesthesia. Local anesthetic was 10 mL of 0.5% Marcaine.,TOURNIQUET TIME: , On the left was 29 minutes.,COMPLICATIONS: ,There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HISTORY AND PHYSICAL: ,The patient is a 13-year-old right-hand dominant girl, who fell off a swing at school around 1:30 today. The patient was initially seen at an outside facility and brought here by her father, given findings on x-ray, a closed reduction was attempted on the left elbow. After the attempted reduction, the patient was noted to have an incarcerated medial epicondyle fracture as well as increasing ulnar paresthesias that were not present prior to the procedure. Given this finding, the patient needed urgent open reduction and internal fixation to relieve the pressure on the ulnar nerve. At that same time, the patient's mildly angulated radial shaft fracture will be reduced. This was explained to the father. The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for later hardware removal, and possible continuous nerve symptoms. All questions were answered. The father agreed to the above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was then administered. The patient received Ancef preoperatively. The left upper extremity was then prepped and draped in the standard surgical fashion. Attempts to remove the incarcerated medial epicondyle with supination, valgus stress, and with extension were unsuccessful. It was decided at this time that she would need open reduction. The arm was wrapped in Esmarch prior to inflation of the tourniquet to 250 mmHg. The Esmarch was then removed. An incision was then made. Care was taken to avoid any injury to the ulnar nerve. The medial epicondyle fracture was found incarcerated into the anterior aspect of the joint. This was easily removed. The ulnar nerve was also identified, and appeared to be intact. The medial epicondyle was then transfixed using a guidewire into its anatomic position with the outer cortex over drilled with a 3.2 drill bit, and subsequently a 44-mm 4.5 partially threaded cannulated screw was then placed with a washer to hold the medial epicondyle in place. After fixation of the fragment, the ulnar nerve was visualized as it traveled around the medial epicondyle fracture with no signs of impingement. The wound was then irrigated with normal saline and closed using 2-0 Vicryl and 4-0 Monocryl. The wound was clean and dry, dressed with Steri-Strips and Xeroform. The area was infiltrated with 0.5% Marcaine. The patient was then placed in a long-arm posterior well-molded splint with 90 degrees of flexion and neutral rotation. The tourniquet was released at 30 minutes prior to placement of the dressing, showed no significant bleeding. Attention was then turned to right side, the arm was then manipulated and a well-molded long-arm cast placed. The final position in the cast revealed a very small residual volar apex angulation, which is quite acceptable in this age. The patient tolerated the procedure well, was subsequently extubated and taken to recovery in a stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized for pain control and neurovascular testing for the next 1 to 2 days. The father was made aware of the intraoperative findings. All questions answered. orthopedic, orif, elbow fracture, dislocation, open reduction internal fixation, closed reduction, left medial epicondyle fracture, long-arm posterior well-molded splint, splint, radial shaft fracture, volar apex angulation, medial epicondyle fracture, medial epicondyle, internal fixation, epicondyle fracture, ulnar nerve, epicondyle, fracture, reduction, tourniquet, ulnar, nerve, Orthopedic Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible. The patient fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture. ORIF Mandibular Fracture & Dental Implant Removal PREOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,POSTOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,PROCEDURE PERFORMED: , Open reduction and internal fixation (ORIF) of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.,ANESTHESIA: , General nasotracheal.,ESTIMATED BLOOD LOSS: , 125 mL.,FLUIDS GIVEN: , 1 L of crystalloids.,SPECIMEN: , Soft tissue from the fracture site sent for histologic diagnosis.,CULTURES: , Also sent for Gram stain, aerobic and anaerobic, culture and sensitivity.,INDICATIONS FOR THE PROCEDURE: , The patient is a 79-year-old male, who fell in his hometown, following an episode of syncope. He sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in the above-mentioned fracture. He was admitted to hospital in Harleton, Texas, where his initial evaluation showed the rib fractures have also showed a nodule on his right upper lobe as well as a mediastinal mass. His mandible fracture was not noted initially. The patient also has a history of prostate cancer and a renal cell carcinoma. The patient at that point underwent a bronchoscopy with a biopsy of the mediastinal mass and the results of that biopsy are still pending. The patient later saw a local oral surgeon. He diagnosed his mandible fracture and advised him to seek treatment in Houston. He presented to my office for evaluation on January 18, 2010, and he was found to have an extremely atrophic mandible with a fracture in the left parasymphysis region involving a failed dental implant, which had been placed approximately 15 years ago. The patient had significant discomfort and could eat foods and drink fluids with difficulty. Due to the nature of his fracture and the complex medical history, he was sent to the hospital for admission and following cardiac clearance, he was scheduled for surgery today.,PROCEDURE IN DETAIL: , The patient was taken to the operating room, and placed in a supine position. Following a nasal intubation and induction of general anesthesia, the surgeon then scrubbed, gowned, and gloved in the normal sterile fashion. The patient was then prepped and draped in a manner consistent with sterile procedures. A marking pen was first used to outline the incision in the submental region and it was extended from the left mandibular body to the right mandibular body region, approximately 1.5 cm medial to the inferior border of the mandible. A 1 mL of lidocaine 1% with 1:100,000 epinephrine was then infiltrated along the incision and then a 15-blade was used to incise through the skin and subcutaneous tissue. A combination of sharp and blunt dissection was then used to carry the dissection superiorly to the inferior border of the mandible. Electrocautery as well as 4.0 silk ties were used for hemostasis. A 15-blade was then used to incise the periosteum along the inferior border of the mandible and it was reflected exposing the mandible as well as the fracture site. The fracture site was slightly distracted allowing access to the dental implant within the bone and it was easily removed from the wound. Cultures of this site were also obtained and then the granulation tissue from the wound was also curetted free of the wound and sent for a histologic diagnosis. Manipulation of the mandible was then used to achieve an anatomic reduction and then an 11-hole Synthes reconstruction plate was then used to stand on the fracture site. Since there was an area of weakness in the right parasymphysis region, in the location of another dental implant, the bone plate was extended posterior to that site. When the plate was adapted to the mandible, it was then secured to the bone with 9 screws, each being 2 mm in diameter and each screw was placed bicortically. All the screws were also locking screws. Following placement of the screws, there was felt to be excellent stability of the fracture, so the wound was irrigated with a copious amount of normal saline. The incision was closed in multiple layers with 4.0 Vicryl in the muscular and subcutaneous layers and 5.0 nylon in the skin. A sterile dressing was then placed over the incision. The patient tolerated the procedure well and was taken to the recovery room with spontaneous respirations and stable vital signs. Estimated blood loss is 125 mL. orthopedic, atrophic mandibular fracture, dental implant, open reduction and internal fixation, orif, mandibular fracture, mandible, atrophic, mandibular, dental, implant, Orthopedic Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture. Closed reduction and screw fixation of right femoral neck fracture. Retrograde femoral nail using a striker T2 retrograde nail. Irrigation and debridement of knee and elbow abrasions. ORIF, Closed Reduction, Screw Fixation, Etc. TITLE OF OPERATION:,1. Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture including skin, muscle, and bone using a Synthes 3.5 mm locking plate on the lateral malleolus and two Synthes 4.5 mm cannulated screws medial malleolus.,2. Closed reduction and screw fixation of right femoral neck fracture using one striker Asnis 8.0 mm cannulated screw and two 6.5 mm cannulated screws.,3. Retrograde femoral nail using a striker T2 retrograde nail 10 x 340 with a 10 mm INCAP and two 5 mm distal locking screws and two 5 mm proximal locking screws.,4. Irrigation and debridement of right knee.,5. Irrigation and debridement of right elbow abrasions.,PREOP DIAGNOSIS:,1. Right open ankle fracture.,2. Right femoral shaft fracture.,3. Right femoral neck fracture.,4. Right open knee.,5. Right elbow abrasions.,POSTOP DIAGNOSIS:,1. Right open ankle fracture.,2. Right femoral shaft fracture.,3. Right femoral neck fracture.,4. Right open knee.,5. Right elbow abrasions.,INTRAVENOUS FLUIDS: , 650 packed red blood cells.,TOURNIQUET TIME: , 2 hours.,URINE OUTPUT: ,1600 cubic centimeters.,ESTIMATED BLOOD LOSS: , 250 cubic centimeters.,COMPLICATIONS:, None.,PLAN:, non-weightbearing right lower extremity, clindamycin x 48 hours.,OPERATIVE NARRATIVE:, The patient is a 53-year-old female who is a pedestrian struck, in a motor vehicle accident and sustained numerous injuries. She sustained a right open ankle fracture, right femur fracture, right femoral neck fracture, right open knee, and right elbow abrasions. Given the emergent nature of the right femoral neck fracture and her young age as well as the open fracture, it was decided to proceed with an urgent operative intervention. The risks of surgery were discussed in detail and the consents were signed. The operative site was marked. The patient was taken to the operating room where she was given preoperative clindamycin. The patient had then general anesthetic performed by anesthesia.,A well-padded side tourniquet was placed. Attention was turned to the right ankle first. The large medical laceration was extended and the tissues were debrided. All dirty of the all injured bone, muscle, and tissues were debrided. Wound was then copiously irrigated with 8 liters of normal saline. At this point, the medial malleolus fracture was identified and was reduced. This was then fixed in with two 4.5 mm cannulated Synthes screws.,Next, the attention was turned to lateral malleolus. Incision was made over the distal fibula. It was carried down sharply through the skin in the subcutaneous issues. Care was taken to preserve the superficial peroneal nerve. The fracture was identified, and there was noted to be very comminuted distal fibula fracture. The fracture was reduced and confirmed with fluoroscopy. A 7 hole Synthes 3.5 mm locking plate was placed. This was placed in a bridging fashion with three screws above and three screws below the fracture. Appropriate reduction was confirmed under fluoroscopy. A cotton test was performed, and the ankle did not open up. Therefore, it was decided not to proceed with syndesmotic screw.,Next, the patient was then placed in the fracture table and all extremities were well padded. All prominences were padded. The right leg was then prepped and draped in usual sterile fashion. A 2-cm incision was made just distal to the greater trochanter. This was carried down sharply through the skin to the fascia. The femur was identified. The guidewire for a striker Asnis 6.5 mm screw was placed in the appropriate position. The triangle guide was then used to ensure appropriate triangular formation of the remainder of the screws. A reduction of the fracture was performed prior to placing all the guide wires. A single 8 mm Asnis screw was placed inferiorly followed by two 6.5 mm screws superiorly.,Next, the abrasions on the right elbow were copiously irrigated. The necrotic and dead tissue was removed. The abrasions did not appear to enter the joints. They were wrapped with Xeroform 4 x 4 x 4 Kerlix and Ace wrap.,Next, the lacerations of the anterior knee were connected and were extended in the midline. They were carried down sharply to the skin and the retinacular issues to the joint. The intercondylar notch was identified. A guide wire for the striker T2 retrograde nail was placed and localized with fluoroscopy. The opening reamer was used following the bolted guide wire was then passed. The femur was then sequentially reamed using the flexible reamers. A T2 retrograde nail 10 x 340 was then passed. Two 5 mm distal locking screws and two 5 mm proximal locking screws were then placed.,Prior to reaming and passing the retrograde nail, the knee was copiously irrigated with 8 liters of normal saline. Any dead tissues in the knee were identified and were debrided using rongeurs and curettes.,The patient was placed in the AO splints for the right ankle. The wounds were dressed with Xeroform 4 x 4 x 4s and IO band. The care was then transferred for the patient to Halstead Service.,The plan will be non-weightbearing right lower extremity and antibiotics for 48 hours.,Dr. X was present and scrubbed for the entirety of the procedure. Orthopedic Patient suffers from neck and lower back pain radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms. Ortho - Letter - 2 XYZ, D.C.,60 Evergreen Place,Suite 902,East Orange, NJ 07018,Re: orthopedic, paraspinal musculature, palpable trigger points, trigger point injections, lumbar, region, paraspinal, musculature, injections, trigger, Orthopedic Open reduction and internal fixation of left distal radius. ORIF of Left Distal Radius PREOPERATIVE DIAGNOSIS: , Left distal radius fracture, metaphyseal extraarticular.,POSTOPERATIVE DIAGNOSIS: , Left distal radius fracture, metaphyseal extraarticular.,PROCEDURE: , Open reduction and internal fixation of left distal radius.,IMPLANTS: ,Wright Medical Micronail size 2.,ANESTHESIA: , LMA.,TOURNIQUET TIME: , 49 minutes.,BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,PATHOLOGY: , None.,TIME OUT: , Time out was performed before the procedure started.,INDICATIONS:, The patient was a 42-year-old female who fell and sustained a displaced left metaphyseal distal radius fracture indicated for osteosynthesis. The patient was in early stage of gestation. Benefits and risks including radiation exposure were discussed with the patient and consulted her primary care doctor.,DESCRIPTION OF PROCEDURE: , Supine position, LMA anesthesia, well-padded arm, tourniquet, Hibiclens, alcohol prep, and sterile drape.,Exsanguination achieved, tourniquet inflated to 250 mmHg. First, under fluoroscopy the fracture was reduced. A 0.045 K-wire was inserted from dorsal ulnar corner of the distal radius and crossing fracture line to maintain the reduction. A 2-cm radial incision, superficial radial nerve was exposed and protected. Dissecting between the first and second dorsal extensor retinaculum, the second dorsal extensor compartment was elevated off from the distal radius. The guidewire was inserted under fluoroscopy. A cannulated drill was used to drill antral hole. Antral awl was inserted. Then we reamed the canal to size 2. Size 2 Micronail was inserted to the medullary canal. Using distal locking guide, three locking screws were inserted distally. The second dorsal incision was made. The deep radial dorsal surface was exposed. Using locking guide, two proximal shaft screws were inserted and locked the nail to the radius. Fluoroscopic imaging was taken and showing restoration of the height, tilt, and inclination of the radius. At this point, tourniquet was deflated, hemostasis achieved, wounds irrigated and closed in layers. Sterile dressing applied. The patient then was extubated and transferred to the recovery room under stable condition.,Postoperatively, the patient will see a therapist within five days. We will immobilize wrist for two weeks and then starting flexion-extension and prosupination exercises. orthopedic, distal radius fracture, dorsal extensor, locking guide, radius fracture, extraarticular, metaphyseal, guidewire, fracture, dorsal, distal, Orthopedic Open reduction and internal fixation of left tibia. ORIF - Left Tibia 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. orthopedic, intraarticular extension, tibial tubercle avulsion fracture, tubercle avulsion fracture, jp drain, cortical screw, hardware removal, tibial tubercle, tourniquet, orif, tubercle, tibial, Orthopedic Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture. ORIF - Followup REASON FOR VISIT:, Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.,HISTORY OF PRESENT ILLNESS: , The patient is now approximately week status post removal of Ex-Fix from the right knee with an MUA following open reduction internal fixation of right tibial plateau fracture. The patient states that this pain is well controlled. He has had no fevers, chills or night sweats. He has had some mild drainage from his pin sites. He just started doing range of motion type exercises for his right knee. He has had no numbness or tingling.,FINDINGS: , On exam, his pin sites had no erythema. There is some mild drainage but they have been dressing with bacitracin, it looks like there may be part of the fluid noted. The patient had 3/5 strength in the EHL, FHL. He has intact sensation to light touch in a DP, SP, and tibial nerve distribution.,X-rays taken include three views of the right knee. It demonstrate status post open reduction internal fixation of the right tibial plateau with excellent hardware placement and alignment.,ASSESSMENT: , Status post open reduction and internal fixation of right tibial plateau fracture with removal ex fix.,PLANS: , I gave the patient a prescription for aggressive range of motion of the right knee. I would like to really work on this as he has not had much up to this time. He should remain nonweightbearing. I would like to have him return in 2 weeks' time to assess his knee range of motion. He should not need x-rays at that time. orthopedic, external fixator, open reduction internal fixation, tibial plateau fracture., ex fix, tibial plateau fracture, internal fixation, tibial plateau, orif, Orthopedic Hawkins IV talus fracture. Open reduction internal fixation of the talus, medial malleolus osteotomy, and repair of deltoid ligament. ORIF - Talus 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. orthopedic, deltoid ligament, medial malleolus osteotomy, open reduction internal fixation of the talus, hawkins iv talus fracture, medial malleolus, fracture site, malleolus, talus, medial, fracture, tourniquet, ligament, osteotomy, Orthopedic Open reduction and internal fixation of left lateral malleolus. Left lateral malleolus fracture. ORIF - Malleolus 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. orthopedic, open reduction and internal fixation, esmarch, internal fixation, malleolus fracture, lateral malleolus, tourniquet, orif, fixation, ankle, reduction, fracture, malleolus Orthopedic Open reduction and internal fixation, high grade Frykman VIII distal radius fracture. ORIF - 2 PREOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,POSTOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,OPERATIVE PROCEDURE: ,Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.,ANESTHESIA: , General endotracheal.,PREOPERATIVE INDICATIONS: , This is a 52-year-old patient of mine who I have repaired both shoulder rotator cuffs, the most recent one in the calendar year 2007. While he was climbing a ladder recently in the immediate postop stage, he fell suffering the aforementioned heavily comminuted Frykman fracture. This fracture had a fragment that extended in the distal radial ulnar joint, a die-punch fragment in the center of the radius. The ulnar styloid and the radial styloid were off and there were severe dorsal comminutions. He presented to my office the morning of April 3, 2007, having had a left reduction done elsewhere a day ago. The reduction, although adequate, had allowed for the fragments to settle and I discussed with him the severity of the injury on a scale of 1-8, this was essentially an 8. The best results have been either with external fixation or internal fixation, most recently volar plating of a locking variety has been popular, and I felt that this would be appropriate in his case.,Risks and benefits otherwise described were bleeding, infection, need to do operative revise or removal of hardware. He is taking a job out of state in the next couple of months. Hence I felt that even with close followup, this is a particularly difficult fracture as far as the morbidity of the injury proceeds.,OPERATIVE NOTE: , After adequate general endotracheal anesthesia was obtained, one gram of Ancef was given intravenously. The left upper extremity was prepped and draped in supine position with the left hand in the arm table, magnification was used throughout. The time out procedure was done to the satisfaction of all present that this was indeed the appropriate extremity on the appropriate patient. A small C-arm was brought in to help guide the incision which was a volar curvilinear incision that included as part of this due to the fracture blisters eminent compartment syndrome and numbness in fingers. A carpal tunnel release was done with the transverse carpal ligament being protected with a Freer elevator. The usual amount of dissection of the pronator quadratus was necessary to view the distal radial fragment. The pronator quadratus actually grasped several of the fragments itself which had to be dissected free from them, specifically the distal radial ulnar joint and die-punch fragment. At this point, a locking Synthes distal radius plate from the modular handset was selected that had five articular screws as well as five locking shaft screws. The ulnar styloid was not affixed in any portion of this repair. The plate was viewed under the image intensification device, i.e., x-ray and the screws were placed in this order. The most proximal shaft screw was placed to allow the remainder of the plate to form a buttress to then rearrange the fragments around the locking screws and a locking plate having been selected from the volar approach, a locking 12-mm screw through 16-mm screws were placed in the following order. Most proximal on the radial shaft of the plate, then the radial styloid, i.e., the most distal and lateral screw, the next most proximal shaft screw followed by the distal radial ulnar joint screw. Three screws were locking across the die-punch fragment. The remaining two screws were placed into the radial shaft. All of these were locking screws of 2 mm in diameter and as the construct was created, the relative motion of the intra-articular fragment in dorsal comminution all diminished greatly, although the exposure as well as the amount of reduction force used was substantial. The tourniquet time was 1.5 hours. At this point, the tourniquet was let down. The entire construct was irrigated with copious amounts of bacitracin and normal saline. Closure was affected with 0 Vicryl underneath the skin surface followed by 3-0 Prolene in interrupted sutures in the volar wound. Several image intensification x-rays were taken at the conclusion of the case to check screw length. Screw lengths were changed out during the case as needed based on the x-ray findings. The wound was injected with Marcaine, lidocaine, Depo-Medrol, and Kantrex. A very heavily padded fluffy cotton Jones-type dressing was applied with a volar splint. Estimated blood loss was 10 mL. There were no specimens. Tourniquet time was 1.5 hours. orthopedic, distal radius, c-arm, depo-medrol, frykman, jones-type dressing, kantrex, marcaine, open reduction and internal fixation, die-punch, intra-articular, lidocaine, pronator quadratus, radial styloid, ulnar styloid, distal radial ulnar joint, radial ulnar joint, distal, screws, orif, fracture, radial Orthopedic Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture. ORIF - 3 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. Orthopedic Fractured right fifth metatarsal. Open reduction and internal screw fixation right fifth metatarsal. Application of short leg splint. ORIF - Fifth Metatarsal PREOPERATIVE DIAGNOSIS: , Fractured right fifth metatarsal.,POSTOPERATIVE DIAGNOSIS: , Fractured right fifth metatarsal.,PROCEDURE PERFORMED:,1. Open reduction and internal screw fixation right fifth metatarsal.,2. Application of short leg splint.,ANESTHESIA:, TIVA/local.,HISTORY: , This 32-year-old female presents to Preoperative Holding Area after keeping herself n.p.o., since mid night for open reduction and internal fixation of a fractured right fifth metatarsal. The patient relates that approximately in mid-June that she was working as a machinist at Detroit Diesel and dropped a large set of tools on her right foot. She continued to walk on the foot and found nothing was wrong despite the pain. She was recently seen by Dr. X and was referred to Dr. Y for surgery. The risks versus benefits of the procedure had been explained to the patient in detail by Dr. Y. The consent is available on the chart for review. The urine beta was taken in the preoperative area and was negative.,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 the supine position. 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 applied. After adequate IV sedation was administered by the Department of Anesthesia, a total of 10 cc of 0.5% Marcaine plain was used to perform an infiltrative type block to the right fifth metatarsal area of the right foot. 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 operative field and a sterile stocking was reflected. Attention was directed to the right fifth metatarsal base. The Xi-scan and fluoroscopic unit was used to visualize the fractured fifth metatarsal. An avulsion fracture of the right fifth metatarsal base was visualized. The fracture was linear in nature from distal lateral to proximal medial. There appeared to be a pseudoarthrosis on the lateral view. A skin scrub was used to carefully mark out all the landmarks including the peroneus longus and brevis tendons in the fifth metatarsal and the sural nerve. A linear incision was created with a #10 blade. A #15 blade was used to deepen the incision through the subcutaneous tissue. All small veins traversing the subcutaneous tissue were ligated with electrocautery. Next, using combination of sharp and blunt dissection, the deep fascia was reached. Next a linear capsuloperiosteal incision was made down to the bone using a #15 blade. Next, using a periosteal elevator and a #15 blade, the capsuloperiosteal tissues were stripped from the bone. The fracture site was not clearly visualized due to bony callus. A #25 gauge needle was introduced into the fracture site under fluoroscopy. The fracture site was easily found. An osteotome was used to separate the pseudoarthrosis.,A curette was used to remove the hypertrophic excessive pseudoarthrotic bone. Next, a small ball burr was used to resect the remaining hypertrophic bone. Next, a #1.0 drill bit was used to drill the subchondral bone on either side of the fracture site and a good healthy bleeding bone. Next, a bone clamp was applied and the fracture was reduced. Next, a threaded K-wire was thrown from the proximal base of the fifth metatarsal across the fracture site distally. A #4-0 mm Synthes partially threaded, cannulated 50 mm screw was thrown using standard AO technique from the proximal fifth metatarsal base down the shaft and the fracture site was fixated rigidly. All this was done under fluoroscopy. Next, the wound was flushed with copious amounts of sterile saline. The fracture site was found to have rigid compression. The hypertrophic bone on the lateral aspect of the metatarsal was reduced with a ball burr and the wound was again flushed. Next, the capsuloperiosteal tissues were closed with #3-0 Vicryl in a simple interrupted fashion. A few fibers of the peroneus brevis tendon that were stripped from the base of the proximal phalanx were reattached carefully with Vicryl. Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted suture technique. Next, the skin was closed with #5-0 Prolene in a horizontal mattress technique. A postoperative fluoroscopic x-ray was taken and the bony alignment was found to be intact and the screw placement had excellent appearance. A dressing consisting of Owen silk, 4x4s, fluff, and Kerlix were applied.,A sterile stockinet was applied over the foot. Next, copious amounts of Webril were applied to pad all bony prominences. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits. Next, 4-inch, pre-moulded, well-padded posterior splint was applied. The capillary refill time of the digits was less than three seconds. The patient tolerated the above anesthesia and procedure without complications. After anesthesia was reversed, she was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot. She was given Vicodin 5/500 mg #30 1-2 p.o. q.4-6h. p.r.n., pain, Naprosyn 500 mg p.o. b.i.d. p.c., Keflex 500 mg #30 one p.o. t.i.d., till gone. She was given standard postoperative instructions to be non-weightbearing and was dispensed with crutches. She will rest, ice, and elevate her right leg. She is to follow up in the clinic on 08/26/03 at 10:30 a.m.. She was given emergency contact numbers and will call or return if problems arise earlier. orthopedic, metatarsal, internal screw fixation, leg splint, fractured right fifth metatarsal, pneumatic ankle tourniquet, ankle tourniquet, metatarsal base, fracture site, fractured, hypertrophic, bernstein, orif Orthopedic Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture and right carpal tunnel release. ORIF - 1 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. orthopedic, intraarticular fracture, esmarch, k-wires, open reduction and internal fixation, tourniquet, carpal tunnel release, carpal tunnel syndrome, flexor carpi radialis, flexor pronator muscles, intraarticular, right distal radius, transverse carpal ligament, volar flexion crease, pronator quadratus, flexor carpi, carpi radialis, flexion crease, carpal ligament, carpal tunnel, carpal, volar Orthopedic MRI L-Spine - Bilateral lower extremity numbness Normal L-Spine MRI 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. orthopedic, bilateral lower extremity numbness, mri l spine, bilateral lower extremity, lower extremity numbness, bilateral, spine, mri, extremities, numbness Orthopedic Repair of nerve and tendon, right ring finger and exploration of digital laceration. Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger. Nerve & Tendon Repair - Finger PREOPERATIVE DIAGNOSIS:, Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury.,POSTOPERATIVE DIAGNOSES:,1. Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis.,2. 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.,PROCEDURE PERFORMED:,1. Repair of nerve and tendon, right ring finger.,2. Exploration of digital laceration.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,TOTAL TOURNIQUET TIME: ,57 minutes.,COMPLICATIONS: , None.,DISPOSITION: ,To PACU in stable condition.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 13-year-old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger.,GROSS OPERATIVE FINDINGS: , After wound exploration, it was found there was a 100% laceration to the ulnar digital neurovascular bundle. The FDS had a partial ulnar slip laceration and the FDP had a 25% transverse laceration as well. The radial neurovascular bundle was found to be completely intact.,OPERATIVE PROCEDURE: ,The patient was taken to the operating room and placed in the supine position. All bony prominences were adequately padded. Tourniquet was placed on the right upper extremity after being packed with Webril, but not inflated at this time. The right upper extremity was prepped and draped in the usual sterile fashion. The hand was inspected. Palmar surface revealed approximally 0.5 cm laceration at the base of the right ring finger at the base of proximal phalanx, which was approximated with nylon suture. The sutures were removed and the wound was explored. It was found that the ulnar digital neurovascular bundle was 100% transected. The radial neurovascular bundle on the right ring finger was found to be completely intact. We explored the flexor tendon and found that there was a partial laceration of the ulnar slip of the FDS and a 25% laceration in a transverse fashion to the FDP. We copiously irrigated the wound. Repair was undertaken of the FDS with #3-0 undyed Ethibond suture. The laceration of the FDP was not felt that it need to repair due to majority of the substance in the FDP was still intact. Attention during our repair at the flexor tendon, the A1 pulley was incised for better visualization as well as better tendon excursion after repair. Attention was then drawn to the ulnar digital bundle which has been transected prior during the injury. The digital nerve was dissected proximally and distally to likely visualize the nerve. The nerve was then approximated using microvascular technique with #8-0 nylon suture. The hands were well approximated. The nerve was not under undue tension. The wound was then copiously irrigated and the skin was closed with #4-0 nylon interrupted horizontal mattress alternating with simple suture. Sterile dressing was placed and a dorsal extension Box splint was placed. The patient was transferred off of the bed and placed back on a gurney and taken to PACU in stable condition. Overall prognosis is good. orthopedic, laceration, flexor tendon, volar laceration, digital laceration, ulnar slip, flexor digitorum, neurovascular bundle, nerve, injury, ring, finger, neurovascular, fds, bundle, tendon, repair, flexor, digital, ulnar, Orthopedic Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy. ORIF - Discharge Summary ADMISSION DIAGNOSIS: , Right tibial plateau fracture.,DISCHARGE DIAGNOSES: , Right tibial plateau fracture and also medial meniscus tear on the right side.,PROCEDURES PERFORMED:, Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.,CONSULTATIONS: , To rehab, Dr. X and to Internal Medicine for management of multiple medical problems including hypothyroid, diabetes mellitus type 2, bronchitis, and congestive heart failure.,HOSPITAL COURSE: , The patient was admitted and consented for operation, and taken to the operating room for open reduction and internal fixation of right Schatzker III tibial plateau fracture and partial medial meniscectomy performed without incidence. The patient seemed to be recovering well. The patient spent the next several days on the floor, nonweightbearing with CPM machine in place, developed a brief period of dyspnea, which seems to have resolved and may have been a combination of bronchitis, thick secretions, and fluid overload. The patient was given nebulizer treatment and Lasix increased the same to resolve the problem. The patient was comfortable, stabilized, breathing well. On day #12, was transferred to ABCD.,DISCHARGE INSTRUCTIONS: , The patient is to be transferred to ABCD after open reduction and internal fixation of right tibial plateau fracture and partial medial meniscectomy.,DIET:, Regular.,ACTIVITY AND LIMITATIONS: , Nonweightbearing to the right lower extremity. The patient is to continue CPM machine while in bed along with antiembolic stockings. The patient will require nursing, physical therapy, occupational therapy, and social work consults.,DISCHARGE MEDICATIONS: , Resume home medications, but increase Lasix to 80 mg every morning, Lovenox 30 mg subcu daily x2 weeks, Vicodin 5/500 mg one to two every four to six hours p.r.n. pain, Combivent nebulizer every four hours while awake for difficulty breathing, Zithromax one week 250 mg daily, and guaifenesin long-acting one twice a day b.i.d.,FOLLOWUP: , Follow up with Dr. Y in 7 to 10 days in office.,CONDITION ON DISCHARGE:, Stable. orthopedic, open reduction, internal fixation, schatzker iii tibial plateau fracture, meniscectomy, tibial plateau fracture, orif, schatzker, fixation, reduction, tibial, fracture, plateau, Orthopedic Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection. Neuroplasty PREOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:, Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS:, None.,SUMMARY: ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details). Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle. After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle. These needles were removed and the patient was discharged in stable condition. orthopedic, nerve root decompression, discectomy, epidural fibrosis, nerve root entrapment, transforaminal neuroplasty, neural foramen, nerve root, foramen, neuroplasty, transforaminal, needle, epidural, Orthopedic Incision and drainage and excision of the olecranon bursa, left elbow. Acute infected olecranon bursitis, left elbow. Olecranon Bursa - Excision 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. orthopedic, incision and drainage, infected olecranon, olecranon bursitis, olecranon bursa, olecranon, wound, excision, drainage, elbow, bursa Orthopedic Chronic plantar fasciitis, right foot. Open plantar fasciotomy, right foot. Open Plantar Fasciotomy 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. orthopedic, plantar fascial band, plantar fasciitis, plantar fasciotomy, plantar fascial, anesthesia, plantar, fascia, fasciotomy, fascial, band, foot, Orthopedic Neck pain with right upper extremity radiculopathy and cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis. Neck Pain - Discharge Summary ADMISSION DIAGNOSES,1. Neck pain with right upper extremity radiculopathy.,2. Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,DISCHARGE DIAGNOSES,1. Neck pain with right upper extremity radiculopathy.,2. Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,OPERATIVE PROCEDURES,1. Anterior cervical discectomy with decompression C4-C5, C5-C6, and C6-C7.,2. Arthrodesis with anterior interbody fusion C4-C5, C5-C6, and C6-C7.,3. Spinal instrumentation C4 through C7.,4. Implant.,5. Allograft.,COMPLICATIONS:, None.,COURSE ON ADMISSION: , This is the case of a very pleasant 41-year-old Caucasian female who was seen in clinic as an initial consultation on 09/13/07 complaining of intense neck pain radiating to the right shoulder blade to top of the right shoulder in to the right upper extremity to the patient's hand. The patient's symptoms have been persistent and had gotten worse with subjective weakness of the right upper extremity since its onset for several weeks now. The patient has been treated with medications, which has been unrelenting. The patient had imaging studies that showed evidence of cervical spondylosis with herniated disk and stenosis at C4-C5, C5-C6 and C6-C7. The patient underwent liver surgery and postoperatively her main issue was that of some degree of on and off right shoulder pain and some operative site soreness, which was treated well with IV morphine. The patient has resolution of the pain down the arm, but she does have some tingling of the right thumb and right index finger. The patient apparently is doing well with slight dysphagia, we treated her with Decadron and we will send her home with Medrol. The patient will have continued pain medication coverage with Darvocet and Flexeril. The patient will follow up with me as scheduled. Instructions have been given. orthopedic, radiculopathy, cervical spondylosis, neck pain, anterior cervical discectomy, herniated nucleus pulposus, cervical, anterior, herniated, Orthopedic Initial evaulation - neck and back pain. Neck & Back Pain "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." Orthopedic MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal. MRI T-Spine - Spinal Mets 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. Orthopedic Patient with wrist pain and swelling, status post injury. MRI Wrist - 1 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. orthopedic, fourth dorsal compartment, tendon sheath thickening, tendon sheaths, dorsal compartment, volar, carpals, tear, ulnar, synovitis, sheaths, ligament, thickening, dorsal, tendon, injury, Orthopedic MRI T-spine and CXR - Aortic Dissection. MRI T-Spine "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." orthopedic, mri, a&o, aortic dissection, cxr, irregular rate and rhythm, mri scan, neurology service, t-spine, carotid bruitts, epidural hemorrhage, mediastinum, paraplegia, person, place, stocking distribution, time, weakness, mri t spine, sensory level, neurology, spine, Orthopedic The thoracic spine was examined in the AP, lateral and swimmer's projections. MRI T-Spine - 1 EXAM: ,Thoracic Spine.,REASON FOR EXAM: , Injury.,INTERPRETATION: , The thoracic spine was examined in the AP, lateral and swimmer's projections. There is mild chronic-appearing anterior wedging of what is believed to represent T11 and 12 vertebral bodies. A mild amount of anterior osteophytic lipping is seen involving the thoracic spine. There is a suggestion of generalized osteoporosis. The intervertebral disc spaces appear generally well preserved.,The pedicles appear intact.,IMPRESSION:,1. Mild chronic-appearing anterior wedging of what is believed to represent the T11 and 12 vertebral bodies.,2. Mild degenerative changes of the thoracic spine.,3. Osteoporosis. orthopedic, thoracic spine, swimmer's projections, osteoporosis, osteophytic lipping, anterior wedging, vertebral bodies, thoracic, spine, Orthopedic Arthroscopy with arthroscopic rotator cuff debridement, anterior acromioplasty, and Mumford procedure left shoulder. Partial rotator cuff tear with impingement syndrome. Degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion. Mumford Procedure & Acromioplasty PREOPERATIVE DIAGNOSES:,1. Partial rotator cuff tear with impingement syndrome.,2. Degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion.,POSTOPERATIVE DIAGNOSES:,1. Partial rotator cuff tear with impingement syndrome.,2. Degenerative osteoarthritis of acromioclavicular joint, left shoulder.,PROCEDURE PERFORMED:,1. Arthroscopy with arthroscopic rotator cuff debridement.,2. Anterior acromioplasty.,3. Mumford procedure left shoulder.,SPECIFICATIONS: , The entire operative procedure was done in Inpatient Operative Suite, Room #1 at ABCD General Hospital. This was done in a modified beach chair position with interscalene and subsequent general anesthetic.,HISTORY AND GROSS FINDINGS: , This is a 38-year-old morbidly obese white male suffering increasing pain in his left shoulder for a number of months prior to surgical intervention. He was refractory to conservative outpatient therapy. He had injection of his AC joint, which removed symptoms but was not long lasting. After discussing the alternatives of the care as well as advantages and disadvantages, risks, complications, and expectations, he elected to undergo the above-stated procedure on this date.,Intraarticular viewing of the joint revealed a partial rotator cuff tear on the supraspinatus insertion on the joint side. All else was noted to be intact including the glenohumeral joint, the long head of the biceps, and the labrum. The remainder of the rotator cuff observed was noted to be intact. Subacromially, the patient was noted to have increased synovitis. Degenerative changes were noted upon observation of the distal clavicle.,OPERATIVE PROCEDURE: , The patient was laid supine upon the operative table. After receiving interscalene block anesthetic by Anesthesia Department, the patient was placed in modified beach chair position. He was prepped and draped in the usual sterile manner. Portals were created posteriorly and anteriorly from outside to in. A full and complete diagnostic intraarticular arthroscopy was carried out. Debridement was carried out through a 3.5 meniscal shaver to the 4.2 meniscal shaver to the undersurface of the partial tear of the rotator cuff. Retrospectively it was approximately 25% of the generalized thickness.,Attention was then turned to the subacromial region. The scope was directed subacromially. A portal was created laterally. Ultimately, the patient needed a general anesthetic once we were closer to the distal clavicle. Gross bursectomy was carried out with a 4.2 meniscal shaver. #18-gauge spinal needles have been placed to outline the anterior acromion prior to this.,It was difficult to control the patient's blood pressure with systolics ranging anywhere from 165 or 170 up to 200. Because of this and difficulties with his anesthetic, it was elected to change to an open procedure. Thus, the patient was anesthetized safely and secured. An oblique incision was carried at the cross Langer's line across the outlet of the shoulder through the skin and subcutaneous tissue. Hemostasis was controlled via electrocoagulation. Flaps were created. Anterior deltoid was reflected inferiorly. Anterior acromioplasty was carried out with a saw then a Micro-Aire and then a beaver-tail rasp. An excellent decompression was present. CA ligament had been previously resected. We then took the incision over the distal clavicle. The end of the distal clavicle approximately 12 mm to 14 mm was isolated and removed with the Micro-Aire saw. The beaver-tail rasp was utilized to smooth off the edges. Pain buster catheter was placed deep to closure of the AC capsule and then to the deltoid with interrupted #1 Vicryl. Transosseous sutures were placed across the acromion and the deltoid was elevated and closed with the same. A superficial running #2-0 Vicryl suture was utilized for deltoid closure distally. Interrupted #2-0 Vicryl was utilized to subcutaneous fat closure, running #4-0 subcuticular stitch for skin closure and Adaptic, 4x4s, ABDs, and Elastoplast tape placed for compression dressing. 0.25% Marcaine was flooded into the joint prior to the skin closure. Pain buster catheter was hooked up. The patient's arm was placed in arm sling. He was safely transferred to the PACU in apparent satisfactory condition. Expected surgical prognosis on this patient is fair. orthopedic, slap lesion, acromioclavicular joint, impingement syndrome, mumford procedure, acromioplasty, arthroscopy, arthroscopic, arthroscopic rotator cuff debridement, anterior acromioplasty, rotator cuff tear, arthroscopic rotator, meniscal shaver, cuff tear, rotator cuff, debridement, osteoarthritis, acromioclavicular, clavicle, deltoid, rotator, cuff, shoulder, joint Orthopedic Patient status post vehicular trauma. Low Back syndrome and Cervicalgia. Neck & Lower Back Pain - Consult 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. Orthopedic MRI T-L spine - L2 conus medullaris lesion and syndrome secondary to Schistosomiasis. MRI T-L Spine - Schistosomiasis "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." Orthopedic MRI left shoulder. MRI Shoulder - 5 EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 26 year old with a history of instability. Examination was preformed on 12/20/2005.,FINDINGS:,There is supraspinatus tendinosis without a full-thickness tear, gap or fiber retraction and there is no muscular atrophy (series #105 images #4-6).,Normal infraspinatus and subscapularis tendons.,Normal long biceps tendon within the bicipital groove. There is medial subluxation of the tendon under the transverse humeral ligament, and there is tendinosis of the intracapsular portion of the tendon with partial tearing, but there is no complete tear or discontinuity. Biceps anchor is intact (series #105 images #4-7; series #102 images #10-22).,There is a very large Hill-Sachs fracture, involving almost the entire posterior half of the humeral head (series #102 images #13-19). This is associated with a large inferior bony Bankart lesion that measures approximately 15 x 18mm in AP and craniocaudal dimension with impaction and fragmentation (series #104 images #10-14; series #102 images #18-28). There is medial and inferior displacement of the fragment. There are multiple interarticular bodies, some of which may be osteochondromatous and some may be osseous measuring up to 8mm in diameter. (These are too numerous to count.) There is marked stretching, attenuation and areas of thickening of the inferior and middle glenohumeral ligaments, compatible with a chronic tear with scarring but there is no discontinuity or demonstrated HAGL lesion (series #105 images #5-10).,Normal superior glenohumeral ligament.,There is no SLAP tear.,Normal acromioclavicular joint without narrowing of the subacromial space.,Normal coracoacromial, coracohumeral and coracoclavicular ligaments.,There is fluid in the glenohumeral joint and biceps tendon sheath.,IMPRESSION:,There is a very large Hill-Sachs fracture involving most of the posterior half of the humeral head with an associated large and inferior and medial displaced osseous Bankart lesion.,There are multiple intraarticular bodies, and there is a partial tear of the inferior and middle glenohumeral ligaments.,There is medial subluxation of the long biceps tendon under the transverse humeral ligament with partial tearing of the intracapsular portion., orthopedic, inferior and middle glenohumeral, biceps tendon, partial tearing, glenohumeral ligaments, mri, shoulder, ligament, ligaments, biceps, humeral, glenohumeral, tear, tendons Orthopedic MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis. MRI Spine - Epidural Lipoma "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." Orthopedic A 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear. MRI Shoulder - 4 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. orthopedic, level of the rotator, impinging lesion, rotator interval, retracted tendon, muscular atrophy, partial tearing, tendon, mri, shoulder, rotator, superior, tear, Orthopedic MRI of the Cervical, Thoracic, and Lumbar Spine MRI Spine 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., orthopedic, cervical spine, mri, cervical, thoracic, lumbar, transversing nerve root, vertebral body height, vertebral body, disc protrusion, foraminal compromise, central, foraminal, disc, spineNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. Orthopedic MRI of lumbar spine without contrast to evaluate chronic back pain. MRI of Lumbar Spine w/o Contrast EXAM: , MRI of lumbar spine without contrast.,HISTORY:, A 24-year-old female with chronic back pain.,TECHNIQUE: , Noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting.,FINDINGS: , The visualized cord is normal in signal intensity and morphology with conus terminating in proper position. Visualized osseous structures are normal in marrow signal intensity and morphology without evidence for fracture/contusion, compression deformity, or marrow replacement process. There are no paraspinal masses.,Disc heights, signal, and vertebral body heights are maintained throughout the lumbar spine.,L5-S1: Central canal, neural foramina are patent.,L4-L5: Central canal, neural foramina are patent.,L3-L4: Central canal, neural foramen is patent.,L2-L3: Central canal, neural foramina are patent.,L1-L2: Central canal, neural foramina are patent.,The visualized abdominal aorta is normal in caliber. Incidental note has been made of multiple left-sided ovarian, probable physiologic follicular cysts.,IMPRESSION: , No acute disease in the lumbar spine. orthopedic, mri, central canal, noncontrast, abdominal aorta, axial, back pain, contrast, follicular cysts, images, lumbar spine, morphology, neural foramina, sagittal, signal intensity, without contrast, mri of lumbar spine, mri of lumbar, lumbar, foramina, neural, patent, spine Orthopedic MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding. MRI L-Spine - Subarachnoid Seeding "CC:, Progressive lower extremity weakness.,HX: ,This 52y/o RHF had a h/o right frontal glioblastoma multiforme (GBM) diagnosed by brain biopsy/partial resection, on 1/15/1991. She had been healthy until 1/6/91, when she experienced a generalized tonic-clonic type seizure during the night. She subsequently underwent an MRI brain scan and was found to have a right frontal enhancing lesion in the mesial aspect of the right frontal lobe at approximately the level of the coronal suture. There was minimal associated edema and no mass effect. Following extirpation of the tumor mass, she underwent radioactive Iodine implantation and 6020cGy radiation therapy in 35 fractions. In 11/91 she received BCNU and Procarbazine chemotherapy protocols. This was followed by four courses of 5FU/Carboplatin (3/92, 6/92, 9/92 ,10/92) chemotherapy.,On 10/12/92 she presented for her 4th course of 5FU/Carboplatin and complained of non-radiating dull low back pain, and proximal lower extremity weakness, but was still able to ambulate. She denied any bowel/bladder difficulty.,PMH: ,s/p oral surgery for wisdom tooth extraction.,FHX/SHX: ,1-2 ppd cigarettes. rare ETOH use. Father died of renal CA.,MEDS: ,Decadron 12mg/day.,EXAM: ,Vitals unremarkable.,MS: Unremarkable.,Motor: 5/5 BUE, LE: 4+/5- prox, 5/5 distal to hips. Normal tone and muscle bulk.,Sensory: No deficits appreciated.,Coord: Unremarkable.,Station: No mention in record of being tested.,Gait: Mild difficulty climbing stairs.,Reflexes: 1+/1+ throughout and symmetric. Plantar responses were down-going bilaterally.,INITIAL IMPRESSION:, Steroid myopathy. Though there was enough of a suspicion of ""drop"" metastasis that an MRI of the L-spine was obtained.,COURSE:, The MRI L-spine revealed fine linear enhancement along the dorsal aspect of the conus medullaris, suggestive of subarachnoid seeding of tumor. No focal mass or cord compression was visualized. CSF examination revealed: 19RBC, 22WBC, 17 Lymphocytes, and 5 histiocytes, Glucose 56, Protein 150. Cytology (negative). The patient was discharged home on 10/17/92, but experienced worsening back pain and lower extremity weakness and became predominantly wheelchair bound within 4 months. She was last seen on 3/3/93 and showed signs of worsening weakness (left hemiplegia: R > L) as her tumor grew and spread. She then entered a hospice." orthopedic, glioblastoma multiforme, gbm, steroid myopathy, hemiplegia, progressive lower extremity weakness, mri l spine, lower extremity weakness, frontal glioblastoma, subarachnoid seeding, lower extremity, glioblastoma, subarachnoid, spine, mri, lower, weakness, Orthopedic MRI right knee without gadolinium MRI Knee - 5 EXAM:,MRI RIGHT KNEE WITHOUT GADOLINIUM,CLINICAL:,This is a 21-year-old male with right knee pain after a twisting injury on 7/31/05. Patient has had prior lateral meniscectomy in 2001.,FINDINGS:,Examination was performed on 8/3/05,Normal medial meniscus without intrasubstance degeneration, surface fraying or discrete meniscal tear.,There is subtle irregularity along the superior and inferior articular surfaces of the lateral meniscus, likely reflecting previous partial meniscectomy and contouring, although subtle surface tearing cannot be excluded, particularly along the undersurface of the lateral meniscus (series #3, image #17). There is no displaced tear or displaced meniscal fragment.,There is a mild interstitial sprain of the anterior cruciate ligament without focal tear or discontinuity.,Normal posterior cruciate ligament.,Normal medial collateral ligament.,There is a strain of the popliteus muscle and tendon without complete tear.,There is a sprain of the posterolateral and posterocentral joint capsule (series #5 images #10-18). There is marrow edema within the posterolateral corner of the tibia, and there is linear signal adjacent to the cortex suggesting that there may be a Segond fracture for which correlation with radiographs is recommended (series #6, images #4-7).,Biceps femoris tendon and iliotibial band are intact and there is no discrete fibular collateral ligament tear. Normal quadriceps and patellar tendons.,There is contusion within the posterior non-weight bearing surface of the medial femoral condyle, as well as in the posteromedial corner of the tibia. There is linear vertically oriented signal within the distal tibial diaphyseal-metaphyseal junction (series #7, image #8; series #2, images #4-5). There is no discrete fracture line, and this is of uncertain significance, but this should be correlated with radiographs.,The patellofemoral joint is congruent without patellar tilt or subluxation. Normal medial and lateral patellar retinacula. There is a joint effusion.,IMPRESSION:,Changes within the lateral meniscus most likely reflect previous partial meniscectomy and re-contouring although a subtle undersurface tear in the anterior horn may be present.,Mild anterior cruciate ligament interstitial sprain.,There is a strain of the popliteus muscle and tendon and there is a sprain of the posterolateral and posterocentral joint capsule with a possible Second fracture which should be correlated with radiographs., orthopedic, mri right knee, posterolateral and posterocentral, posterocentral joint capsule, lateral meniscus, cruciate ligament, mri, meniscectomy, cruciate, tendon, posterolateral, patellar, ligament, tear Orthopedic MRI left knee. MRI Knee - 3 EXAM:,MRI LEFT KNEE,CLINICAL:,This is a 41 -year-old-male with knee pain, mobility loss and swelling. The patient had a twisting injury one week ago on 8/5/05. The examination was performed on 8/10/05,FINDINGS:,There is intrasubstance degeneration within the medial meniscus without a discrete surfacing tear.,There is intrasubstance degeneration within the lateral meniscus, and there is a probable small tear in the anterior horn along the undersurface at the meniscal root.,There is an interstitial sprain/partial tear of the anterior cruciate ligament. There is no complete tear or discontinuity, and the ligament has a celery stick appearance.,Normal posterior cruciate ligament.,Normal medial collateral ligament.,There is a sprain of the femoral attachment of the fibular collateral ligament, without complete tear or discontinuity. The fibular attachment is intact.,Normal biceps femoris tendon, popliteus tendon and iliotibial band.,Normal quadriceps and patellar tendons.,There are no fractures.,There is arthrosis, with high-grade changes in the patellofemoral compartment, particularly along the midline patellar ridge and lateral facet. There are milder changes within the medial femorotibial compartments. There are subcortical cystic changes subjacent to the tibial spine, which appear chronic.,There is a joint effusion. There is synovial thickening.,IMPRESSION:,Probable small tear in the anterior horn of the lateral meniscus at the meniscal root.,Interstitial sprain/partial tear of the anterior cruciate ligament.,Arthrosis, joint effusion and synovial hypertrophy.,There are several areas of focal prominent medullary fat within the medial and lateral femoral condyles. orthopedic, mri left knee, interstitial sprain/partial tear, anterior cruciate ligament, lateral meniscus, cruciate ligament, synovial, mri, meniscus, sprain/partial, cruciate, knee, ligament Orthopedic A 32-year-old male with shoulder pain. MRI Shoulder - 3 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. orthopedic, impinging lesion, os acromiale, shoulder, tendon, acromiale, osseous Orthopedic A 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months. MRI Shoulder - 2 EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months. Received for second opinion. Study performed on 10/04/05.,FINDINGS:,The patient was scanned in a 1.5 Tesla magnet.,There is a flat undersurface of the acromion (Type I) morphology, with anterior downsloping orientation.,There is inflammation of the anterior rotator interval capsule with peritendinous edema involving the intracapsular long biceps tendon best appreciated on the (axial gradient echo T2 series #3 images #6-9). There is edema with thickening of the superior glenohumeral ligament (axial T2 series #3 image #7). There is flattening of the long biceps tendon as it enters the bicipital groove (axial T2 series #3 image #9-10), but no subluxation. The findings suggest early changes of a “hidden” lesion.,Normal biceps labral complex and superior labrum, and there is no demonstrated superior labral tear.,There is minimal tendinitis with intratendinous edema of the insertion of the subscapularis tendon (axial T2 series #3 image #10). There is minimal fluid within the glenohumeral joint capsule within normal physiologic volume limits.,Normal anterior and posterior glenoid labra.,Normal supraspinatus, infraspinatus, and teres minor tendons.,Normal muscles of the rotator cuff and there is no muscular atrophy.,There is minimal fluid loculated within the labral ligamentous capsular complex along the posterior-superior labrum (sagittal T2 series #7 image #5; coronal T2 series #5 image #7), but there is no demonstrated posterior-superior labral tear or paralabral cyst or ganglion.,Normal acromioclavicular articulation.,IMPRESSION:,Inflammation of the anterior rotator interval capsule with interstitial edema of the superior glenohumeral ligament.,Flattening of the long biceps tendon as it enters the bicipital groove, but no subluxation. Findings suggest early changes of a hidden lesion.,Mild tendinitis of the distal insertion of the subscapularis tendon, but no tendon tear.,Normal supraspinatus, infraspinatus, and teres minor tendons and muscular complexes.,Type I morphology with an anterior downsloping orientation of the acromion, but no inferior acromial osteophyte. orthopedic, insertion of the subscapularis, supraspinatus infraspinatus and teres, infraspinatus and teres minor, axial t series, supraspinatus infraspinatus, teres minor, minor tendons, posterior superior, biceps tendon, rotator, capsule, glenohumeral, tendon, series, superior Orthopedic MRI L-S-Spine for Cauda Equina Syndrome secondary to L3-4 disc herniation - Low Back Pain (LBP) with associated BLE weakness. MRI L-S Spine - Cauda Equina Syndrome "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." orthopedic, ble weakness, carotid doppler, disc herniation, guillain-barre syndrome, amyotrophy, polymyositis, epidural hematoma, mri l s spine, cauda equina syndrome, flexors & extensors, cauda equina, herniation, cauda, equina, extensors, reflexes, mri, hip, flexors, weakness, Orthopedic Left shoulder pain. Evaluate for rotator cuff tear. MRI Shoulder - 1 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., orthopedic, rotator cuff tear, cuff tear, rotator cuff, joint, mri, rotator, cuff, shoulder, tear, Orthopedic MRI left knee without contrast. MRI Knee - 1 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. orthopedic, collateral ligament, mri, knee, collateral, sprain, medial, ligament, Orthopedic A 53-year-old female with left knee pain being evaluated for ACL tear. MRI Knee - 2 EXAM:,MRI LEFT KNEE WITHOUT CONTRAST,CLINICAL:,This is a 53-year-old female with left knee pain being evaluated for ACL tear.,FINDINGS:,This examination was performed on 10-14-05.,Normal medial meniscus without intrasubstance degeneration, surface fraying or discrete meniscal tear.,There is a discoid lateral meniscus and although there may be minimal superficial fraying along the inner edge of the body, there is no discrete tear (series #6 images #7-12).,There is a near-complete or complete tear of the femoral attachment of the anterior cruciate ligament. The ligament has a balled-up appearance consistent with at least partial retraction of most of the fibers of the ligament. There may be a few fibers still intact (series #4 images #12-14; series #5 images #12-14). The tibial fibers are normal.,Normal posterior cruciate ligament.,There is a sprain of the medial collateral ligament, with mild separation of the deep and superficial fibers at the femoral attachment (series #7 images #6-12). There is no complete tear or discontinuity and there is no meniscocapsular separation.,There is a sprain of the lateral ligament complex without focal tear or discontinuity of any of the intraarticular components.,Normal iliotibial band.,Normal quadriceps and patellar tendons.,There is contusion within the posterolateral corner of the tibia. There is also contusion within the patella at the midline patellar ridge where there is an area of focal chondral flattening (series #8 images #10-13). The medial and lateral patellar facets are otherwise normal as is the femoral trochlea in the there is no patellar subluxation.,There is a mild strain of the vastus medialis oblique muscle extending into the medial patellofemoral ligament and medial patellar retinaculum but there is no complete tear or discontinuity.,Normal lateral patellar retinaculum. There is a joint effusion and plica.,IMPRESSION:, Discoid lateral meniscus without a tear although there may be minimal superficial fraying along the inner edge of the body. Near-complete if not complete tear of the femoral attachment of the anterior cruciate ligament. Medial capsule sprain with associated strain of the vastus medialis oblique muscle. There is focal contusion within the patella at the midline patella ridge. Joint effusion and plica. orthopedic, vastus medialis oblique muscle, medialis oblique, oblique muscle, patellar retinaculum, joint effusion, femoral attachment, cruciate ligament, complete tear, meniscus, superficial, cruciate, sprain, femoral, medial, ligament, tear, patellar Orthopedic Pain and swelling in the right foot. MRI Foot - 2 EXAM:,MRI RIGHT FOOT,CLINICAL:,Pain and swelling in the right foot.,FINDINGS: ,Obtained for second opinion interpretation is an MRI examination performed on 11-04-05.,There is a transverse fracture of the anterior superior calcaneal process of the calcaneus. The fracture is corticated however and there is an active marrow stress phenomenon. There is a small ganglion measuring approximately 8 x 5 x 5mm in size extending along the bifurcate ligament.,There is no substantial joint effusion of the calcaneocuboid articulation. There is minimal interstitial edema involving the short plantar calcaneal cuboid ligament.,Normal plantar calcaneonavicular spring ligament.,Normal talonavicular articulation.,There is minimal synovial fluid within the peroneal tendon sheaths.,Axial imaging of the ankle has not been performed orthogonal to the peroneal tendon distal to the retromalleolar groove. The peroneus brevis tendon remains intact extending to the base of the fifth metatarsus. The peroneus longus tendon can be identified in its short axis extending to its distal plantar insertion upon the base of the first metatarsus with minimal synovitis.,There is minimal synovial fluid within the flexor digitorum longus and flexor hallucis longus tendon sheath with pooling of the fluid in the region of the knot of Henry.,There is edema extending along the deep surface of the extensor digitorum brevis muscle.,Normal anterior, subtalar and deltoid ligamentous complex.,Normal naviculocuneiform, intercuneiform and tarsometatarsal articulations.,The Lisfranc’s ligament is intact.,The Achilles tendon insertion has been excluded from the field-of-view.,Normal plantar fascia and intrinsic plantar muscles of the foot.,There is mild venous distention of the veins of the foot within the tarsal tunnel.,There is minimal edema of the sinus tarsus. The lateral talocalcaneal and interosseous talocalcaneal ligaments are normal.,Normal deltoid ligamentous complex.,Normal talar dome and no occult osteochondral talar dome defect.,IMPRESSION:,Transverse fracture of the anterior calcaneocuboid articulation with cortication and cancellous marrow edema.,Small ganglion intwined within the bifurcate ligament.,Interstitial edema of the short plantar calcaneocuboid ligament.,Minimal synovitis of the peroneal tendon sheaths but no demonstrated peroneal tendon tear.,Minimal synovitis of the flexor tendon sheaths with pooling of fluid within the knot of Henry.,Minimal interstitial edema extending along the deep surface of the extensor digitorum brevis muscle. Orthopedic MRI left knee without contrast. MRI Knee - 4 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. orthopedic, lateral collateral ligament, medial collateral ligament, posterior cruciate ligament, anterior cruciate ligament, collateral ligament complex, myxoid degenerative, partial tear, collateral ligament, ligament complex, cruciate ligament, mri, effusion, cartilage, collateral, cruciate, knee, tear, ligament Orthopedic A 49-year-old female with ankle pain times one month, without a specific injury. MRI Foot - 3 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. orthopedic, lateral plantar cutaneous, plantar cutaneous nerves, posterior tibialis tendon, medial and lateral, subcutis adipose, adipose space, achilles tendon, tendon thickening, hallucis longus, lateral plantar, plantar cutaneous, cutaneous nerves, medial malleolus, posterior tibialis, tibialis tendon, plantar, tendon, posterior, flexor, tibialis, medial, Orthopedic Pain and swelling in the right foot, peroneal tendon tear. MRI Foot - 1 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., orthopedic, peroneus longus tendon, peroneal tendon, lateral margin, peroneus longus, longus tendon, cuboid bone, foot, peroneal, peroneus, longus, avulsion, tendon, bones, cuboid, Orthopedic MRI C-spine: C4-5 Transverse Myelitis. MRI C-spine "CC:, Left hemibody numbness.,HX:, This 44y/o RHF awoke on 7/29/93 with left hemibody numbness without tingling, weakness, ataxia, visual or mental status change. She had no progression of her symptoms until 7/7/93 when she notices her right hand was stiff and clumsy. She coincidentally began listing to the right when walking. She denied any recent colds/flu-like illness or history of multiple sclerosis. She denied symptoms of Lhermitte's or Uhthoff's phenomena.,MEDS:, none.,PMH:, 1)Bronchitis twice in past year (last 2 months ago).,FHX:, Father with HTN and h/o strokes at ages 45 and 80; now 82 years old. Mother has DM and is age 80.,SHX:, Denies Tobacco/ETOH/illicit drug use.,EXAM:, BP112/76 HR52 RR16 36.8C,MS: unremarkable.,CN: unremarkable.,Motor: 5/5 strength throughout except for slowing of right hand fine motor movement. There was mildly increased muscle tone in the RUE and RLE.,Sensory: decreased PP below T2 level on left and some dysesthesias below L1 on the left.,Coord: positive rebound in RUE.,Station/Gait: unremarkable.,Reflexes: 3+/3 throughout all four extremities. Plantar responses were flexor, bilaterally.,Rectal exam not done.,Gen exam reportedly ""normal."",COURSE:, GS, CBC, PT, PTT, ESR, Serum SSA/SSB/dsDNA, B12 were all normal. MRI C-spine, 7/145/93, showed an area of decreased T1 and increased T2 signal at the C4-6 levels within the right lateral spinal cord. The lesion appeared intramedullary and eccentric, and peripherally enhanced with gadolinium. Lumbar puncture, 7/16/93, revealed the following CSF analysis results: RBC 0, WBC 1 (lymphocyte), Protein 28mg/dl, Glucose 62mg/dl, CSF Albumin 16 (normal 14-20), Serum Albumin 4520 (normal 3150-4500), CSF IgG 4.1mg/dl (normal 0-6.2), CSF IgG, % total CSF protein 15% (normal 1-14%), CSF IgG index 1.1 (normal 0-0.7), Oligoclonal bands were present. She was discharged home.,The patient claimed her symptoms resolved within one month. She did not return for a scheduled follow-up MRI C-spine." orthopedic, mri c-spine, c-spine, lhermitte's, myelitis, transverse myelitis, uhthoff's, ataxia, clumsy, hemibody numbness, mental status, numbness, tingling, weakness, mri c spine, hemibody, mri, spine, csf, Orthopedic MRI of elbow - A middle-aged female with moderate pain, severe swelling and a growth on the arm. MRI Elbow - 2 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., orthopedic, growth on the arm, subluxing ulnar nerve, collateral ligamentous complex, common extensor tendon, posteromedial aspect, epimysial sheath, extensor tendon, tendon insertions, ulnar nerve, elbow, edema, olecranon, inflammation, nerve, ulnar, tendon Orthopedic MRI Elbow - A middle-aged female complaining of elbow pain. MRI Elbow - 1 FINDINGS:,There is severe tendinitis of the common extensor tendon origin with diffuse intratendinous inflammation (coronal T2 image #1452, sagittal T2 image #1672). There is irregularity of the deep surface of the tendon consistent with mild fraying (#1422 and 1484) however there is no distinct tear.,There is a joint effusion of the radiocapitellar articulation with mild fluid distention.,The radial collateral (proper) ligament remains intact. There is periligamentous inflammation of the lateral ulnar collateral ligament (coronal T2 image #1484) of the radial collateral ligamentous complex. There is no articular erosion or osteochondral defect with no intra-articular loose body.,There is minimal inflammation of the subcutis adipose space extending along the origin of the common flexor tendon (axial T2 image #1324). The common flexor tendon otherwise is normal.,There is minimal periligamentous inflammation of the anterior band of the ulnar collateral ligament (coronal T2 image #1516, axial T2 image #1452) with an intrinsically normal ligament.,The ulnotrochlear articulation is normal.,The brachialis and biceps tendons are normal with a normal triceps tendon. The anterior, posterior, medial and lateral muscular compartments are normal.,The radial, median and ulnar nerves are normal with no apparent ulnar neuritis.,IMPRESSION:,Lateral epicondylitis with severe tendinitis of the common extensor tendon origin and minimal deep surface fraying, without a discrete tendon tear.,Periligamentous inflammation of the radial collateral ligamentous complex as described above with intrinsically normal ligaments.,Small joint effusion of the radiocapitellar articulation with no osteochondral defect or intra-articular loose body.,Mild peritendinous inflammation of the subcutis adipose space adjacent to the common flexor tendon origin with an intrinsically normal tendon.,Minimal periligamentous inflammation of the anterior band of the ulnar collateral ligament with an intrinsically normal ligament. orthopedic, radial collateral ligamentous complex, intra articular loose body, axial t image, ulnar collateral ligament, common flexor tendon, mri elbow, ligamentous complex, radial collateral, ulnar collateral, collateral ligament, flexor tendon, periligamentous inflammation, mri, tendon Orthopedic MRI Cervical Spine without contrast. MRI Cervical Spine - 2 EXAM:,MRI SPINAL CORD CERVICAL WITHOUT CONTRAST,CLINICAL:,Right arm pain, numbness and tingling.,FINDINGS:,Vertebral alignment and bone marrow signal characteristics are unremarkable. The C2-3 and C3-4 disk levels appear unremarkable.,At C4-5, broad based disk/osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour. A discrete cord signal abnormality is not identified. There may also be some narrowing of the neuroforamina at this level.,At C5-6, central disk-osteophyte contacts and mildly impresses on the ventral cord contour. Distinct neuroforaminal narrowing is not evident.,At C6-7, mild diffuse disk-osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface. Distinct cord compression is not evident. There may be mild narrowing of the neuroforamina at his level.,A specific abnormality is not identified at the C7-T1 level.,IMPRESSION:,Disk/osteophyte at C4-5 through C6-7 with contact and may mildly indent the ventral cord contour at these levels. Some possible neuroforaminal narrowing is also noted at levels as stated above. orthopedic, mri cervical spine, ventral cord contour, cervical spine, spinal cord, cord contour, ventral cord, mri, narrowing, ventral, cord Orthopedic MRI Brain & MRI C-T spine: Multiple hemangioblastoma in Von Hippel Lindau Disease. MRI Brain and C-T Spine 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 Orthopedic MRI C-spine to evaluate right shoulder pain - C5-6 disk herniation. MRI C-Spine - C5-6 Disk Herniation 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. orthopedic, shoulder pain, stiffness, numbness, lhermitte's phenomena, c-spine lesion, disk herniation, mri c spine, reflexes, biceps, mri, disk, shoulder, spine, herniation, Orthopedic MRI cervical spine. MRI Cervical Spine - 1 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. orthopedic, borderline central canal stenosis, mri cervical spine, borderline central canal, central canal stenosis, degenerative disc, annular bulging, ap diameter, endplate spondylosis, borderline central, canal stenosis, disc desiccation, central canal, cervical, disc, spondylosis, stenosis, cord, canal, Orthopedic MRI right ankle. MRI Ankle - 2 EXAM:,MRI OF THE RIGHT ANKLE,CLINICAL:,Pain.,FINDINGS:,The bone marrow demonstrates normal signal intensity. There is no evidence of bone contusion or fracture. There is no evidence of joint effusion. Tendinous structures surrounding the ankle joint are intact. No abnormal mass or fluid collection is seen surrounding the ankle joint.,IMPRESSION,: NORMAL MRI OF THE RIGHT ANKLE. orthopedic, ankle joint, bone, mri, ankle Orthopedic Left third digit numbness and wrist pain. MRI C3 - Cord Compression. 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. Orthopedic MRI report Cervical Spine (Chiropractic Specific) MRI Cervical Spine - Chiropractic Specific FINDINGS:,Normal foramen magnum.,Normal brainstem-cervical cord junction. There is no tonsillar ectopia. Normal clivus and craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: There is disc desiccation but no loss of disc space height, disc displacement, endplate spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina.,C3-4: There is disc desiccation with a posterior central disc herniation of the protrusion type. The small posterior central disc protrusion measures 3 x 6mm (AP x transverse) in size and is producing ventral thecal sac flattening. CSF remains present surrounding the cord. The residual AP diameter of the central canal measures 9mm. There is minimal right-sided uncovertebral joint arthrosis but no substantial foraminal compromise.,C4-5: There is disc desiccation, slight loss of disc space height with a right posterior lateral pre-foraminal disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis. The disc osteophyte complex measures approximately 5mm in its AP dimension. There is minimal posterior annular bulging measuring approximately 2mm. The AP diameter of the central canal has been narrowed to 9mm. CSF remains present surrounding the cord. There is probable radicular impingement upon the exiting right C5 nerve root.,C5-6: There is disc desiccation, moderate loss of disc space height with a posterior central disc herniation of the protrusion type. The disc protrusion measures approximately 3 x 8mm (AP x transverse) in size. There is ventral thecal sac flattening with effacement of the circumferential CSF cleft. The residual AP diameter of the central canal has been narrowed to 7mm. Findings indicate a loss of the functional reserve of the central canal but there is no cord edema. There is bilateral uncovertebral and apophyseal joint arthrosis with moderate foraminal compromise.,C6-7: There is disc desiccation, mild loss of disc space height with 2mm of posterior annular bulging. There is bilateral uncovertebral and apophyseal joint arthrosis (left greater than right) with probable radicular impingement upon the bilateral exiting C7 nerve roots.,C7-T1, T1-2: There is disc desiccation with no disc displacement. Normal central canal and intervertebral neural foramina.,T3-4: There is disc desiccation with minimal 2mm posterior annular bulging but normal central canal and CSF surrounding the cord.,IMPRESSION:,Multilevel degenerative disc disease with uncovertebral joint arthrosis with foraminal compromise as described above.,C3-4 posterior central disc herniation of the protrusion type but no cord impingement.,C4-5 right posterior lateral disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis with probable radicular impingement upon the right C5 nerve root.,C5-6 degenerative disc disease with a posterior central disc herniation of the protrusion type producing borderline central canal stenosis with effacement of the circumferential CSF cleft indicating a limited functional reserve of the central canal.,C6-7 degenerative disc disease with annular bulging and osseous foraminal compromise with probable impingement upon the bilateral exiting C7 nerve roots.,T3-4 degenerative disc disease with posterior annular bulging. orthopedic, exiting c nerve roots, loss of disc space, posterior central disc herniation, herniation of the protrusion, uncovertebral and apophyseal joint, intervertebral neural foramina, ventral thecal sac, thecal sac flattening, disc osteophyte complex, disc space height, central disc herniation, apophyseal joint arthrosis, posterior annular bulging, degenerative disc disease, posterior central disc, csf cleft, osteophyte complex, radicular impingement, disc disease, central disc, annular bulging, disc desiccation, joint arthrosis, central canal, cervical, degenerative, csf, foraminal, bulging, impingement, protrusion, uncovertebral, arthrosis, canal Orthopedic Patient with right ankle pain. MRI Ankle - 1 "EXAM:,MRI RIGHT ANKLE,CLINICAL:,This is a 51 year old female who first came into the office 3/4/05 with right ankle pain. She stepped on ice the evening prior and twisted her ankle. PF's showed no frank fracture, dislocation, or subluxations.,FINDINGS:,Received for interpretation is an MRI examination performed on 4/28/2005.,There is a ""high ankle sprain"" of the distal tibiofibular syndesmotic ligamentous complex involving the anterior tibiofibular ligament with marked ligamentous inflammatory thickening and diffuse interstitial edema. There is osteoarthritic spur formation at the anterior aspect of the fibula with a small 2mm osseous structure within the markedly thickened anterior talofibular ligament suggesting a small ligamentous osseous avulsion. The distal tibiofibular syndesmotic ligamentous complex remains intact without a complete rupture. There is no widening of the ankle mortis. The posterior talofibular ligament remains intact.,There is marked ligamentous thickening of the anterior talofibular ligament of the lateral collateral ligamentous complex suggesting the sequela of a remote lateral ankle sprain. There is thickening of the posterior talofibular and calcaneofibular ligaments.,There is a flat retromalleolar sulcus.,There is a full-thickness longitudinal split tear of the peroneus brevis tendon within the retromalleolar groove. The tear extends to the level of the inferior peroneal retinaculum. There is anterior displacement of the peroneus longus tendon into the split peroneus tendon tear.,There is severe synovitis of the peroneus longus tendon sheath with prominent fluid distention. The synovitis extends to the level of the inferior peroneal retinaculum.,There is a focal area of chondral thinning of the hyaline cartilage of the medial talar dome with a focal area of subchondral plate cancellous marrow resorption consistent with and area of prior talar dome contusion but there is no focal osteochondral impaction or osteochondral defect.,There is minimal fluid within the tibiotalar articulation.,There is minimal fluid within the posterior subtalar articulation with mild anterior capsular prolapse. Normal talonavicular and calcaneocuboid articulations. The anterior superior calcaneal process is normal.,There is mild tenosynovitis of the posterior tibialis tendon sheath but an intrinsically normal tendon. There is an os navicularis (Type II synchondrosis) with an intact synchondrosis and no active marrow stress phenomenon.,Normal flexor digitorum longus tendon.,There is prominent fluid distention of the flexor hallucis longus tendon sheath with capsular distention proximal to the posterior talar processes with prominent fluid distention of the synovial sheath.,There is a loculated fluid collection within Kager’s fat measuring approximately 1 x 1 x 2.5cm in size, extending to the posterior subtalar facet joint consistent with a ganglion of either posterior subtalar facet origin or arising from the flexor hallucis longus tendon sheath.,There is mild tenosynovitis of the Achilles tendon with mild fusiform enlargement of the non-insertional Watershed zone of the Achilles tendon but there is no demonstrated tendon tear or tenosynovitis. There is a low-lying soleus muscle that extends to within 4cm of the teno-osseous insertion of the Achilles tendon. There is no Haglund’s deformity.,There is a plantar calcaneal spur measuring approximately 6mm in size, without a reactive marrow stress phenomenon. Normal plantar fascia.,IMPRESSION:,Partial high ankle sprain with diffuse interstitial edema of the anterior tibiofibular ligament with a ligamentous chip avulsion but without a disruption of the anterior tibiofibular ligament.,Marked ligamentous thickening of the lateral collateral ligamentous complex consistent with the sequela of a remote lateral ankle sprain.,Full-thickness longitudinal split tear of the peroneus brevis tendon with severe synovitis of the peroneal tendon sheath.,Post-traumatic deformity of the medial talar dome consistent with a prior osteochondral impaction injury but no osteochondral defect. Residual subchondral plate cancellous marrow edema.,Severe synovitis of the flexor hallucis longus tendon sheath with prominent fluid distention of the synovial sheath proximal to the posterior talar processes.,Septated cystic structure within Kager’s fat triangle extending along the superior aspect of the calcaneus consistent with a ganglion of either articular or synovial sheath origin.,Plantar calcaneal spur but no reactive marrow stress phenomenon.,Mild tendinosis of the Achilles tendon but no tendinitis or tendon tear.,Os navicularis (Type II synchondrosis) without an active marrow stress phenomenon." Orthopedic MRI Brain & T-spine - Demyelinating disease. MRI Brain & T-spine - Demyelinating disease. "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." orthopedic, sensory loss, lumbar puncture, peritrigonal region, centrum semiovale, mri brain, white matter, demyelinating disease, csf, demyelinating, mri, brain, Orthopedic Right hallux abductovalgus deformity. Right McBride bunionectomy. Right basilar wedge osteotomy with OrthoPro screw fixation. McBride Bunionectomy & Wedge Osteotomy 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., orthopedic, hallux, abductovalgus, bunionectomy, mcbride, basilar, wedge, osteotomy, orthopro, screw, fixation, wedge osteotomy Orthopedic Arthroscopy, medial meniscoplasty, lateral meniscoplasty, medial femoral chondroplasty, and medical femoral microfracture, right knee. Patellar chondroplasty. Lateral femoral chondroplasty. Meniscal tear, osteochondral lesion, degenerative joint disease, and chondromalacia, Meniscoplasty & Chondroplasty 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. Orthopedic Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism. Lumbar Radiculopathy - Consult FAMILY HISTORY:, Her father died from leukemia. Her mother died from kidney and heart failure. She has two brothers; five sisters, one with breast cancer; two sons; and a daughter. She describes cancer, hypertension, nervous condition, kidney disease, high cholesterol, and depression in her family.,SOCIAL HISTORY:, She is divorced. She does not have support at home. She denies tobacco, alcohol, and illicit drug use.,ALLERGIES: , Hypaque dye when she had x-rays for her kidneys.,MEDICATIONS: , Prempro q.d., Levoxyl 75 mcg q.d., Lexapro 20 mg q.d., Fiorinal as needed, currently she is taking it three times a day, and aspirin as needed. She also takes various supplements including multivitamin q.d., calcium with vitamin D b.i.d., magnesium b.i.d., Ester-C b.i.d., vitamin E b.i.d., flax oil and fish oil b.i.d., evening primrose 1000 mg b.i.d., Quercetin 500 mg b.i.d., Policosanol 20 mg two a day, glucosamine chondroitin three a day, coenzyme-Q 10 30 mg two a day, holy basil two a day, sea vegetables two a day, and very green vegetables.,PAST MEDICAL HISTORY:, Anemia, high cholesterol, and hypothyroidism.,PAST SURGICAL HISTORY:, In 1979, tubal ligation and three milk ducts removed. In 1989 she had a breast biopsy and in 2007 a colonoscopy. She is G4, P3, with no cesarean section.,REVIEW OF SYSTEMS: ,HEENT: For headaches and sore throat. Musculoskeletal: She is right handed with joint pain, stiffness, and decreased range of motion. Cardiac: For heart murmur. GI: Negative and noncontributory. Respiratory: Negative and noncontributory. Urinary: Negative and noncontributory. Hem-Onc: Negative and noncontributory. Vascular: Negative and noncontributory. Psychiatric: Negative and noncontributory. Genital: Negative and noncontributory. She denies any bowel or bladder dysfunction or loss of sensation in her genital area.,PHYSICAL EXAMINATION: , She is 5 feet 2 inches tall. Current weight is 132 pounds, weight one year ago was 126 pounds. BP is 122/68. On physical exam, patient is alert and oriented with normal mentation and appropriate speech, in no acute distress. General, a well-developed and well-nourished female in no acute distress. HEENT exam, head is atraumatic and normocephalic. Eyes, sclerae are anicteric. Teeth good dentition. Cranial nerves II, III, IV, and VI, vision is intact, visual fields are full to confrontation, EOMs full bilaterally, and pupils are equal, round, and reactive to light. Cranial nerves V and VII, normal facial sensation and symmetrical facial movement. Cranial nerve VIII, hearing intact. Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically.,Cranial nerve XI, strong and symmetrical shoulder shrugs against resistance. Cardiac, regular rate and rhythm. Chest and lungs are clear bilaterally. Skin is warm and dry, normal turgor and texture. No rashes or lesions are noted. General musculoskeletal exam reveals no gross deformities, fasciculations, or atrophy. Peripheral vascular, no cyanosis, clubbing, or edema. Examination of the low back reveals some mild paralumbar spasms. She is nontender to palpation of her spinous processes, SI joints, and paralumbar musculature. She does have some poking sensation to deep palpation into the left buttock where she describes some zinging sensation. Deep tendon reflexes are 2+ bilateral knees and ankles. No ankle clonus is elicited. Babinski, toes are downgoing. Straight leg raising is negative bilaterally. Strength on manual exam is 5/5 and equal bilateral lower extremity. She is able to ambulate on her toes and her heels without any difficulty. She is able to get up standing on one foot on to the toes. She does have some difficulty getting up on to her heels when standing on one foot. She has trouble with this on the left and right. She complains of increased pain while doing this as well. She also has positive Patrick/FABER on the right with pain with internal and external rotation, negative on the left. Sensation is intact. She has good accuracy to pinprick, dull versus sharp.,FINDINGS: , The patient brings in lumbar spine MRI dated November 20, 2007, which demonstrates degenerative disc disease throughout. At L4-L5, there is an annular disc bulge with fissuring with facet arthrosis and ligamentum flavum hypertrophy yielding moderate central stenosis and neuroforaminal narrowing but the nerves do not appear to be impinged. At L5-S1, in the right neuroforamina, there appears to be soft tissue density just lateral and posterior to the nerve root, which may cause some displacement, but it is unclear. This could represent a facet synovial cyst. This is lateral to the facet. She does not have x-rays for review. She has had hip and knee x-rays taken but does not bring them in with her.,ASSESSMENT: , Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.,PLAN: , We discussed treatment options with this patient including:,1 Do nothing.,2. Conservative therapies.,3. Surgery.,She seems to have some issues with her right hip, so I would like for her to fax us over the report of her hip and knee x-rays. We will also order some x-rays of her lumbar spine as well as lower extremity EMG.,At this point, the patient has not exhausted conservative measures and would like to start with epidural steroid injections, so we will go ahead and send her out for that. After she has gotten her second epidural injection, she will return to the office for a followup visit to see how she is doing. All questions and concerns were addressed. If she should have any further questions, concerns, or complications, she will contact our office immediately. Otherwise, we will see her as scheduled. Case was reviewed and discussed with Dr. L. orthopedic, back pain, hip pain, low back pain, x-rays, lumbar spinal stenosis, degenerative disc disease, spinal stenosis, lumbar spine, lumbar radiculopathy, cranial nerves, lumbar, degenerative, anemia, Orthopedic Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation. Lumbar Re-exploration PREOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,POSTOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,PROCEDURE: , Lumbar re-exploration for removal of fractured internal fixation plate from T11 through L2 followed by a repositioning of the L2 pedicle screws and evaluation of the fusion from T11 through L2 followed by a bilateral hemilaminectomy and diskectomy for decompression at L4-5 and L5-S1 with posterior lumbar interbody fusion using morselized autograft bone and the synthetic spacers from the Capstone system at L4-5 and L5-S1 followed by placement of the pedicle screw fixation devices at L3, L4, L5, and S1 and insertion of a 20 cm fixation plate that range from the T11 through S1 levels and then subsequent onlay fusion using morselized autograft bone and bone morphogenetic soaked sponge at L1-2 and then at L3-L4, L4-L5, and L5-S1 bilaterally.,DESCRIPTION OF PROCEDURE: ,This is a 68-year-old lady who presents with a history of osteomyelitis associated with the percutaneous vertebroplasty that was actually treated several months ago with removal of the infected vertebral augmentation and placement of a posterior pedicle screw plate fixation device from T11 through L2. She subsequently actually done reasonably well until about a month ago when she developed progressive severe intractable pain. Imaging study showed that the distal hardware at the plate itself had fractured consistent with incomplete fusion across her osteomyelitis area. There was no evidence of infection on the imaging or with her laboratory studies. In addition, she developed a pretty profound stenosis at L4-L5 and L5-S1 that appeared to be recurrent as well. She now presents for revision of her hardware, extension of fusion, and decompression.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia. She was placed on the operative table in the prone position. Back was prepared with Betadine, iodine, and alcohol. We elliptically excised her old incision and extended this caudally so that we had access from the existing hardware fixation all the way down to her sacrum. The locking nuts were removed from the screw post and both plates refractured or significantly weakened and had a crease in it. After these were removed, it was obvious that the bottom screws were somewhat loosened in the pedicle zone so we actually tightened one up and that fit good snugly into the nail when we redirected so that it actually reamed up into the upper aspect of the vertebral body in much more secure purchase. We then dressed the L4-L5 and L5-S1 levels which were profoundly stenotic. This was a combination of scar and overgrown bone. She had previously undergone bilateral hemilaminectomies at L4-5 so we removed scar bone and actually cleaned and significantly decompressed the dura at both of these levels. After completing this, we inserted the Capstone interbody spacer filled with morselized autograft bone and some BMP sponge into the disk space at both levels. We used 10 x 32 mm spacers at both L4-L5 and L5-S1. This corrected the deformity and helped to preserve the correction of the stenosis and then after we cannulated the pedicles of L4, L5 and S1 tightened the pedicle screws in L3. This allowed us to actually seat a 20 cm plate contoured to the lumbar lordosis onto the pedicle screws all the way from S1 up to the T11 level. Once we placed the plate onto the screws and locked them in position, we then packed the remaining BMP sponge and morselized autograft bone through the plate around the incomplete fracture healing at the L1 level and then dorsolaterally at L4-L5 and L5-S1 and L3-L4, again the goal being to create a dorsal fusion and enhance the interbody fusion as well. The wound was then irrigated copiously with bacitracin solution and then we closed in layers using #1 Vicryl in muscle and fascia, 3-0 in subcutaneous tissue and approximated staples in the skin. Prior to closing the skin, we confirmed correct sponge and needle count. We placed a drain in the extrafascial space and then confirmed that there were no other foreign bodies. The Cell Saver blood was recycled and she was given two units of packed red blood cells as well. I was present for and performed the entire procedure myself or supervised. orthopedic, degenerative spondylolisthesis, spondylolisthesis, stenosis, lumbar re-exploration, internal fixation plate, hemilaminectomy, diskectomy, synthetic spacers, pedicle screws, fusion, lumbar, pedicle, fixation, hardware, Orthopedic Medial branch rhizotomy, lumbosacral. Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine. Medial Branch Rhizotomy PROCEDURE: , Medial branch rhizotomy, lumbosacral.,INFORMED CONSENT:, The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications. I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing. The patient understood the informed consent and desired to have the procedure performed.,SEDATION: , The patient was given conscious sedation and monitored throughout the procedure. Oxygenation was given. The patient's oxygenation and vital signs were closely followed to ensure the safety of the administration of the drugs.,PROCEDURE: ,The patient remained awake throughout the procedure in order to interact and give feedback. The x-ray technician was supervised and instructed to operate the fluoroscopy machine. The patient was placed in the prone position on the treatment table with a pillow under the abdomen to reduce the natural lumbar lordosis. The skin over and surrounding the treatment area was cleaned with Betadine. The area was covered with sterile drapes, leaving a small window opening for needle placement. Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine. With fluoroscopy, a Teflon coated needle, ***, was gently guided into the region of the Medial Branch nerves from the Dorsal Ramus of ***. Specifically, each needle tip was inserted to the bone at the groove between the transverse process and superior articular process on lumbar vertebra, or for sacral vertebrae at the lateral-superior border of the posterior sacral foramen. Needle localization was confirmed with AP and lateral radiographs.,The following technique was used to confirm placement at the Medial Branch nerves. Sensory stimulation was applied to each level at 50 Hz; paresthesias were noted at,*** volts. Motor stimulation was applied at 2 Hz with 1 millisecond duration; corresponding paraspinal muscle twitching without extremity movement was noted at *** volts.,Following this, the needle Trocar was removed and a syringe containing 1% lidocaine was attached. At each level, after syringe aspiration with no blood return, 1cc 1% lidocaine was injected to anesthetize the Medial Branch nerve and surrounding tissue. After completion of each nerve block a lesion was created at that level with a temperature of 85 degrees Celsius for 90 seconds. All injected medications were preservative free. Sterile technique was used throughout the procedure.,COMPLICATIONS:, None. No complications.,The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable. The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day. The patient was told to resume all medications. The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week. orthopedic, lumbosacral, medial branch rhizotomy, medial branch nerves, rhizotomy, fluoroscopy, Orthopedic Injection for myelogram and microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain. Lumbar Laminectomy & Discectomy 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. orthopedic, microscopic-assisted lumbar laminectomy, discectomy, nerve root, lumbar laminectomy, herniated nucleus, thecal sac, spinal needle, nucleus pulposus, disc space, root, nerve, weakness, lumbar, laminectomy, nucleus, pulposus, myelogram Orthopedic Low back pain and right lower extremity pain - Lumbar spine herniated nucleus pulposus. Lumbar Spine HNP - Consult 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. Orthopedic Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal. Lumbar stenosis and cerebrospinal fluid fistula. Lumbar Laminectomy 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. orthopedic, microtechniques, fistula, duraseal, foraminotomies, lumbar, stenosis, cerebrospinal, lumbar laminectomy, ligamentum flavum, csf, laminectomy, lamina, Orthopedic Lumbar puncture. 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. Lumbar Puncture - 2 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. orthopedic, spinal needle, lumbar puncture, lumbar, gauge, csf Orthopedic Lumbar discogram L2-3, L3-4, L4-5, and L5-S1. Low back pain. Lumbar Discogram 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. orthopedic, back pain, c-arm, fluoroscopic projections, disc space, lumbar discogram, fluoroscopic, needle, Orthopedic Lumbar muscle strain and chronic back pain. Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago. Lower back pain "HISTORY OF PRESENT ILLNESS:, Patient is a 50-year-old white male complaining of continued lower back pain. Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago. He states he helped a friend unload a motorcycle from a vehicle two-and-a-half days ago, after which he ""felt it"" in his lower back. The following day (two days ago), he states he rode to Massachusetts and Maine to pick up clients. He feels that this aggravated his chronic back pain as well. He also claims to have a screw in his right hip from a previous surgery to repair a pelvic fracture. He is being prescribed Ultram, Celebrex, gabapentin, and amitriptyline by his PCP for his chronic back pain. He states that his PCP has informed him that he does not prescribe opiate medications for chronic back pain.,The patient did self-refer to another physician, who suggested that he follow up at a pain clinic for his chronic back pain to discuss other alternatives, particularly the medications that the patient feels that he needs. Patient states he did not do this because he was feeling well at that time.,The patient did present to our emergency room last night, at which time he saw Dr. X. He was given a prescription for 12 Vicodin as well as some to take home last night. The patient has not picked up his prescription as of yet and informed the triage nurse that he was concerned that he would not have enough to last through the weekend. Patient states he also has methadone and Darvocet at home from previous prescription and is wondering if he should restart these medicines. He is on several medications, the list of which is attached to the chart.,MEDICATIONS: , In addition to the aforementioned medications, he is on Cymbalta, pantoprazole, and a multivitamin.,ALLERGIES:, HE IS ALLERGIC TO RELAFEN (ITCHING).,SOCIAL HISTORY: , The patient is married and lives with his wife.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse is elevated at 105. Temp and other vitals signs are all within normal limits.,GENERAL: Patient is a middle-aged white male who is sitting on the stretcher in no acute distress.,BACK: Exam of the back shows some generalized tenderness on palpation of the musculature surrounding the lumbar spine, more so on the right than on the left. There is a well-healed upper lumbar incision from his previous L1-L2 fusion. There is no erythema, ecchymosis, or soft-tissue swelling. Mobility is generally very good without obvious signs of discomfort.,HEART: Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS: Clear without rales, rhonchi, or wheezes.,MUSCULOSKELETAL: With the patient supine, there is some discomfort in the lower back with bent-knee flexion of both hips as well as with straight leg abduction of the left leg. There is some mild discomfort on internal and external rotation of the hips as well. DTRs are 1+ at the knees and trace at the ankles.,I explained to the patient that he is suffering from a chronic condition and as his PCP has made it clear that he is unwilling to prescribe opiate medication, which the patient feels that he needs, and he is obligated to follow up at the pain clinic as suggested by the other physician even if he is having a ""good day."" I explained to him that if he did not investigate other alternatives to what his PCP is willing to prescribe, then on a ""bad day,"" he will have nowhere else to turn. I explained to him that some emergency physicians do chose to use opiates for a short term as Dr. X did last night. It is unclear if the patient is looking for a different opiate medication, but I do not think it is wise to give him more, particularly as he has not even filled the prescription that was given to him last night. I did suggest that he not restart his methadone and Darvocet at this time as he is already on five different medications for his back (Celebrex, tramadol, amitriptyline, gabapentin, and the Vicodin that he was given last night). I did suggest that we could try a different anti-inflammatory if he felt that the Celebrex is not helping. The patient is agreeable to this.,ASSESSMENT,1. Lumbar muscle strain.,2. Chronic back pain.,PLAN: , At this point in time, I felt that it was safe for the patient to transition to heat to his back which he may use as often as possible. Rx for Voltaren 75 mg tabs, dispensed 20, sig. one p.o. q.12h. for pain instead of Celebrex. He may continue with his other medications as directed but not the methadone or Darvocet. I did urge him to reschedule his pain clinic appointment as he was urged to do originally. If unimproved this week, he should follow up with Dr. Y." orthopedic, back pain, lumbar muscle strain, chronic back pain, illness, lower, medications, Orthopedic Microscopic lumbar discectomy, left L5-S1. Extruded herniated disc, left L5-S1. Left S1 radiculopathy (acute). Morbid obesity. Lumbar Discectomy - Microscopic PREOPERATIVE DIAGNOSES:,1. Extruded herniated disc, left L5-S1.,2. Left S1 radiculopathy (acute).,3. Morbid obesity.,POSTOPERATIVE DIAGNOSES:,1. Extruded herniated disc, left L5-S1.,2. Left S1 radiculopathy (acute).,3. Morbid obesity.,PROCEDURE PERFORMED: , Microscopic lumbar discectomy, left L5-S1.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,50 cc.,HISTORY: , This is a 40-year-old female with severe intractable left leg pain from a large extruded herniated disc at L5-S1. She has been dealing with these symptoms for greater than three months. She comes to my office with severe pain, left my office and reported to the Emergency Room where she was admitted for pain control one day before surgery. I have discussed the MRI findings with the patient and the potential risks and complications. She was scheduled to go to surgery through my office, but because of her severe symptoms, she was unable to keep that appointment and reported right to the Emergency Room. We discussed the diagnosis and the operative procedure in detail. I have reviewed the potential risks and complications and she had agreed to proceed with the surgery. Due to the patient's weight which exceeds 340 lb, there was some concern about her operative table being able to support her weight and also my standard microlumbar discectomy incision is not ________ in this situation just because of the enormous size of the patient's back and abdomen and I have discussed this with her. She is aware that she will have a much larger incision than what is standard and has agreed to accept this.,OPERATIVE PROCEDURE: ,The patient was taken to OR #5 at ABCD General Hospital. While in the hospital gurney, Department of Anesthesia administered general anesthetic, endotracheal intubation was followed. A Jackson table was prepared for the patient and was reinforced replacing struts under table to prevent the table from collapsing. The table reportedly does have a limit of 500 lb, but the table has never been stressed above 275 lb. Once the table was reinforced, the patient was carefully rolled in a prone position on the Jackson table with the bony prominences being well padded. A marker was placed in from the back at this time and an x-ray was obtained for incision localization. The back is now prepped and draped in the usual sterile fashion. A midline incision was made over the L5-S1 disc space taking through subcutaneous tissue sharply with a #10 Bard-Parker scalpel. The lumbar dorsal fascia was then encountered and incised to the left of midline. In the subperiosteal fashion, the musculature was elevated off the lamina at L5 and S1 after facet joint, but not disturbing the capsule. A second marker was now placed and an intraoperative x-ray confirms our location at the L5-S1 disc space. The microscope was brought into the field at this point and the remainder of the procedure done with microscopic visualization and illumination. A high speed drill was used to perform a laminotomy by removing small portion of the superior edge of the S1 lamina and the inferior edge of the L5 lamina. Ligaments and fragments were encountered and removed at this time. The epidural space was now encountered. The S1 nerve root was now visualized and found to be displaced dorsally as a result of a large disc herniation while the nerve was carefully protected with a Penfield. A small stab incision was made into the disc fragment and probably a large portion of disc extrudes from the opening. This disc fragment was removed and the nerve root was much more supple, it was carefully retracted. The nerve root was now retracted and using a series of downgoing curettes, additional disc material was removed from around the disc space and from behind the body of S1 and L5. At this point, all disc fragments were removed from the epidural space. Murphy ball was passed anterior to the thecal sac in the epidural space and there was no additional compression that I can identify. The disc space was now encountered and loose disc fragments were removed from within the disc space. The disc space was then irrigated. The nerve root was then reassessed and found to be quite supple. At this point, the Murphy ball was passed into the foramen of L5 and this was patent and also into the foramen of S1 by passing ventral and dorsal to the nerve root and there were no obstructions in the passage of the device. At this point, the wound was irrigated copiously and suctioned dry. Gelfoam was used to cover the epidural space. The retractors were removed at this point. The fascia was reapproximated with #1 Vicryl suture, subcutaneous tissue with #2-0 Vicryl suture and Steri-Strips for curved incision. The patient was transferred to the hospital gurney in supine position and extubated by Anesthesia, subsequently transferred to Postanesthesia Care Unit in stable condition. orthopedic, extruded herniated disc, radiculopathy, microscopic, lumbar, discectomy, lumbar discectomy, morbid obesity, herniated disc, epidural space, nerve root, disc space, space, intractable, lamina, epidural, incision, nerve, herniated, Orthopedic New patient consultation - Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation. Low Back Pain - Consult FAMILY HISTORY: , His parents are deceased. He has two brothers ages 68 and 77 years old, who are healthy. He has siblings, a brother and a sister who were twins who died at birth. He has two sons 54 and 57 years old who are healthy. He describes history of diabetes and heart attack in his family.,SOCIAL HISTORY: ,He is married and has support at home. He denies tobacco and illicit drug use and drinks two to three alcoholic beverages a day and up to four to nine per week.,ALLERGIES:, Garamycin.,MEDICATIONS: , Insulin 20 to 25 units twice a day. Lorazepam 0.05 mg, he has a history of using this medication, but most recently stopped taking it. Glipizide 5 mg with each meal, Advair 250 as needed, aspirin q.h.s., cod liver oil b.i.d., Centrum AZ q.d.,PAST MEDICAL HISTORY: ,The patient has been diabetic for 35 years, has been insulin-dependent for the last 20 years. He also has a history of prostate cancer, which was treated by radiation. He says his PSA is at 0.01.,PAST SURGICAL HISTORY:, In 1985, he had removal of a testicle due to enlarged testicle, he is not quite sure of the cause but he states it was not cancer.,REVIEW OF SYSTEMS: , Musculoskeletal: He is right-handed. Respiratory: For shortness of breath. Urinary: For frequent urination. GI: He denies any bowel or bladder dysfunction. Genital: He denies any loss of sensation or erectile problems. HEENT: Negative and noncontributory. Hem-Onc: Negative and noncontributory. Cardiac: Negative and noncontributory. Vascular: Negative and noncontributory. Psychiatric: Negative and noncontributory.,PHYSICAL EXAMINATION: , He is 5 feet 10 inches tall. Current weight is 204 pounds, weight one year ago was 212. BP is 130/66. Pulse is 78. On physical exam, the patient is alert and oriented with normal mentation and appropriate speech, in no acute distress. HEENT exam, head is atraumatic and normocephalic. Eyes, sclerae are anicteric. Teeth, poor dentition. Cranial nerves II, III, IV, and VI, vision intact, visual fields full to confrontation, EOMs full bilaterally, and pupils are equal, round, and reactive to light. Cranial nerves V and VII, normal facial sensation and symmetrical facial movements. Cranial nerve VIII, hearing is intact. Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically. Cardiac, regular rate, a holosystolic murmur is also noted which is about grade 1 to 2. Chest and lungs are clear bilaterally. Skin is warm and dry, normal turgor and texture. No rashes or lesions are noted. Peripheral vascular, no cyanosis, clubbing, or edema is noted. General musculoskeletal exam reveals no gross deformities, fasciculations, or atrophy. Station and gait are appropriate. He ambulates well without any difficulties or assistance. No antalgic or spastic gait is noted. Examination of the low back reveals no paralumbar spasms. He is nontender to palpation over his spinous process, SI joints, or paralumbar musculature. Deep tendon reflexes are 2+ bilaterally at the knees and 1+ at the ankles. No ankle clonus is elicited. Babinski, toes are downgoing. Sensation is intact.,He does have some decreased sensation to pinprick, dull versus sharp over the right lower extremity compared to that of the left. Strength is 5/5 and equal bilateral lower extremities. He is able to ambulate on his toes and his heels without any weakness noted. He has negative straight leg raising bilaterally.,FINDINGS:, The patient brings in lumbar spine MRI for 11/15/2007, which demonstrates degenerative disc disease throughout. At L4-L5 and L5-S1 he has severe disc space narrowing. At L3-L4, he has degenerative changes of the facet with ligamentum flavum hypertrophy and annular disc bulge, which caused moderate neuroforaminal narrowing. At L4-L5, degenerative changes within the facets with ligamentum flavum hypertrophy as well causing neuroforaminal narrowing and central stenosis. At L5-S1, there is an annular disc bulge more to the right causing right-sided neuroforaminal stenosis, which is quite severe compared to that on the left.,ASSESSMENT: , Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation.,PLAN: , We discussed treatment options with this patient including:,1. Do nothing.,2. Conservative therapies.,3. Surgery.,The patient states that his pain is very well tolerated by minimizing his activity and would like to do just pain management with some pain pills only as needed. We went ahead and obtained an EKG in the office today due to the fact that I heard a murmur on exam. I did phone the patient's primary care doctor, Dr. O. Unfortunately Dr. O is out of the country, and I did speak with Dr. K, who is covering for Dr. O. I informed Dr. K that the patient had a new-onset murmur and that I did have some concerns for the patient does not recollect having this diagnosis before, so I obtained an EKG. A copy was provided to the patient and the patient was referred back to his primary care physician for workup. He was also released from our care at this time to a p.r.n. basis, but the patient does not wish to proceed with any neurosurgical intervention nor any conservative measures besides medications, which he will receive from his primary doctor.,All questions and concerns were addressed. If he should have any further questions, concerns, or complications, he will contact our office immediately. Otherwise, we will see him p.r.n. Warning signs and symptoms were gone over with him. Case was reviewed and discussed with Dr. L. orthopedic, back pain, ligamentum flavum hypertrophy, annular disc bulge, degenerative disc disease, spinal stenosis, cranial nerves, degenerative, Orthopedic " Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus of L5-S1 on the left. " Lumbar Laminotomy & Discectomy PREOPERATIVE DIAGNOSIS:, Herniated nucleus pulposus of L5-S1 on the left.,POSTOPERATIVE DIAGNOSIS: ,Herniated nucleus pulposus of L5-S1 on the left.,PROCEDURE PERFORMED:, Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMENS: , Disc that was not sent to the lab.,DRAINS: , None.,COMPLICATIONS: , None.,SURGICAL PROGNOSIS: , Remains guarded due to her ongoing pain condition and Tarlov cyst at the L5 nerve root distally.,SURGICAL INDICATIONS: , The patient is a 51-year-old female who has had unrelenting low back pain that radiated down her left leg for the past several months. The symptoms were unrelieved by conservative modalities. The symptoms were interfering with all aspects of daily living and inability to perform any significant work endeavors. She is understanding the risks, benefits, potential complications, as well as all treatment alternatives. She wished to proceed with the aforementioned surgery due to her persistent symptoms. Informed consent was obtained.,OPERATIVE TECHNIQUE: , The patient was taken to OR room #5 where she was given general anesthetic by the Department of Anesthesia. She was subsequently placed on the Jackson spinal table with the Wilson attachment in the prone position. Palpation did reveal the iliac crest and suspected L5-S1 interspace. Thereafter the lumbar spine was serially prepped and draped. A midline incision was carried over the spinal process of L5 to S1. Skin and subcutaneous tissue were divided sharply. Electrocautery provided hemostasis. Electrocautery was then utilized to dissect through the subcutaneous tissues to the lumbar fascia. Lumbar fascia was identified and the decussation of fibers was identified at the L5-S1 interspace. On the left side, superior aspect dissection was carried out with the Cobb elevator and electrocautery. This revealed the interspace of suspect level of L5-S1 on the left. A Kocher clamp was placed between the spinous processes of the suspect level of L5-S1. X-ray did confirm the L5-S1 interval. Angled curet was utilized to detach the ligamentum flavum from its bony attachments at the superior edge of S1 lamina and the inferior edge of the L5 lamina. Meticulous dissection was undertaken and the ligamentum flavum was removed. Laminotomy was created with Kerrison rongeur, both proximally and distally. The microscope was positioned and the dura was inspected. A blunt Penfield elevator was then utilized to dissect and identify the L5-S1 nerve root on the left. It was noted to be tented over a disc extrusion. The nerve root was protected and medialized. It was retracted with a nerve root retractor. This did reveal a subligamentous disc herniation at approximately the L5-S1 disc space and neuroforaminal area. A #15 Bard-Parker blade was utilized to create an annulotomy. Medially, disc material was extruding through this annulotomy. Two tier rongeur was then utilized to grasp the disc material and the disc was removed from the interspace. Additional disc material was then removed, both to the right and left of the annulotomy. Up and downbiting pituitary rongeurs were utilized to remove any other loose disc pieces. Once this was completed, the wound was copiously irrigated with antibiotic solution and suctioned dry. The Penfield elevator was placed in the disc space of L5-S1 and a crosstable x-ray did confirm this level. Nerve root was again expected exhibiting the foramina. A foraminotomy was created with a Kerrison rongeur. Once this was created, the nerve root was again inspected and deemed free of tension. It was mobile within the neural foramina. The wound was again copiously irrigated with antibiotic solution and suctioned dry. A free fat graft was then harvested from the subcutaneous tissues and placed over the exposed dura. Lumbar fascia was then approximated with #1 Vicryl interrupted fashion, subcutaneous tissue with #2-0 Vicryl interrupted fashion, and #4-0 undyed Vicryl was utilized to approximate the skin. Compression dressing was applied. The patient was turned, awoken, and noted to be moving all four extremities without apparent deficits. She was taken to the recovery room in apparent satisfactory condition. Expected surgical prognosis remains guarded due to her ongoing pain syndrome that has been requiring significant narcotic medications. orthopedic, lumbar laminotomy with discectomy, microscopic assisted, herniated nucleus pulposus, subcutaneous tissue, ligamentum flavum, kerrison rongeur, penfield elevator, lumbar laminotomy, lumbar fascia, nerve root, discectomy, lumbar, laminotomy, herniated, Orthopedic Evaluation for right L4 selective nerve root block. Lower Extremity Pain REASON FOR REFERRAL:, Evaluation for right L4 selective nerve root block.,CHIEF COMPLAINT:, Orthopedic Ligament reconstruction and tendon interposition arthroplasty of right wrist. Ligament Reconstruction & Tendon Interposition Arthroplasty 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. orthopedic, arthroplasty, ligament, tendon, fcr, tendon interposition arthroplasty, ligament reconstruction, reconstruction, trapezium, metacarpal, joint, interposition, Orthopedic Closed reduction and placement of long-arm cast. Long-Arm Cast PREOPERATIVE DIAGNOSIS:, Left distal radius fracture displaced.,POSTOPERATIVE DIAGNOSIS: , Left distal radius fracture displaced.,SURGERY: ,Closed reduction and placement of long-arm cast, CPT code 25605.,ANESTHESIA: ,General LMA.,FINDINGS: ,The patient was found to have a displaced fracture. She was found to be in perfect alignment after closed reduction and placement of cast. The radial deviation was well corrected.,INDICATIONS: , The patient is 5 years old. She was seen in our office today 1 week after being placed into a cast for a displaced fracture. She was noted to have significant loss of alignment especially on the lateral view. She was indicated for closed reduction and placed of the long-arm cast. Risks and benefits were discussed at length with the family. They wished to proceed.,PROCEDURE: ,The patient was brought to the operating room and placed on the operating table in supine position. General anesthesia was induced without incident. Previous cast was previously removed. An arm was approached and a closed reduction was performed. This was checked under AP and lateral projection and was found to be in adequate alignment. There was very mild residual dorsiflexion deformity noted.,A long-arm cast was then placed with plaster and molding. Repeat x-rays demonstrated adequate alignment on both views.,The cast was then reinforced with fiberglass. The patient was awakened from anesthesia and taken to recovery room in good condition. There were no complications. All instruments, sponge, and needle counts were correct at the end of case.,PLAN: ,The patient will be discharged home. She will return in 3 weeks for cast removal and clinical examination. She would likely be placed into a wrist-guard at that time. She has a prescription for Tylenol with codeine elixir., orthopedic, long-arm cast, closed reduction, displaced fracture, radial deviation, distal radius fracture, arm cast Orthopedic Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin. Repair of lateral meniscus using two fast fixed meniscal repair sutures. Partial medial meniscectomy. Partial chondroplasty of patella. Lateral retinacular release. Open medial plication as well of the right knee. Ligament Reconstruction & Meniscus Repair PREOPERATIVE DIAGNOSES:,1. Torn anterior cruciate ligament, right knee.,2. Patellofemoral instability, right knee.,3. Possible torn medial meniscus.,POSTOPERATIVE DIAGNOSES:,1. Complete tear anterior cruciate ligament, right knee.,2. Complex tear of the posterior horn lateral meniscus.,3. Tear of posterior horn medial meniscus.,4. Patellofemoral instability.,5. Chondromalacia patella.,PROCEDURES PERFORMED:,1. Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin.,2. Repair of lateral meniscus using two fast fixed meniscal repair sutures.,3. Partial medial meniscectomy.,4. Partial chondroplasty of patella.,5. Lateral retinacular release.,6. Open medial plication as well of the right knee.,ANESTHESIA:, General.,COMPLICATIONS:, None.,TOURNIQUET TIME:, 130 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , There was noted to be a grade-II chondromalacia patellofemoral joint. The patella was noted to be situated laterally past the lateral femoral condyle. There was a tear to the posterior horn of the medial meniscus within the white zone. There was a complex tear involving a horizontal cleavage component to the posterior horn of the lateral meniscus as well in the entire meniscus. There was a complete tear of the anterior cruciate ligament. The posterior cruciate ligament appeared intact. Preoperatively, she had a positive Lachman with a positive pivot shift test as well as increased patellofemoral instability.,HISTORY: , This is a 39-year-old female who has sustained a twisting injury to her knee while on trampoline in late August. She was diagnosed per MRI. An MRI confirmed the clinical diagnosis of anterior cruciate ligament tear. She states she has had multiple episodes of instability to the patellofemoral joint throughout the years with multiple dislocations. She elected to proceed with surgery to repair the anterior cruciate ligament as well as possibly plicate the medial retinaculum to help prevent further dislocations of the patellofemoral joint. All risks and benefits of surgery were discussed with her at length. She was in agreement with the treatment plan.,PROCEDURE: ,On 09/11/03, she was taken to the operating room at ABCD General Hospital. She was placed supine on the operating table. General anesthetic was applied by the Anesthesiology Department. Tourniquet was placed on the proximal thigh and it was then placed in a knee holder. She was sterilely prepped and draped in the usual fashion. An Esmarch was used to exsanguinate the lower extremity. Tourniquet was inflated to 325 mmHg. Longitudinal incision was made just medial to the tibial tubercle. The subcutaneous tissue was carefully dissected. Hemostasis was controlled with electrocautery. The tendons of gracilis and semitendinosus were identified and isolated, and then stripped off the musculotendinous junction. They were taken on the back table. The soft tissue debris was removed from the tendons. The ends of the tendons were sewn together using #5 Tycron whip type sutures. The tendons were measured on back table and found to be 8 mm as the most adequate size, they were then placed under tension on the back table. Stab incision was made in the inferolateral parapatellar region, through this camera was placed in the knee. The knee was inflated with saline solution and operative pictures were obtained. The above findings were noted. A second port site was initiated in the inferomedial parapatellar region. Through this, a probe was placed. Tear in the posterior horn medial meniscus was identified. It was resected using a meniscal resector. It was then further contoured using arthroscopic shaver. Attention was then taken to the lateral compartment. A partial meniscectomy was performed using the resector and the shaver. The posterior periphery of the lateral meniscus was also noticed to be unstable. A repair was then performed using two fasting fixed meniscal repair sutures to help anchor the meniscus around the popliteus tendon. There was noted to be excellent fixation. The shaver was then taken into the intrachondral notch. First a partial chondroplasty was performed on the patella to remove the loose articular debris as well as a partial synovectomy to the medial aspect of the patellar femoral joint. Next, the remnant of the anterior cruciate ligament was removed using the arthroscopic shaver and arthroplasty was then performed on the medial aspect of the lateral femoral condyle. Next, a tibial guide was placed through the anterior medial portal. A ___ pin was then placed up through the anterior incision entering the tibial eminence just anterior to the posterior cruciate ligament. This tibial tunnel was then drilled using 8 mm cannulated drill. Next, an over-the-top guide was then placed at approximately the 11:30 position. A ____ pin was then placed into the femur and 8 mm drill was then used to drill this femoral tunnel approximately 35 mm. Next the U shape guide was placed through tibial tunnel into the femur. A pin was then placed through the distal femur from lateral to medial, through the U-shaped guide a puller wire was then passed through the distal femur. It was then pulled out through the tibial tunnel using the You-shaped guide. The tendon was then placed around the wire. The wire was pulled back up through the tibial into the femoral tunnel. A 40 mm bioabsorbable pin was then placed through the femoral tunnel securing the hamstring tendons. Attention was then pulled through the tibial tunnel. The knee was cycled approximately 20 times. A 9 mm bioabsorbable screw was then placed through the tibial tunnel fixating the distal aspect of the graft. There was noted definite fixation of the graft. There was no evidence of impingement either in full flexion or full extension. The knee was copiously irrigated and it was then suctioned dry. A longitudinal incision was made just medial to the patellofemoral joint. Soft tissues were carefully dissected and the medial retinaculum was incised along with the incision. Following this, a release of lateral retinaculum was performed using a knife to further release the patellofemoral joint and allow further medial plication. The medial retinaculum was then plicated using #1 Ethibond sutures and then oversewn with #0 Vicryl suture. The subcuticular tissues were reapproximated with #2-0 Vicryl simple interrupted sutures followed by a #4-0 PDS running subcuticular stitch. She was placed in a DonJoy knee immobilizer. The tourniquet was deflated. It was noted the lower extremity was warm and pink with good capillary refill. She was transferred to the recovery room in apparent stable and satisfactory condition. Prognosis for this patient is guarded. She will be full weightbearing on the lower extremity using the knee immobilizer locked in extension. She may remove her dressing two to three days, however, follow back in the office in 10 to 14 days for suture removal. She will require one to two more physical therapy to help regain motion and strength to the lower extremity. Orthopedic Lateral release with lengthening of the ECRB tendon. Lateral epicondylitis. Lateral Epicondylitis Release PREOPERATIVE DIAGNOSIS: ,Lateral epicondylitis. orthopedic, lateral release, ecrb tendon, ecrl, lateral epicondylitis, tourniquet, aponeurosis, epicondyle, antebrachial, epicondylitis, dissection, extensor, ecrb Orthopedic Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots. Right L4-S1 posterolateral fusion with local bone graft. Left L4 through S1 segmental pedicle screw instrumentation. Preparation harvesting of local bone graft. Laminotomy, Facetectomy & Foraminotomy PREOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,POSTOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,OPERATION PERFORMED:,1. Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.,2. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.,3. Right L4-S1 posterolateral fusion with local bone graft.,4. Left L4 through S1 segmental pedicle screw instrumentation.,5. Preparation harvesting of local bone graft.,ANESTHESIA: , General endotracheal.,PREPARATION:, Povidone-iodine.,INDICATION: , This is a gentleman with right-sided lumbosacral radiculopathy, MRI disclosed and lateral recess stenosis at the L4-5, L5-S1 foraminal narrowing in L4 and L5 roots. The patient was felt to be a candidate for decompression stabilization pulling distraction between the screws to relieve radicular pain. The patient understood major risks and complications such as death and paralysis seemingly rare, main concern is a 10 to 15% of failure rate to respond to surgery for which further surgery may or may not be indicated, small risk of wound infection, spinal fluid leak. The patient is understanding and agreed to proceed and signed the consent.,PROCEDURE: , The patient was brought to the operating room, peripheral venous lines were placed. General anesthesia was induced. The patient was intubated. Foley catheter was in place. The patient laid prone onto the OSI table using 6-post, pressure points were carefully padded; the back was shaved, sterilely prepped and draped. A previous incision was infiltrated with local and incised with a scalpel. The posterior spine on the right side was exposed in routine fashion along with transverse processes in L4-L5 in the sacral ala. Laminotomies were then performed at L4-L5 and L5-S1 in a similar fashion using Midas Rex drill with AM8 bit, inferior portion of lamina below and superior portion of lamina above, and the medial facet was drilled down to the thin shelf of bone. The thin shelf of bone along the ligamentum flavum moved in a piecemeal fashion with 2 and 3 mm Kerrison, bone was harvested throughout to be used for bone grafting. The L5 and S1 roots were completely unroofed in the lateral recess working lateral to the markedly hypertrophied facet joints. Transpedicular approaches were carried out for both L4 and L5 roots working lateral to medial and medial to lateral with foraminotomies, L4-L5 roots were extensively decompressed. Pars interarticularis were maintained. Using angled 2-mm Kerrisons hypertrophied ligamentum flavum, the superior facet of S1 and L5 was resected increasing the dimensions for the foramen passed lateral to medial and medial to lateral without further compromise. Pedicle screws were placed L4-L5 and S1 on the right side. Initial hole began with Midas Rex drill, deepened with a gear shift and with 4.5 mm tap, palpating with pedicle probe. It showed no penetration outside the pedicle vertebral body. At L4-L5 5.5 x 45 mm screws were placed and at S1 5.5 x 40 mm screw was placed. Good bone purchase was obtained. Gelfoam was placed over the roots laterally, corticated transverse processes lateral facet joints were prepared, small infuse sponge was placed posterolaterally on the right side, then the local bone graft from L4 to S1. Traction was applied between the L4-L5, L5-S1 screws locking notes were tightened out, heads were rotated fractured off about 2-3 mm traction were applied at each side, further opening the foramen for the exiting roots. Prior to placement of BMP, the wound was irrigated with antibiotic irrigation. Medium Hemovac drain was placed in the depth of wound, brought out through a separate stab incision. Deep fascia was closed with #1 Vicryl, subcutaneous fascia with #1 Vicryl, and subcuticular with 2-0 Vicryl. Skin was stapled. The drain was sutured in place with 2-0 Vicryl and connected to closed drain system. The patient was laid supine on the bed, extubated, and taken to recovery room in satisfactory condition. The patient tolerated the procedure well without apparent complication. Final sponge and needle counts are correct. Estimated blood loss 600 mL.,The patient received 200 mL of cell saver blood back. orthopedic, lumbosacral radiculopathy, lumbar spondylolysis, laminotomies, medial facetectomies, foraminotomies, decompression, nerve roots, fusion, bone graft, segmental, pedicle screw, transverse processes, bone, facetectomies, transpedicular, graft, pedicle Orthopedic History of right leg pain. Leg pain is no longer present. Leg Pain - Progress Note HISTORY OF PRESENT ILLNESS: , The patient is a 44-year-old man who was seen for complaints of low back and right thigh pain. He attributes this to an incident in which he was injured in 1994. I do not have any paperwork authenticating his claim that there is an open claim. Most recently he was working at Taco Bell, when he had a recurrence of back pain, and he was seen in our clinic on 04/12/05. He rated pain of approximately 8/10 in severity., ,He took a Medrol Dosepak and states that his pain level has decreased to approximately 4-5/10. He still localizes it to a band between L4 and the sacrum. He initially had some right leg pain but states that this is minimal and intermittent at the present time. His back history is significant for two laminectomies and a discectomy performed from 1990 to 1994. The area of concern was L4-L5., ,The patient's MRI dated 10/18/04 showed multi-level degenerative changes, with facet involvement at L2-L3, L3-L4 and L5-S1. There was no neural impingement. He also had an MR myelogram, which showed severe stenosis at L3-L4, however it was qualified in that it may have been artifact, rather than a genuine finding., ,REVIEW OF SYSTEMS:, Focal lower paralumbar pain, affecting both right and left sides, as well as intermittent right leg pain which appears to have improved significantly with the Medrol Dosepak. He denies any recent illness. He has no constitutional complaints such as fevers, chills or sweats. HEENT: The patient denies any cephalgia, ocular, nasopharyngeal symptoms. He has no dysphagia. Cardiovascular: He denies any palpitations, chest pain, syncope or near-syncope. Pulmonary: He denies any dyspnea or respiratory difficulties. GI: The patient has no abdominal pain, nausea or vomiting. GU: The patient denies any urinary frequency or dysuria. There is no gross hematuria. Dermatologic: The patient notes no new onset of rash or other dermatological abnormalities. Musculoskeletal: Denies any recent falls or near-falls. He denies any abnormalities of endocrine, immunologic, hematologic, organ systems. , ,MEDICATIONS: , Atenolol, Zestril, Vicodin., ,ALLERGIES:, None., ,SOCIOECONOMIC STATUS:, Lifting limitations of 5 pounds and limited stooping, bending and twisting., ,PHYSICAL EXAMINATION: , Vital signs: Blood pressure 158/86, respiration 14, pulse 60, temperature 100.2. He is sitting upright, alert and oriented and in no acute distress. Skin is warm and dry. Gross neurologic examination is normal. ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes. Neck: Full range of motion with no adenopathy or thyromegaly. Cardiovascular: Regular rate and rhythm. Lungs: Clear. , ,On examination of the lumbar spine, he is minimally tender to palpation. There is no overt muscular spasm. His range of motion is estimated at 40 degrees of flexion and 15 degrees of extension. Straight leg raises do not elicit any leg complaints on today's visit. Lower extremity reflexes are symmetric., ,DIAGNOSIS: , Low back pain with a history of right leg pain. The leg pain is no longer present. His pain level has improved., ,PLAN: ,1. The patient will take another Medrol Dosepak.,2. He can continue with physical therapy.,3. He also continues with the same lifting restrictions.,4. Follow up is within one week. Orthopedic Complete laminectomy, L4. and facetectomy, L3-L4 level. A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level. Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System. Posterior spinal fusion, L4 to S1. Insertion of morselized autograft, L4 to S1. Laminectomy & Facetectomy 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. Orthopedic Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation. Laminectomy & Foraminotomy Followup "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." orthopedic, spinal fusion, restless leg syndrome, posterior spinal fusion, pedicle screw, lumbar spine, bilateral foraminotomies, fluid collection, foraminotomy, instrumentation, laminectomy, screw, spine, Orthopedic A 13-year-old new patientfor evaluation of thoracic kyphosis. Family history of kyphosis in a maternal aunt and grandfather. She was noted by her parents to have round back posture. Kyphosis REASON FOR VISIT: , Kyphosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 13-year-old new patient is here for evaluation of thoracic kyphosis. The patient has a family history in a maternal aunt and grandfather of kyphosis. She was noted by her parents to have round back posture. They have previously seen another orthopedist who recommended observation at this time. She is here for a second opinion in regards to kyphosis. The patient denies any pain in her back or any numbness, tingling, or weakness in her upper or lower extremities. No problems with her bowels or bladder.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , Bilateral pinning of her ears.,SOCIAL HISTORY: ,She is currently an eighth grader at Middle School and is interested in basketball. She lives with both of her parents and has a 9-year-old brother. She had menarche beginning in September.,FAMILY HISTORY: ,Of kyphosis in great grandmother and second cousin.,REVIEW OF SYSTEMS: , She is in her usual state of health and is negative except otherwise as mentioned in the history of present illness.,MEDICATIONS: , She is currently on Zyrtec, Flonase, and Ceftin for an ear infection.,ALLERGIES: , No known drug allergies.,FINDINGS: , On physical exam, she is alert, oriented, and in no acute distress standing 63 inches tall. In regards to her back, her skin is intact with no rashes, lesions, and/or no dimpling or hair spots. No cafe au lait spots. She is not tender to palpation from her occiput to her sacrum. There is no evidence of paraspinal muscle spasm. On forward bending, there is a mild kyphosis. She is not able to touch her toes indicating her hamstring tightness. She has a full 5 out of 5 in all muscle groups. Her lower extremities including iliopsoas, quadriceps, gastroc-soleus, tibialis anterior, and extensor hallucis longus. Her sensation intact to light touch in L1 through L2 dermatomal distributions. She has symmetric limb lengths as well bilaterally from both the coronal and sagittal planes.,X-rays today included PA and lateral sclerosis series. She has approximately 46 degree kyphosis.,ASSESSMENT: , Kyphosis.,PLANS: ,The patient's kyphosis is quite mild. While this is likely in the upper limits of normal or just it is normal for an adolescent and still within normal range as would be expected return at home. At this time, three options were discussed with the parents including observation, physical therapy, and bracing. At this juncture, given that she has continued to grow, they are Risser 0. She may benefit from continued observation with physical therapy, bracing would be a more aggressive option certainly that thing would be lost with following at this time. As such, she was given a prescription for physical therapy for extension based strengthening exercises, flexibility range of motion exercises, postural training with no forward bending. We will see her back in 3 months' time for repeat radiographs at that time including PA and lateral standing of scoliosis series. Should she show evidence of continued progression of her kyphotic deformity, discussions of bracing would be held at time. We will see her back in 3 months' time for repeat evaluation. orthopedic, thoracic kyphosis, round back posture, physical therapy, kyphosis, patientfor, orthopedist, Orthopedic Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP. Status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy. Laminectomy & Discectomy & Facetectomy 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. orthopedic, revision laminectomy, discectomy, facetectomy, arthrodesis, lumbar spondylosis, hypermobility, collapsed disk space, medial facetectomy, interbody graft, herniated disk, interbody, laminectomy, disk, therapy, lumbar, herniated, space, Orthopedic Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1. Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation. 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. Laminectomy & Foraminotomy Revision 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. Orthopedic Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5. Songer wire. Right iliac bone graft. Laminectomy & Foraminotomy & Cervical Fusion PREOPERATIVE DIAGNOSES,1. Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2. Cervical radiculopathy involving the left arm.,3. Disc degeneration at C3-C4 and C6-C7.,POSTOPERATIVE DIAGNOSES,1. Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2. Cervical radiculopathy involving the left arm.,3. Disc degeneration at C3-C4 and C6-C7.,OPERATIVE PROCEDURES,1. Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy.,2. Posterior cervical fusion C4-C5.,3. Songer wire.,4. Right iliac bone graft.,TECHNIQUE: ,The patient was brought to the operating room. Preoperative evaluations included previous cervical spine surgery. The patient initially had some relief; however, his left arm pain did recur and gradually got worse. Repeat studies including myelogram and postspinal CTs revealed some blunting of the nerve root at C4-C5 and C5-C6. There was also noted to be some annular bulges at C3-C4, and C6-C7. The CT scan in March revealed that the fusion was not fully solid. X-rays were done in November including flexion and extension views, it appeared that the fusion was solid.,The patient had been on pain medication. The patient had undergone several nonoperative treatments. He was given the option of surgical intervention. We discussed Botox, I discussed with the patient and posterior cervical decompression. I explained to the patient this will leave a larger scar on his neck, and that no guarantee would help, there would be more bleeding and more pain from the posterior surgery than it was from the anterior surgery. If at the time of surgery there was some motion of the C4-C5 level, I would recommend a fusion. The patient was a smoker and had been advised to quit smoking but has not quit smoking. I have therefore recommended that he use iliac bone graft. I explained to the patient that this would give him a scar over the back of the right pelvis and could be a source of chronic pain for the patient for the rest of his life. Even if this type of bone graft was used, there was no guarantee that it will fuse and he should stop smoking completely.,The patient also was advised that if I did a fusion, I would also use post instrumentation, which was a wire. The wire would be left permanently.,Even with all these procedures, there was no guarantee that his symptoms would improve. His numbness, tingling, and weakness could get worse rather than better, his neck pain and arm pain could persist. He still had some residual bursitis in his left shoulder and this would not be cured by this procedure. Other procedures may be necessary later. There is still with a danger of becoming quadriplegic or losing total control of bowel or bladder function. He could lose total control of his arms or legs and end up in the bed for the rest of his life. He could develop chronic regional pain syndromes. He could get difficulty swallowing or eating. He could have substantial weakness in the arm. He was advised that he should not undergo the surgery unless the pain is persistent, severe, and unremitting.,He was also offered his records if he would like any other pain medications or seek other treatments, he was advised that Dr. X would continue to prescribe pain medication if he did not wish to proceed with surgery.,He stated he understood all the risks. He did not wish to get any other treatments. He said the pain has reached the point that he wished to proceed with surgery.,PROCEDURE IN DETAIL: , In the operating room, he was given general endotracheal anesthesia.,I then carefully rolled the patient on thoracic rolls. His head was controlled by a horseshoe holder. The anesthesiologist checked the eye positions to make sure there was no pressure on the orbits and the anesthesiologist continued to check them every 15 minutes. The arms, the right hip, and the neck was then prepped and draped. Care was taken to position both arms and both legs. Pulses were checked.,A midline incision was made through the skin and subcutaneous tissue on the cervical spine. A loupe magnification and headlamp illumination was used. Bleeding vessels were cauterized. Meticulous hemostasis was carried out throughout the procedure. Gradually and carefully I exposed the spinous process of the C6, C5, and C4. A lateral view was done after an instrument in place. This revealed the C6-C7 level. I therefore did a small laminotomy opening at C4-C5. I placed an instrument and x-rays confirmed C4-C5 level.,I stripped the muscles from the lamina and then moved them laterally and held with a self-retaining retractor.,Once I identified the level, I then used a bur to thin the lamina of C5. I used a 1-mm, followed by a 2-mm Kerrison rongeur to carefully remove the lamina off C5 on the left. I removed some of the superior lamina of C6 and some of the inferior lamina of C4. This allowed me to visualize the dura and the nerve roots and gradually do neural foraminotomies for both the C5 and C6 nerve roots. There was some bleeding from the epidural veins and a bipolar cautery was used. Absolutely no retractors were ever placed in the canal. There was no retraction. I was able to place a small probe underneath the nerve root and check the disc spaces to make sure there was no fragments of disc or herniation disc and none were found.,At the end of the procedure, the neuroforamen were widely patent. The nerve roots had been fully decompressed.,I then checked stability. There was micromotion at the C4-C5 level. I therefore elected to proceed with a fusion.,I debrided the interspinous ligament between C4 and C5. I used a bur to roughen up the surface of the superior portion of the spinous process of C5 and the inferior portion of C4. Using a small drill, I opened the facet at C4-C5. I then used a very small curette to clean up the articular cartilage. I used a bur then to roughen up the lamina at C4-C5.,Attention was turned to the right and left hip, which was also prepped. An incision made over the iliac crest. Bleeding vessels were cauterized. I exposed just the posterior aspect of the crest. I removed some of the bone and then used the curette to remove cancellous bone.,I placed the Songer wire through the base of the spinous process of C4 and C5. Drill holes made with a clip. I then packed cancellous bone between the decorticated spinous process. I then tightened the Songer wire to the appropriate tension and then cut off the excess wire.,Prior to tightening the wire, I also packed cancellous bone with facet at C4-C5. I then laid bone upon the decorticated lamina of C4 and C5.,The hip wound was irrigated with bacitracin and Kantrex. Deep structures were closed with #1 Vicryl, subcutaneous suture and subcuticular tissue was closed.,No drain was placed in the hip.,A drain was left in the posterior cervical spine. The deep tissues were closed with 0 Vicryl, subcutaneous tissue and skin were then closed. The patient was taken to the recovery room in good condition. Orthopedic KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels and bone biopsy. Kyphoplasty PRE-OP DIAGNOSIS:, Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,POST-OP DIAGNOSIS:, Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,PROCEDURE:,1. KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels.,2. Bone biopsy (medically necessary).,ANESTHESIA:, General,COMPLICATIONS:, None,BLOOD LOSS:, Minimal,INDICATIONS:, Mrs. Smith is a 75-year-old female who has had severe back pain that began approximately three months ago and is debilitating. She has been unresponsive to nonoperative treatment modalities including bed rest and analgesics. She presents with and is on medication therapy for COPD, diabetes and hypertension (other co-morbidities may be present upon admission and should be documented in the operative note).,Radiographic imaging including MRI confirms multiple compression fractures of the thoracolumbar spine including T12, L1 and L2. In addition to the fractures, she presents with kyphotic posture. Films on 1/04 demonstrated L1 and L2 osteoporotic fractures. Films on 2/04 demonstrated increased loss of height at L1. Films on 3/04 demonstrated a new compression fracture at T12 and further collapse of L1. The L2 fracture is documented on radiographic studies as being chronic and a year or more old. The T12 fracture has the most significant kyphotic deformity. Based on these findings, we have decided to perform KYPHON Balloon Kyphoplasty on the L1 and T12 fractures.,PROCEDURE:, The patient was brought to the operating room/radiology suite and general anesthesia/local sedation with endotracheal intubation was performed. The patient was positioned prone on the Jackson table. The back was prepped and draped. The image intensifier (C-arm) was brought into position and the T12 pedicles were identified and marked with a skin marker. In view of the collapse of T12, a transpedicular approach to the vertebral body was appropriate. An 11-gauge needle was advanced through the T12 pedicle to the junction of the pedicle and vertebral body on the right side. Positioning was confirmed on the AP and lateral plane. Following satisfactory placement of the needle, the stylet was removed. A guide pin was inserted through the 11g to a point 3mm from the anterior cortex. AP and lateral images were taken to verify position and trajectory. Alongside of the guide pin a 1-cm paramedian incision was made. The needle was then removed leaving the guide pin in place. The osteointroducer was placed over the guide pin and advanced through the pedicle. Once I was at the junction of the pedicle and the vertebral body, a lateral image was taken to insure that the cannula was positioned approximately 1cm past the vertebral body wall. Through the cannula, a drill was advanced into the vertebral body under fluoroscopic guidance toward the anterior cortex, creating a channel. The anterior cortex was probed with the guide pin to ensure no perforations in the anterior cortex. After completing the entry into the vertebral body, a 15 mm inflatable bone tamp was inserted through the cannula and advanced under fluoroscopic guidance into the vertebral body near the anterior cortex. The radiopaque marker bands on the bone tamp were identified using AP and lateral images. The above sequence of instrument placement was then repeated on the left side of the T12 vertebral body. Once both bone tamps were in position, they were inflated to 0.5 cc and 50 psi. Expansion of the bone tamps was done sequentially in increments of 0.25 to 0.5 cc of contrast, with careful attention being paid to the inflation pressures and balloon position. The inflation was monitored with AP and lateral imaging. The final balloon volume was 3.5 cc on the right side and 3 cc on the left. There was no breach of the lateral wall or anterior cortex of the vertebral body. Direct reduction of the fracture was achieved, end plate movement was noted and approximately 5 mm of height restoration was achieved. Under fluoroscopic imaging, and the use of the bone void fillers, internal fixation was achieved through a low-pressure injection of KYPHON HV-R bone cement. The cavity was filled with a total volume of 3.5 cc on the right side and 3 cc on the left side. Once the bone cement had hardened, the cannulas were then removed.,At this time, we proceeded to perform a balloon kyphoplasty at L1 using the same sequence of steps as on T12. An entry needle was placed bilaterally through the pedicle into the vertebral body, a cortical window was created, inflation of the bone tamps directly reduced the fracture, the bone tamps were removed, and internal fixation by bone void filler insertion was achieved. Throughout the procedure, AP and lateral imaging monitored positioning.,Post-procedure, all incisions were closed with sutures. The patient was kept in the prone position for approximately 10 minutes post cement injection. She was then turned supine, monitored briefly and returned to the floor. She was moving both her lower extremities at this time.,Throughout the procedure, there were no intraoperative complications. Estimated blood loss was minimal. orthopedic, osteoporosis, pathologic fractures, kyphosis, bone cement, balloon kyphoplasty, kyphon balloon kyphoplasty, bone biopsy, kyphon, insertion of kyphon, ap and lateral, vertebral body, kyphon balloon, anterior cortex, vertebral, body, fractures, insertion, bone, kyphoplasty, guide, balloon, pedicles, cortex, positioned, therapy Orthopedic Left medial compartment osteoarthritis of the knee. Left unicompartmental knee replacement. Knee Replacement PREOPERATIVE DIAGNOSIS: , Left medial compartment osteoarthritis of the knee.,POSTOPERATIVE DIAGNOSIS:, Left medial compartment osteoarthritis of the knee.,PROCEDURE PERFORMED:, Left unicompartmental knee replacement.,COMPONENTS USED:, Biomet size medium femoral component size B tibial tray and a 3 mm polyethylene component.,COMPLICATIONS:, None.,TOURNIQUET TIME: , 59 minutes.,BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE: , A 55-year-old female who had previously undergone a Biomet Oxford unicompartmental knee replacement on the right side. She has done quite well with this. She now has had worsening left knee pain predominantly on the inside of her knee and has consented for unicompartmental knee replacement on the left.,DESCRIPTION OF PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed supine on the operating room table. After appropriate anesthesia, the left lower extremity was identified with a time out procedure. Preoperative antibiotics were given. Left lower extremity was then prepped and draped in usual sterile fashion after applying a thigh tourniquet. The tourniquet was insufflated after elevation of the limb, and a standard medial parapatellar incision was used. Soft tissue dissection was carried down the retinaculum, was opened sharply to expose the joint, meniscus that was visible along the tibia was removed. The anterior fat pad was removed. The knee was then examined. The ACL was found to be intact. The lateral compartment had very minimal arthritis. There were some osteoarthritic changes of the patellofemoral joint, but these were felt to be mild. Following this, the tibial external alignment guide was placed and pinned into place in the appropriate place. Tibial bone cut was made and checked with a feeler gauge and felt to be an adequate resection. Following this resection, the femoral intramedullary guide was placed without difficulty. The femoral cutting guide was then placed and referenced off of this femoral intramedullary guide. Once in the appropriate position, it was pinned and drilled. This was removed, and the posterior cutting block was inserted. It was impacted into place. Posterior bone cut was made for the medium femoral component. Next, a zero spigot was used and the distal femur was reamed. Following this, the check of the extension and flexion gaps revealed that an additional 1 mm needed to be reamed, so 1 spigot was used and this was reamed as well. Next, trial components were placed into the knee and the knee was taken through range of motion and felt to come out to full extension with a 3 mm poly with a good fit. Next, the tibia was prepared. The tibial tray was pinned into place, and the cuts for the keel of the tibia were made. These were removed with a small osteotome from the set. Following this, a trial tibial with the keel was placed and it did fit nicely. After this, all trial components were removed. The knee was copiously irrigated. Cement was begun mixing. Drill holes were used along the femur for cement interdigitation. The wound was cleaned and dried. Cement was placed on the tibia. Tibial tray was impacted into place. Excess cement was removed. Tibia was placed in the femur. Femoral component was impacted into place. Excess cement was removed. It was held with a 4 mm trial insert and approximately 30 degrees of knee flexion until the cement had hardened. Following this, it was again trialed with a meniscal bearing implant and it was felt that 3 mm would be the appropriate size. A 3 mm polyethylene was chosen and inserted in the knee without difficulty, taken through range of motion and found to come out to full extension with no impingement and full flexion. The intramedullary rod removed from the femur. The wound was irrigated with normal saline. The retinaculum was closed with #1 PDS, 2-0 Monocryl was used for the subcutaneous tissue and staples used for the skin. A sterile dressing was placed. Tourniquet was then desufflated. Sponge and needle counts were correct at the end of the procedure. Dr. Jinnah was present for the surgery. The patient was transferred to the recovery room in stable condition. She will be weightbearing as tolerated in the left lower extremity and will be maintained on Lovenox for DVT prophylaxis. Prior to closure, the posterior capsule was injected with the joint cocktail. orthopedic, knee replacement, osteoarthritis, osteoarthritis of the knee, excess cement was removed, medium femoral component, medial compartment osteoarthritis, unicompartmental knee replacement, medium femoral, femoral intramedullary, intramedullary guide, medial compartment, femoral component, tibial tray, lower extremity, unicompartmental knee, tibial, knee, tourniquet, intramedullary, extension, flexion, compartment, unicompartmental, replacement, femoral, cement, Orthopedic The patient with an L5 compression fracture.is to come to the hospital for bilateral L5 kyphoplasty. The patient has a history of back and buttock pain for some time. Kyphoplasty - Consult HISTORY: , The patient is to come to the hospital for bilateral L5 kyphoplasty. The patient is an 86-year-old female with an L5 compression fracture.,The patient has a history of back and buttock pain for some time. She was found to have an L5 compression fracture. She was treated conservatively over several months, but did not improve. Unfortunately, she has continued to have significant ongoing back pain and recent CT scan has shown a sclerosis with some healing of her L5 compression fracture, but without complete healing. The patient has had continued pain and at this time, is felt to be a candidate for kyphoplasty.,She denies bowel or bladder incontinence. She does complain of back pain. She has been wearing a back brace and corset. She does not have weakness.,PAST MEDICAL HISTORY:, The patient has a history of multiple medical problems including hypothyroidism, hypertension, and gallbladder difficulties.,PAST SURGICAL HISTORY:, She has had multiple previous surgeries including bowel surgery, hysterectomy, rectocele repair, and appendectomy. She also has a diagnosis of polymyalgia rheumatica.,CURRENT MEDICATIONS: , She is on multiple medications currently.,ALLERGIES: , SHE IS ALLERGIC TO CODEINE, PENICILLIN, AND CEPHALOSPORINS.,FAMILY HISTORY: , The patient's parents are deceased.,PERSONAL AND SOCIAL HISTORY: , The patient lives locally. She is a widow. She does not smoke cigarettes or use illicit drugs.,PHYSICAL EXAMINATION: , GENERAL: The patient is an elderly frail white female in no distress. LUNGS: Clear. HEART: Sounds are regular. ABDOMEN: She has a protuberant abdomen. She has tenderness to palpation in the lumbosacral area. Sciatic notch tenderness is not present. Straight leg raise testing evokes back pain. NEUROLOGICAL: She is awake, alert, and oriented. Speech is intact. Comprehension is normal. Strength is intact in the upper extremities. She has giveaway strength in the lower extremities. Reflexes are diminished at the knees and ankles. Gait is otherwise normal.,DATA REVIEWED: , Plain studies of the lumbar spine show an L5 compression fracture. A CT scan has shown some healing of this fracture. She has degenerative change at the L4-L5 level with a very slight spondylolisthesis at this level.,ASSESSMENT AND PLAN: , The patient is a woman with a history of longstanding back, buttock, and leg pain. She has a documented L5 compression fracture, which has not healed despite appropriate conservative treatments. At this point, I believe the patient is a good candidate for L5 kyphoplasty. I have discussed the procedure with her and I have reviewed with her and her family risks, benefits, and alternatives to surgery. Risks of surgery including but not limited to bleeding, infection, stroke, paralysis, death, failure to improve, spinal fluid leak, need for further surgery, cement extravasation, failure to improve her pain, and other potential complications have all been discussed. The patient understands the issues involved. She requested that we proceed with surgery as noted above and will come to the hospital for this surgery on 01/18/08. orthopedic, leg pain, lumbar spine, l5 compression fracture, compression fracture, kyphoplasty, buttock, surgery, fracture, Orthopedic Decreased ability to perform daily living activities secondary to right knee surgery. Knee Surgery - Discharge Summary "CHIEF COMPLAINT:, Decreased ability to perform daily living activities secondary to right knee surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old white female status post right total knee replacement secondary to degenerative joint disease performed by Dr. A at ABCD Hospital on 08/21/2007. The patient was transfused with 2 units of autologous blood postoperatively. She received DVT prophylaxis with a combination of Coumadin, Lovenox, SCD boots, and TED stockings. The remainder of her postoperative course was uneventful. She was discharged on 08/24/2007 from ABCD Hospital and admitted to the transitional care unit at XYZ Services for evaluation and rehabilitation. The patient reports that her last bowel movement was on 08/24/2007 just prior to her discharge from ABCD Hospital. She denies any urological symptoms such as dysuria, incomplete bladder emptying or other voiding difficulties. She reports having some right knee pain, which is most intense at a ""certain position."" The patient is unable to elaborate on which ""certain position"" causes her the most discomfort.,ALLERGIES:, NKDA.,PAST MEDICAL HISTORY: , Hypertension, hypothyroidism, degenerative joint disease, GERD, anxiety disorder, Morton neuroma of her feet bilaterally, and distant history of migraine headaches some 30 years ago.,MEDICATIONS:, On transfer, Celebrex, Coumadin, Colace, Synthroid, Lovenox, Percocet, Toprol XL, niacin, and trazodone.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 96.5, blood pressure 127/72, pulse 70, respiratory rate 20, 95% O2 saturation on room air.,GENERAL: No acute distress at the time of the exam except as mentioned above complains of right knee pain at ""certain position."",HEENT: Normocephalic. Sclerae nonicteric. EOMI. Dentition in good repair. Tongue is in midline with no evidence of thrush.,NECK: No thyroid enlargement. Trachea is midline.,LUNGS: Clear to auscultation.,HEART: Regular rate and rhythm. Normal S1 and S2.,ABDOMEN: Soft, nontender, and nondistended. No organomegaly.,EXTREMITIES: The right knee incision is intact. Steri-Strips are in place. There is some diffuse right knee edema and some limited ecchymosis as well. No calf tenderness bilaterally. Pedal pulses are palpable bilaterally.,MENTAL STATUS: The patient appears slightly anxious during the interview and exam, but she was alert and oriented.,HOSPITAL COURSE: , As mentioned above, the patient was admitted on 08/24/2007 to the Transitional Care Unit at XYZ Services for evaluation and rehabilitation. She was seen in consultation by Physical Therapy and Occupational Therapy and had begun her rehabilitation till recovery. The patient had been properly instructed regarding using the CPM machine and she had been instructed as well to limit each CPM session to two hours. Very early in her hospitalization, the patient enthusiastically used the CPM much longer than two hours and consequently had increased right knee pain. She remarked that she had a better degree of flexibility, but she did report an increased need for pain management. Additionally, she required Ativan and at one point scheduled the doses of Ativan to treat her known history of anxiety disorder. On the fourth hospital day, she was noted to have some rashes about the right upper extremity and right side of her abdomen. The patient reported that this rash was itchy. She reports that she had been doing quite a bit of gardening just prior to surgery and this was most likely contact dermatitis, most likely due to her gardening activities preoperatively. She was treated with betamethasone cream applied to the rash b.i.d. The patient's therapy had progressed and she continued to make a good progress. At one point, the patient reported some insomnia due to right knee pain. She was switched from Percocet to oxycodone SR 20 mg b.i.d. and she had good pain control with this using the Percocet only for breakthrough pain. The DVT prophylaxis was maintained with Lovenox 40 mg subcu daily until the INR was greater than 1.7 and it was discontinued on 08/30/2007 when the INR was 1.92 within therapeutic range. The Coumadin was adjusted accordingly according to the INRs during her hospital course. Early in the hospital course, the patient had reported right calf tenderness and a venous Doppler study obtained on 08/27/2007 showed no DVT bilaterally. Initial laboratory data includes a UA on 08/28/2007, which was negative. Additionally, CBC showed a white count of 6.3, hemoglobin was 12.1, hematocrit was 35.3, and platelets were 278,000. Chemistries were within normal limits. Creatinine was 0.8, BUN was 8, anion gap was slightly decreased at 5, fasting glucose was 102. The remainder of chemistries was unremarkable. The patient continued to make great progress with her therapies so much so that we are anticipating her discharge on Monday, 09/03/2007.,DISCHARGE DIAGNOSES:,1. Status post right total knee replacement secondary to degenerative joint disease performed on 08/21/2007.,2. Anxiety disorder.,3. Insomnia secondary to pain and anxiety postoperatively.,4. Postoperative constipation.,5. Contact dermatitis secondary to preoperative gardening activities.,6. Hypertension.,7. Hypothyroidism.,8. Gastroesophageal reflux disease.,9. Morton neuroma of the feet bilaterally.,10. Distant history of migraine headaches.,INSTRUCTIONS GIVEN TO THE PATIENT AT THE TIME OF DISCHARGE: , The patient is advised to continue taking the following medications: Celebrex 200 mg daily, for one month, Colace 100 mg b.i.d. for one month, Protonix 40 mg b.i.d. for one month, Synthroid 137 mcg daily, Diprosone cream 0.05% cream b.i.d. to the right arm and right abdomen, oxycodone SR 20 mg p.o. q.12h. for five days, then decrease to oxycodone SR 10 mg p.o. q.12h. for five days, Percocet 5/325 mg one to two tablets q.6h. to be used p.r.n. for breakthrough pain, trazodone 50 mg p.o. at bedtime p.r.n. for two weeks, Ativan 0.25 mg b.i.d. for two weeks, and Toprol-XL 50 mg daily. The patient will also take Coumadin and the dose will be adjusted according to the INRs, which will be obtained every Monday and Thursday with results being sent to Dr. A and his fax number is 831-5926. At the present time, the patient is taking Coumadin 7 mg daily. She will remain on Coumadin for 30 days. An INR is to be obtained on 09/03/2007 and should the Coumadin dose be changed, an addendum will be dictated to accompany this discharge summary. Finally, the patient has a followup appointment with Dr. A on 09/21/2007 at noon at his office. The patient is encouraged to follow up with her primary care physician, Dr. B. As mentioned above, the patient will be discharged on 09/03/2007 in stable and improved condition since she is status post right total knee replacement and has made good progress with her therapies and rehabilitation." Orthopedic Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty. Vertebroplasties at T7 and T9 with insertion of prosthetic device. Fracture of the T8 vertebra and T9 vertebra. Kyphoplasty & Vertebroplasty 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. orthopedic, pathologic insufficiency, vertebrae, fracture, fracture reduction, vertebroplasties, kyphoplasty, prosthetic device, jamshidi needles, insertion, prosthetic, Orthopedic Arthroscopy of the left knee with medial meniscoplasty. Internal derangement, left knee. Displaced bucket-handle tear of medial meniscus, left knee. Knee Arthroscopy & Medial Meniscoplasty 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. orthopedic, arthroscopy, meniscoplasty, derangement, internal derangement, knee, displaced bucket handle tear, femoral condyle, tibial plateau, medial meniscoplasty, medial meniscus, medial Orthopedic Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement. While playing tennis she had a non-contact injury in which she injured the right knee. She had immediate pain and swelling. Knee Injury 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. orthopedic, acl graft, acl reconstruction, knee, anterior cruciate ligament, internal derangement, contact injury, knee injury, injury, cruciate, acl, anterior, Orthopedic Left knee arthroscopy with lateral capsular release. Knee Arthroscopy 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. orthopedic, knee arthroscopy, lateral capsular release, chondromalacia, patellar, lateral joint line, medial joint line, lateral joint, medial joint, capsular release, joint line, arthroscopy, tourniquet, knee, Orthopedic Arthroscopic procedure of the knee. Knee Arthroscopy - 1 PROCEDURE IN DETAIL: , After written consent was obtained from the patient, the patient was brought back into the operating room and identified. The patient was placed in the operating room table in supine position and given general anesthetic.,Ancef 1 g was given for infectious prophylaxis. Once the patient was under general anesthesia, the knee was prepped and draped in usual sterile fashion. Once the knee was fully prepped and draped, then we made 2 standard portals medial and lateral. Through the lateral portal, the camera was placed. Through the medial portal, tools were placed. We proceeded to examine scarring of the patellofemoral joint. Then we probed the patellofemoral joint. A chondroplasty was performed using a shaver. Then we moved down to the lateral gutter. Some loose bodies were found using a shaver and dissection. We moved down the medial gutter. No plica was found.,We moved into the medial joint; we found that the medial meniscus was intact. We moved to the lateral joint and found that the lateral meniscus was intact. Pictures were taken. We drained the knee and washed out the knee with copious amounts of sterile saline solution. The instruments were removed. The 2 portals were closed using 3-0 nylon suture. Xeroform, 4 x 4s, Kerlix x2, and TED stocking were placed. The patient was successfully extubated and brought to the recovery room in stable condition. I then spoke with the family going over the case, postoperative instructions, and followup care. orthopedic, chondroplasty, knee, meniscus, patellofemoral, arthroscopy, portals, jointNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., Orthopedic Painful right knee status post total knee arthroplasty many years ago. Status post poly exchange, right knee, total knee arthroplasty. Knee Arthroplasty - Discharge Summary ADMISSION DIAGNOSIS:, Painful right knee status post total knee arthroplasty many years ago. The patient had gradual onset of worsening soreness and pain in this knee. X-ray showed that the poly seems to be worn out significantly in this area.,DISCHARGE DIAGNOSIS:, Status post poly exchange, right knee, total knee arthroplasty.,CONDITION ON DISCHARGE:, Stable.,PROCEDURES PERFORMED:, Poly exchange total knee, right.,CONSULTATIONS: , Anesthesia managed femoral nerve block on the patient.,HOSPITAL COURSE: ,The patient was admitted with revision right total knee arthroplasty and replacement of patellar and tibial poly components. The patient recovered well after this. Working with PT, she was able to ambulate with minimal assistance. Nerve block was removed by anesthesia. The patient did well on oral pain medications. The patient was discharged home. She is actually going to home with her son who will be able to assist her and look after her for anything she might need. The patient is comfortable with this, understands the therapy regimen, and is very satisfied after the procedure.,DISCHARGE INSTRUCTIONS AND MEDICATIONS: , The patient is to be discharged home to the care of the son. Diet is regular. Activity, weight bear as tolerated right lower extremity. Continue to do physical therapy exercises. The patient will be discharged home on Coumadin 4 mg a day as the INR was 1.9 on discharge with twice weekly lab checks. Vicodin 5/500 mg take one to two tablets p.o. q.4-6h. Resume home medications. Call the office or return to the emergency room for any concerns including increased redness, swelling, drainage, fever, or any concerns regarding operation or site of incision. The patient is to follow up with Dr. ABC in two weeks. orthopedic, painful right knee, total knee arthroplasty, poly exchange, femoral nerve block, patellar, tibial poly, knee arthroplasty, knee, arthroplasty, Orthopedic Left knee pain and stiffness. Bilateral knee degenerative joint disease (DJD). Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d. Knee DJD - Consult "CHIEF COMPLAINT: , Left knee pain and stiffness.,HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old with severe bilateral knee DJD, left greater than right, with significant pain and limitations because of both. He is able to walk approximately a 1/2-mile a day but is limited because of his knees. Stairs are negotiated 1 at a time. His problems with bilateral knee DJD have been well documented. He had arthroscopy in the 1991/199two time frame for both of these. He has been on long-standing conservative course for these including nonsteroidals, narcotics, injections. At this point because of his progressive and persistent limitations he has opted for total joint surgery on the left side. He does have other arthritic complaints including multiple back surgeries for spinal stenosis including decompression and epidural steroids. Significant pain is handled by narcotic medication. His attending physician is Dr. X.,PAST MEDICAL HISTORY: , Hypertension.,PRIOR SURGERIES:,1. Inguinal hernia on the left.,2. Baker's cyst.,3. Colon cancer removal.,4. Bilateral knee scopes.,5. Right groin hernia.,6. Low back surgery for spinal stenosis.,7. Status post colon cancer second surgery.,MEDICATIONS:,1. Ambien 12.5 mg nightly.,2. Methadone 10 mg b.i.d.,3. Lisinopril 10 mg daily.,IV MEDICATIONS FOR PAIN: ,Demerol appears to work the best.,ALLERGIES: , Levaquin and Cipro cause rashes; ibuprofen causes his throat to swell, Fortaz causes an unknown reaction.,REVIEW OF SYSTEMS: ,He does have paresthesias down into his thighs secondary to spinal stenosis.,SOCIAL HISTORY: , Married. He is retired, being a Pepsi-Cola driver secondary to his back and knees.,HABITS: , No tobacco or alcohol. Chewed until 2003.,RECREATIONAL PURSUITS: ,Golfs, gardens, woodworks.,FAMILY HISTORY:,1. Cancer.,2. Coronary artery disease.,PHYSICAL EXAMINATION:,GENERAL APPEARANCE: A pleasant, cooperative 57-year-old white male.,VITAL SIGNS: Height 5' 9"", weight 167. Blood pressure 148/86. Pulse 78 per minute and regular.,HEENT: Unremarkable. Extraocular movements are full. Cranial nerves II-XII intact.,NECK: Supple.,CHEST: Clear.,CARDIOVASCULAR: Regular rhythm. Normal S1 and 2.,ABDOMEN: No organomegaly. No tenderness. Normal bowel sounds.,NEUROLOGIC: Intact.,MUSCULOSKELETAL: Left knee reveals a range of -10 degrees extension, 126 flexion. His extensor mechanism is intact. There is mild varus. He has good stability at 30 degrees of flexion. Lachman's and posterior drawer are negative. He has good muscle turgor. Dorsalis pedis pulse 2+.,DIAGNOSTICS: ,X-rays revealed severe bilateral knee DJD with joint space narrowing medially as well as the patellofemoral joint with large osteophytes, left greater than right.,IMPRESSION:,1. Bilateral knee degenerative joint disease.,2. Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d." Orthopedic Evaluation for chronic pain program Knee & Back Pain REASON FOR EVALUATION:, Orthopedic Revision right total knee arthroplasty. Right failed total knee arthroplasty. Knee Arthroplasty - Revision PREOPERATIVE DIAGNOSIS: , Right failed total knee arthroplasty.,POSTOPERATIVE DIAGNOSIS: ,Right failed total knee arthroplasty.,PROCEDURE PERFORMED: , Revision right total knee arthroplasty.,FIRST ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Approximately 75 cc.,TOURNIQUET TIME: , 123 minutes. Then it was let down for approximately 15 minutes and then reinflated for another 26 minutes for a total of 149 minutes.,COMPONENTS: , A Zimmer NexGen Legacy knee size D right stemmed femoral component was used. A NexGen femoral component with a distal femoral augmented block, size 5 mm. A NexGen tibial component, size 3 mm was used. A size 14 mm constrained polyethylene surface was used as well. Original patellar component that the patient had was maintained.,COMPLICATIONS: ,None.,BRIEF HISTORY:, The patient is a 68-year-old female with a history of knee pain for 13 years. She had previous total knee arthroplasty and revision at an outside facility. She had continued pain, snapping, malalignment, difficulty with ambulation, and giving away and wished to undergo additional revision surgery.,PROCEDURE:, The patient was taken to the operative suite and placed on the operating table. Department of Anesthesia administered the spinal anesthetic. Once adequately anesthetized, the patient was placed in a supine position. Care was ensured and she was adequately secured and well padded in position. Once this was obtained, the right lower extremity was prepped and draped in the usual sterile fashion. Tourniquet was inflated to approximately 325 mmHg on the right thigh. At this point, an incision was made over her anterior previous knee scar taking this down to the subcutaneous tissue of the overlying retinaculum. A medial parapatellar arthrotomy was then made by using a second knife and this was taken both distally and proximally to allow us to sublux the patella on the lateral aspect to allow exposure to the joint surface. There was noted to be no evidence of purulence or gross clinical appearance of infection, however, intraoperative cultures were taken to asses this as well. At this point, the previous articular surface was then removed using an osteotome until this was left free and then removed. This was done without difficulty. Attention was then directed removing the femoral component. Osteotome was taken around each of the edges until this was gently lifted up and then a femoral extractor was placed around it and this was back flapped until this was easily removed. After this was performed, attention was then directed to the tibial component. An osteotome was again inserted around the surface and this was easily pried loose. There was noted to be minimal difficulty with this and did not appear to have adequate cement fixation. This was evaluated. The bone stalk appeared to be adequate, however, there were noted to be some deficits where we need to trim cement, so we elected to proceed with stemmed component. The attention was first directed to the femur and the femoral canal was opened up and superficially reamed up to a size 18 mm proximal portion for the Zimmer stemmed component. At this point, the distal femoral cut was evaluated with a intramedullary guide and this was noted to be cut in a varus cut leaving us a large deficit of the medial femoral cut. We elected because of this large amount of retic to take off the medial condyle to correct this varus cut to a six degree valgus cut. We elected to augment the medial aspect and take only 5 mm off of the lateral condyle instead of a full 10 to 12. At this point, the distal femoral cutting guide based on the intramedullary head was then placed. Care was ensured that this was aligned in proper rotation with the external epicondylar axis. Once this was pinned in position, approximately a six degree valgus cut was then made. This allowed a portion of the medial condyle to be removed distally. The anterior cut was checked next using the intramedullary guide. The anterior surface cutting block was then placed. This aligned us to anterior cutting block.,We ensured again that rotation was aligned with the epicondylar axis. Once this was adequately aligned with this and gave us some external rotation, this was pinned in position and new anterior cut was made. It was noted that minimal bone was taken off the surface, only a slight portion on the medial anterior surface. _______ was then removed and the chamfer cutting guide was then placed on. This allowed us to make a box cut and recut some of the angled cuts of the distal femur. Once this was placed and pinned in position. Care was then again taken to check that this was in proper rotation and then the chamfer cuts were recut. It was noted that the anterior chamfers did not need to be cut, take off no bone. The posterior chamfers did remove some bony aspects. This was also taken off some of the posterior aspects of the condyles and then the ossicle saw and reciprocal saw were used to take off a notch cut to open up a constrained component. After all these cuts were taken, the guides were then removed and the trial component with a medial 5 mm augment was then placed. This appeared to have an adequate fit and then packed in position. It appeared to be satisfactory. At this point, this was removed and attention was then directed to the tibia. The intramedullary canal was again opened up using a proximal drill and this was reamed to the appropriate size until good _______ was obtained. At this point, the intramedullary guide was used to evaluate a tibial cut. This appeared to be adequate, however, we elected to remove 2 mm of bone to give us a new fresh bony surface. The cutting guide was placed in adequate alignment and checked both the with intramedullary guide and an external alignment rod, which allowed us to ensure that we had proper external rotation of this tibial component. At this point, this was pinned in position and the tibial cut was made to remove an extra 2 mm of bone. This was again removed and a trial tibial stemmed component was then placed as well as the trial augmented stemmed femoral component. This was placed in a proper position. A 10 mm articular surface was placed in the knee and this was taken through range of motion. This was found to have better alignment and satisfactory position. We elected to take an intraoperative x-ray at this point, to evaluate our cut. The intraoperative x-ray demonstrates satisfactory cuts and alignment of the prosthesis. At this point, all trials were removed. The patella was then examined. The rongeur was used to remove the surrounding synovium. The patella was evaluated and found to have mild wear on the lateral aspect of the inferior butt, however, this was very mild and overall had a good position and was well fixed to the bone. It was elected at this time to maintain this anatomic patella that was previously placed. At this point, the joint again was reevaluated and any bone loose fragments removed. There was noted to be some posterior tightness and mild osteophytes. These were removed with a rongeur.,At this time, while preparing the canals, the tourniquet was deflated due to it being 123 minutes. Approximately 10 minutes did get by, as the knee was copiously irrigated and suctioned dried. The tourniquet was then reinflated. The canals were prepped for cementing. They were suction-dried and cleaned. The tibial component was cemented and then impacted into position and ensured it was adequately aligned in proper external rotation and alignment that was previously tried with the trial. Once this was fixed and secured, all extra cement was removed and attention was directed to the femoral component. The stemmed femoral component was then impacted in position and cemented. Again care was ensured that it was in adequate position and proper rotation. A size 14 mm poly was then inserted in between to provide compression. This was then taken through extension and held until cement cured. This was then removed and the components were evaluated. All excess cement was removed and they were well fixed. Size 14 mm trial Poly was then placed and this was taken through range of motion. This was found to have excellent range of motion and good stability. It was elected at this time that we would go with the size 14 mm Poly. This gave us extra Poly for ware and then provide excellent contact throughout the range of motion. The final articular surface was then placed and tightened into position to allow to _______ secured. The knee was then reduced and the knee was taken through range of motion. The patella was tracking with no-touch technique and adequately positioned. At this point, the tourniquet was deflated for second time and then the knee was copiously irrigated and suctioned dry. All bleeding was cauterized using a Bovie cautery. The retinaculum was then repaired using #1 Ethibond in a figure-of-eight fashion. This was reinforced with a running #2-0 Vicryl. The knee was then flexed and noted that the patella was tracking with good alignment. The wound was again copiously irrigated and suctioned dry. A drain was placed prior to retinaculum repair deep to this to provide adequate drainage. At this point, the subcutaneous tissue was closed with #2-0 Vicryl. Skin was approximated with skin clips. Sterile dressing of Adaptic, 4x4, Webril, and ABDs were then placed. A large Dupre dressing was then placed up the entire lower extremity. The patient was then transferred back to recovery in supine position.,DISPOSITION: , The patient tolerated the procedure well with no complications and transferred to PACU in satisfactory condition. orthopedic, knee arthroplasty, revision, zimmer nexgen, distal femoral, intramedullary guide, femoral component, femoral, knee, arthroplasty, intramedullary, patellar, medial, tibial, Orthopedic Left below-the-knee amputation. Dressing change, right foot. Knee Amputation PREOPERATIVE DIAGNOSES:,1. Left diabetic foot abscess and infection.,2. Left calcaneus fracture with infection.,3. Right first ray amputation.,POSTOP DIAGNOSES:,1. Left diabetic foot abscess and infection.,2. Left calcaneus fracture with infection.,3. Right first ray amputation.,OPERATION AND PROCEDURE:,1. Left below-the-knee amputation.,2. Dressing change, right foot.,ANESTHESIA: , General.,BLOOD LOSS: , Less than 100 mL.,TOURNIQUET TIME:, 24 minutes on the left, 300 mmHg.,COMPLICATIONS:, None.,DRAINS: , A one-eighth-inch Hemovac.,INDICATIONS FOR SURGERY: , The patient is a 62 years of age with diabetes. He developed left heel abscess. He had previous debridements, developed a calcaneal fracture and has now had several debridement with placement of the antibiotic beads. After re-inspecting the wound last week, the plan was for possible debridement and he desired below-the-knee amputation. We are going to change the dressing on the right side also. The risks, benefits, and alternatives of surgery were discussed. The risks of bleeding, infection, damage to nerves and blood vessels, persistent wound healing problems, and the need for future surgery. He understood all the risks and desired operative treatment.,OPERATIVE PROCEDURE IN DETAIL: , After appropriate informed consent obtained, the patient was taken to the operating room and placed in the supine position. General anesthesia induced. Once adequate anesthesia had been achieved, cast padding placed on the left proximal thigh and tourniquet was applied. The right leg was redressed. I took the dressing down. There was a small bit of central drainage, but it was healing nicely. Adaptic and new sterile dressings were applied.,The left lower extremity was then prepped and draped in usual sterile fashion.,A transverse incision made about the mid shaft of the tibia. A long posterior flap was created. It was taken to the subcutaneous tissues with electrocautery. Please note that tourniquet had been inflated after exsanguination of the limb. Superficial peroneal nerve identified, clamped, and cut. Anterior compartment was divided. The anterior neurovascular bundle identified, clamped, and cut. The plane was taken between the deep and superficial compartments. The superficial compartment was reflected posteriorly. Tibial nerve identified, clamped, and cut. Tibial vessels identified, clamped, and cut.,Periosteum of the tibia elevated proximally along with the fibula. The tibia was then cut with Gigli saw. It was beveled anteriorly and smoothed down with a rasp. The fibula was cut about a cm and a half proximal to this using a large bone cutter. The remaining posterior compartment was divided. The peroneal bundle identified, clamped, and cut. The leg was then passed off of the field. Each vascular bundle was then doubly ligated with 0 silk stick tie and 0 silk free tie. The nerves were each pulled at length, injected with 0.25% Marcaine with epinephrine, cut, and later retracted proximally. The tourniquet was released. Good bleeding from the tissues and hemostasis obtained with electrocautery. Copious irrigation performed using antibiotic-impregnated solution. A one-eighth-inch Hemovac drain placed in the depth of wound adhering on the medial side. A gastroc soleus fascia brought up and attached to the anterior fascia and periosteum with #1 Vicryl in an interrupted fashion. The remaining fascia was closed with #1 Vicryl. Subcutaneous tissues were then closed with 2-0 PDS suture using 2-0 Monocryl suture in interrupted fashion. Skin closed with skin staples. Xeroform gauze, 4 x 4, and a padded soft dressing applied. He was placed in a well-padded anterior and posterior slab splint with the knee in extension. He was then awakened, extubated, and taken to recovery in stable condition. There were no immediate operative complications, and he tolerated the procedure well. orthopedic, infection, adaptic, gigli saw, hemovac, abscess, amputation, below-the-knee amputation, calcaneus fracture, debridement, diabetic foot, ray amputation, tourniquet, transverse incision, knee amputation, knee, dressing, clamped, Orthopedic A 66-year-old female with knee osteoarthrosis who failed conservative management. Knee Osteoarthrosis - Discharge Summary PRINCIPAL DIAGNOSIS:, Knee osteoarthrosis.,PRINCIPAL PROCEDURE: , Total knee arthroplasty.,HISTORY AND PHYSICAL:, A 66-year-old female with knee osteoarthrosis. Failed conservative management. Risks and benefits of different treatment options were explained. Informed consent was obtained.,PAST SURGICAL HISTORY: , Right knee surgery, cosmetic surgery, and carotid sinus surgery.,MEDICATIONS: , Mirapex, ibuprofen, and Ambien.,ALLERGIES: , QUESTIONABLE PENICILLIN ALLERGIES.,PHYSICAL EXAMINATION: , GENERAL: Female who appears younger than her stated age. Examination of her gait reveals she walks without assistive devices.,HEENT: Normocephalic and atraumatic.,CHEST: Clear to auscultation.,CARDIOVASCULAR: Regular rate and rhythm.,ABDOMEN: Soft.,EXTREMITIES: Grossly neurovascularly intact.,HOSPITAL COURSE: , The patient was taken to the operating room (OR) on 03/15/2007. She underwent right total knee arthroplasty. She tolerated this well. She was taken to the recovery room. After uneventful recovery room course, she was brought to regular surgical floor. Mechanical and chemical deep venous thrombosis (DVT) prophylaxis were initiated. Routine postoperative antibiotics were administered. Hemovac drain was discontinued on postoperative day #2. Physical therapy was initiated. Continuous passive motion (CPM) was also initiated. She was able to spontaneously void. She transferred to oral pain medication. Incision remained clean, dry, and intact during the hospital course. No pain with calf squeeze. She was felt to be ready for discharge home on 03/19/2007.,DISPOSITION: ,Discharged to home.,FOLLOW UP:, Follow up with Dr. X in one week. Prescriptions were written for Percocet and Coumadin.,INSTRUCTIONS: , Home physical therapy and PT and INR to be drawn at home for adjustment of Coumadin dosing., orthopedic, total knee arthroplasty, conservative management, knee arthroplasty, physical therapy, knee osteoarthrosis, arthroplasty, osteoarthrosis, knee, Orthopedic Bilateral degenerative arthritis of the knees. Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately. Knee Arthroplasty 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. orthopedic, degenerative, arthritis, zimmer nexgen, all-poly, cruciate, patellar component, total knee arthroplasty, knee arthroplasty, tibial component, femoral, patellar, tibial, knee, arthroplasty, anesthesia, Orthopedic Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail. Left tibial shaft fracture status post gunshot wound. Intramedullary Nail Fixation TITLE OF OPERATION: , Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail, 10 x 390 with a one 5-mm proximal locking screw and three 5-mm distal locking screws (CPT code is 27759) (the ICD-9 code again is 823.2 for a tibial shaft fracture).,INDICATION FOR SURGERY: ,The patient is a 19-year-old male, who sustained a gunshot wound to the left tibia with a distal tibial shaft fracture. The patient was admitted and splinted and had compartment checks. The risks of surgery were discussed in detail including, but not limited to infection, bleeding, injuries to nerves, or vital structures, nonunion or malunion, need for reoperation, compartment syndrome, and the risk of anesthesia. The patient understood these risks and wished to proceed.,PREOP DIAGNOSIS: , Left tibial shaft fracture status post gunshot wound (CPT code 27759).,POSTOP DIAGNOSIS: , Left tibial shaft fracture status post gunshot wound (CPT code 27759).,ANESTHESIA: , General endotracheal.,INTRAVENOUS FLUID:, 900.,ESTIMATED BLOOD LOSS: ,100.,COMPLICATIONS:, None.,DISPOSITION: , Stable to PACU.,PROCEDURE DETAIL: ,The patient was met in the preoperative holding area and operative site was marked. The patient was brought to the operating room and given preoperative antibiotics. Left leg was then prepped and draped in the usual sterile fashion. A midline incision was made in the center of the knee and was carried down sharply to the retinacular tissue. The starting guidewire was used to localize the correct starting point, which is on the medial aspect of the lateral tibial eminence. This was advanced and confirmed on the AP and lateral fluoroscopic images. The opening reamer was then used and the ball-tip guidewire was passed. The reduction was obtained over a large radiolucent triangle. After passing the guidewire and achieving appropriate reduction, the flexible reamers were then sequentially passed, starting at 9 mm up to 11.5 mm reamer. At this point, a 10 x 390 mm was passed without difficulty. The guide was used to the proximal locking screw and the appropriate circle technique was used to the distal locking screws. The final images were taken with fluoroscopy and a 15-mm end-cap was placed. The wounds were then irrigated and closed with 2-0 Vicryl followed by staples to the distal screws and 0 Vicryl followed 2-0 Vicryl and staples to the proximal incision. The patient was placed in a short leg, well-padded splint, was awakened and taken to recovery in good condition.,The plan will be nonweightbearing left lower extremity. He will be placed in a short leg splint and should be transitioned to a short leg cast for the next 4 weeks. orthopedic, screw, stryker, tibia, intramedullary nail fixation, tibial shaft fracture, intramedullary, guidewire, nail, fracture, tibial Orthopedic Displaced left subtrochanteric femur fracture. Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade. Intramedullary Rod PREOPERATIVE DIAGNOSIS:, Displaced left subtrochanteric femur fracture.,POSTOPERATIVE DIAGNOSIS:, Displaced left subtrochanteric femur fracture.,OPERATION: , Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade.,COMPLICATIONS:, None.,TOURNIQUET TIME:, None.,ESTIMATED BLOOD LOSS:, 50 mL.,ANESTHESIA: , General.,INDICATIONS: ,The patient suffered a fall at which time she was taken to the emergency room with pain in the lower extremities. She was diagnosed with displaced left subcapital hip fracture, now was asked to consult. With this diagnosis, she was indicated the above-noted procedure. This procedure as well as alternatives to this procedure was discussed at length with the patient and her son, who has the power of attorney, and they understood them well.,Risks and benefits were also discussed. Risks include bleeding, infection, damage to blood vessels, damage to nerves, risk of further surgery, chronic pain, restricted range of motion, risk of continued discomfort, risk of malunion, risk of nonunion, risk of need for further reconstructive procedures, risk of need for altered activities and altered gait, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed. She understood these well and consented, and the son signed the consent for the procedure as described.,DESCRIPTION OF PROCEDURE: , The patient was placed on the operating table and general anesthesia was achieved. The patient was then placed in fracture boots and manipulated under fluoroscopic control until we could obtain near anatomic alignment. External positions were felt to be present. At this point, the left hip and left lower extremity was then prepped and draped in the usual sterile manner. A guidewire was then placed percutaneously into the tip of the greater trochanter and a small incision was made overlying the guidewire. An overlying drill was inserted to the proper depths. A Synthes 11 x 130 degrees trochanteric fixation that was chosen was placed into the intramedullary canal to the proper depth. Proper rotation was obtained and the guide for the helical blade was inserted. A small incision was made for this as well. A guidewire was inserted and felt to be in proper position, in the posterior aspect of the femoral head, lateral, and the center position on AP. This placed the proper depths and lengths better. The outer cortex was enlarged and an 85-mm helical blade was attached to the proper depths and proper fixation was done. Appropriate size screw was then tightened down. At this point, a distal guide was then placed and drilled across both the cortices. Length was better. Appropriate size screw was then inserted. Proper size and fit of the distal screw was also noted. At this point, on fluoroscopic control, it was confirming in AP and lateral direction. We did a near anatomical alignment to the fracture site and all hardware was properly fixed. Proper size and fit was noted. Excellent bony approximation was noted. At this point, both wounds were thoroughly irrigated, hemostasis confirmed, and closure was then begun.,The fascial layers were then reapproximated using #1 Vicryl in a figure-of-eight manner, the subcutaneous tissues were reapproximated in layers using #1 and 2-0 Vicryl sutures, and the skin was reapproximated with staples. The area was then infiltrated with a mixture of a 0.25% Marcaine with Epinephrine and 1% plain lidocaine. Sterile dressing was then applied. No complication was encountered throughout the procedure. The patient tolerated the procedure well. The patient was taken to the recovery room in stable condition. orthopedic, displaced, femur fracture, subtrochanteric, hip, synthes, intramedullary rod, subtrochanteric femur, trochanteric fixation, helical blade, tourniquet, intramedullary, trochanteric, fixation, helical, blade, guidewire, fracture, Orthopedic Bilateral knee degenerative arthritis. Bilateral knee arthroplasty. The Zimmer NexGen total knee system was utilized. Knee Arthroplasty - Bilateral PREOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,PROCEDURE PERFORMED: , Bilateral knee arthroplasty.,Please note this procedure was done by Dr. X for the left total knee and Dr. Y for the right total knee. This operative note will discuss the right total knee arthroplasty.,ANESTHESIA: ,General.,COMPLICATIONS: , None.,BLOOD LOSS: , Approximately 150 cc.,HISTORY:, This is a 79-year-old female who has disabling bilateral knee degenerative arthritis. She has been unresponsive to conservative measures. All risks, complications, anticipated benefits, and postoperative course were discussed. The patient has agreed to proceed with surgery as described below.,GROSS FINDINGS: , There was noted to be eburnation and wear along the patellofemoral joint and femoral tibial articulation medially and laterally with osteophyte formation and sclerosis.,SPECIFICATIONS: , The Zimmer NexGen total knee system was utilized.,PROCEDURE: , The patient was taken to the operating room #2 and placed in supine position on the operating room table. She was administered spinal anesthetic by Dr. Z.,The tourniquet was placed about the proximal aspect of the right lower extremity. The right lower extremity was then sterilely prepped and draped in the usual fashion. An Esmarch bandage was used to exsanguinate the right lower extremity and the tourniquet was inflated to 325 mmHg. Longitudinal incision was made over the anterior aspect of the right knee. Subcutaneous tissue was carefully dissected. A medial parapatellar retinacular incision was made. The patella was then everted and the above noted gross findings were appreciated. A drill hole was placed in the distal aspect of the femur and the distal femoral cutting guides were positioned in place. The appropriate cuts were made at the distal femur as well as with use of the chamfer guide. The trial femoral component was then positioned in place and noted to have good fit. Attention was then directed to proximal tibia, the external tibial alignment guide was positioned in place and the proximal tibial cut was made demonstrating satisfactory cut. The medial and lateral collateral ligaments remained intact throughout the procedure as well as the posterior cruciate ligaments. The remnants of the anterior cruciate ligament and menisci were resected. The tibial trial was positioned in place. Intraoperative radiographs were taken, demonstrating satisfactory alignment of the tibial cut. The tibial holes were then drilled. The patella was then addressed with the Bovie used to remove the soft tissue around the perimeter of the patella. The patellar cutting guide was positioned in place and the posterior aspect of the patella was resected to the appropriate thickness. Three drill holes were made within the patella after it was determined that 35 mm patella would be most appropriate. The knee was placed through range of motion with the trial components marked and then the appropriate components obtained. The tibial tray was inserted with cement, backed it into place, excess methylmethacrylate was removed. The femoral component was inserted with methylmethacrylate. Any excessive methylmethacrylate and bony debris were removed from the joint. Trial Poly was positioned in place and the knee was held in full extension while the methylmethacrylate became firm. The methylmethacrylate was also used at the patella. The prosthesis was positioned in place. The patellar clamp held securely till the methylmethacrylate was firm. After all three components were in place, the knee was then again in placed range of motion and there appeared to be some torsion to the proximal tibial component and concerned regarding the alignment. This component was removed and revised to a stemmed component with better alignment and position. The previous component removed, the methylmethacrylate was removed. Further irrigation was performed and then a stemmed template was positioned in place with the intramedullary alignment guide positioned and the tibia drilled and broached. The trial tibial stemmed component was positioned in place. Knee was placed through range of motion and the tracking was better. Actual component was then obtained, methyl methacrylate was placed within the tibia. The stemmed tibial component was impacted into place with good fit. The Poly was then positioned in place. Knee held in full extension with compression longitudinally after methylmethacrylate was solidified. The trial Poly was removed. Wound was irrigated and the joint was inspected. There was no debris. Collateral ligaments and posterior cruciate ligaments remained intact. Soft tissue balancing was done and a 17 mm Poly was then inserted with the knee and tibial and femoral components with good tracking as well as the patellar component. The tourniquet was deflated. Hemostasis was satisfactory. A drain was placed into the depths of the wound. The medial retinacular incision was closed with one Ethibond suture in interrupted fashion. The knee was placed through range of motion and there was no undue tissue tension, good patellar tracking, no excessive soft tissue laxity or constrain. The subcutaneous tissue was closed with #2-0 undyed Vicryl in interrupted fashion. The skin was closed with surgical clips. The exterior of the wound was cleansed as well padded dressing ABDs and ace wrap over the right lower extremity. At the completion of the procedure, distal pulses were intact. Toes were pink, warm, with good capillary refill. Distal neurovascular status was intact. Postoperative x-ray demonstrated satisfactory alignment of the prosthesis. Prognosis is good in this 79-year-old female with a significant degenerative arthritis. orthopedic, patellofemoral, eburnation, osteophyte, articulation, tibial, femoral, bilateral knee arthroplasty, knee degenerative arthritis, zimmer nexgen, lower extremity, arthroplasty, patella, methylmethacrylate, Orthopedic A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall. IME & Record Review - Orthopedic INTRODUCTION: , The opinions expressed in this report are those of the physician. The opinions do not reflect the opinions of Evergreen Medical Panel, Inc. The claimant was informed that this examination was at the request of the Washington State Department of Labor and Industries (L&I). The claimant was also informed that a written report would be sent to L&I, as requested in the assignment letter from the claims manager. The claimant was also informed that the examination was for evaluative purposes only, intended to address specific injuries or conditions as outlined by L&I, and was not intended as a general medical examination.,CHIEF COMPLAINTS: , This 51-year-old married male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall that occurred on November 20, 2008.,HISTORY OF INDUSTRIAL INJURY:, This patient was injured on November 20, 2008. He works at the Purdy Correctional Facility and an inmate had broken some overhead sprinklers, the floor was thus covered with water and the patient slipped landing on the back of his head, then on his back. The patient said he primarily landed on the left side. After the accident he states that he was generally stun and someone at the institute advised him to be evaluated. He went to a Gig Harbor urgent care facility and they sent him on to Tacoma General Hospital. At the Tacoma General, he indicates that a whiplash and a concussion were diagnosed and it was advised that he have a CT scan. The patient describes that he had a brain CT and a dark spot was found. It was recommended that he have a followup MRI and this was done locally and showed a recurrent acoustic neuroma. Before, when the patient initially had developed an acoustic neuroma, the chiropractor had seen the patient and suggested that he have a scan and this was how his original acoustic neuroma was diagnosed back in October 2005. The patient has been receiving adjustments by the chiropractor since and he also has had a few massage treatments. Overall his spine complaints have improved substantially.,After the fall, he also saw at Prompt Care in the general Bremerton area, XYZ, an Osteopathic Physician and she examined him and released him full duty and also got an orthopedic consult from XYZ. She ordered an MRI of his neck. Cervically this showed that he had a mild disc bulge at C4-C5, but this actually was the same test that diagnosed a recurrent acoustic neuroma and the patient now is just recovering from neurosurgical treatment for this recurrent acoustic neuroma and some radiation is planned.,Since 2002 the patient has been seeing the chiropractor, XYZ for general aches and pain and this has included some treatments on his back and neck.,CURRENT SYMPTOMS: ,The patient describes his current pain as being intermittent.,PAST MEDICAL HISTORY:,Illnesses: The patient had a diagnosis in 2005 of an acoustic neuroma. It was benign, but treated neurosurgically. In February 2004 and again in August 2009 he has had additional treatments for recurrence and he currently has some skull markers in place because radiation is planned as a followup, although the tumor was still indicated to be benign.,Operations: He has a history of an old mastoidectomy. He has a past history of removal of an acoustic neuroma in 2005 as noted.,Medications: The patient takes occasional Tylenol and occasional Aleve.,Substance Use:,Tobacco: He does not smoke cigarettes.,Alcohol: He drinks about five beers a week.,FAMILY HISTORY:, His father died of mesothelioma and his mother died of Lou Gehrig's disease.,SOCIOECONOMIC HISTORY:,Marital Status and Dependents: The patient has been married three times; longest marriage is of two years duration. He has two children. These dependents are ages 15 and twins and are his wife's dependents.,Education: The patient has bachelor's degree.,Military History: He served six years in the army and received an honorable discharge.,Work History: He has worked at Purdy Correctional Institute in Gig Harbor for 19 years.,CHART REVIEW: , Review of the chart indicates a date of injury of November 20, 2008. He was seen at Tacoma General Hospital with a diagnosis of head contusion and cervical strain. He had a CT of his head done because of a fall with possible loss of consciousness, which showed a left cerebellar hypodensity and further evaluation was recommended. He has a history of an old mastoidectomy. He was then seen on November 24, 2008 by XYZ at Prompt Care on November 24, 2008. There is no clearcut history that he had lost consciousness. He has a past history of removal of an acoustic neuroma in 2005 as noted. A diagnosis of concussion and cervical strain status post fall was made along with an underlying history of abnormal CT and previous resection of an acoustic neuroma. Some symptoms of loss of balance and confusion were noted. She recommended additional testing and neurologic evaluation.,The notes from the treating chiropractor begin on November 24, 2008. Adjustments are given to the cervical, thoracic, and lumbar spine.,He was seen back by XYZ on December 9, 2008 and he had been released to full duties. It was recognized the new MRI suggested recurrence of the acoustic neuroma and he was advised to seek further care in this regard. There were some concerns of his feeling of being wobbly since the fall which might be related to the recurrent neuroma. He continued to have chiropractic adjustments. He was seen back at Prompt Care on January 8, 2009. Dr. X indicated that she thought most of his symptoms were related to the tumor, but that the cervical and thoracic stiffness were from the fall.,A followup note by his chiropractor on January 26, 2009 indicates that cervical x-rays have been taken and that continued chiropractic adjustments along with manual traction would be carried out.,On April 13, 2009, he was seen again at Prompt Care for his cervical and thoracic strain. He was indicated to be improving and there was suggestion that he has some physical therapy and an orthopedic consult was felt appropriate. Therapy was not carried out and obviously was then involved with the treatment of his recurrent neuroma.,On April 17, 2009, he was seen by Dr. X, another chiropractor for consultation and further chiropractic treatments were recommended based on cervical and thoracolumbar subluxation complexes and strain.,A repeat consult was carried out on April 29, 2009 by XYZ. He felt that this was hyperextension cervical injury. It might take a period of time to recover. He mentioned that the patient might have a slight ulnar neuropathy. He felt the patient was capable of full duty and the patient was at that time having ongoing treatment for his neuroma.,This concludes the chart review.,PHYSICAL EXAMINATION: , The patient is 6 feet in height, weighs 255 pounds.,Orthopedic Examination: He can walk with a normal gait, but he has, as indicated, a positive Romberg test and he himself has noticed that if he closes his eyes he loses his balance. Overall the patient is a seemingly good historian. There is a visible 3 cm scar at the left base of the neck near the hairline and there are multiple areas where his head has been shaved both anteriorly and posteriorly. These are secondary to drawing for the skull markers. There is a scar behind the patient's left ear from the original treatment of the acoustic neuroma. This was well healed. The patient can perform a toe-heel gait without difficulty. One visibly can see that he has some facial asymmetry and he indicates that the acoustic neuroma has caused some numbness in the left side of his face and also some asymmetry that is now recovering. The patient states he now thinks his recovery is going to get disregarded and that the facial asymmetry and numbness developed from the first surgery he had. The patient has a full range of motion in both of his shoulders. The patient has a full range of motion in his lumbar spine to include 90 degrees of forward bend, lateral bending of 30 degrees in either direction and extension of 10 degrees. There is full range of motion in the patient's cervical spine to include flexion of 50 degrees at which time he can touch his chin on his chest. He extends 40 degrees, laterally bends 30 degrees, and rotates to 80 degrees in either direction. There is slight tenderness on palpating over the right cervical musculature. There is no evidence of any cervical or lumbar muscle spasms. Reflexes in the upper extremities include 1+ biceps and triceps and 1+ brachioradialis. Knee jerks are 2+ and ankle jerks are 1+. Tinel's test was tested at the elbow, it is negative bilaterally with percussion; however, he has slight tingling bilaterally. The patient's grip tested with a Jamar dynamometer increases from 70 to 80 pounds bilaterally. Sensory testing of lower extremities reveal that the patient has slightly decreased sensation to sharp stimulus in his dorsal aspect of the right first toe and a lesser extent to the left. Testing of muscle strength in the upper and lower extremities is normal. The patient upper arms measured four fingerbreadths above the flexion crease of the elbow measure 35 cm bilaterally. The forearms measured four fingerbreadths below the flexion crease of the elbow measure 30 cm bilaterally. The thighs measured four fingerbreadths above the superior pole of the patella measure 48 cm and the lower legs measured four fingerbreadths below the tibial tubercles measure 41 cm. Pressure on the vertex of the head does not bother the patient. Axial loading is negative. As already indicated straight leg raising is entirely negative both sitting and lying for any radiculitis.,DIAGNOSTIC STUDIES: , X-rays the patient brings with him taken by his treating chiropractor dated 11/24/08 showed that there appears to be a little bit of narrowing of the L4-5 disc space. The hip joints are normal. Views of his thoracic spine are normal. Cervical x-rays are in the file. These are of intermittent quality, but the views do show a very slight degree of anterior spurring at the C4-5 with possible slight narrowing of the disc. There is a view of the right shoulder that is unremarkable.,CONCLUSIONS:, The accepted condition under the claim is a sprain of the neck, thoracic, and lumbar.,DIAGNOSES: , Diagnosis based on today's examination is a sprain of the cervical spine and lumbar spine superimposed upon some early degenerative changes.,Additional diagnosis is one of recurrent acoustic neuroma, presumably benign with upcoming additional treatment of radiation plan. The patient also has a significant degree overweight for his height and it will be improved as he himself recognizes by some weight loss and exercise.,DISCUSSION: , He is fixed and stable at this time and his industrial case can be closed relative to his industrial injury of November 20, 2008. Further chiropractic treatments would be entirely palliative and serve no additional medical purpose due to the fact that he has very minimal symptoms and a basis for these symptoms based on mild or early degenerative changes in both cervical and lumbar spine. He is category I relative to the cervical spine under 296-20-240 and category I to the lumbosacral spine under WAC 296-20-270. His industrial case should be closed and there is, as indicated, no basis for any disability award. Orthopedic Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening. Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm. Open reduction, right both bone forearm fracture with placement of long-arm cast. I&D & Open Reduction - Forearm 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. orthopedic, compound fracture, mid-shaft radius, ulna, open reduction, irrigation and debridement, subcutaneous, tissues, muscle, bone, forearm, radius and ulna, forearm fracture, anatomic alignment, arm cast, puncture wound, tourniquet, i&d, fracture, Orthopedic Postoperative wound infection, complicated. Irrigation and debridement of postoperative wound infection. Removal of foreign body. Placement of vacuum-assisted closure.device. I&D - ORIF Wound 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. orthopedic, irrigation and debridement, removal of foreign body, vacuum-assisted closure device, foreign body, postoperative wound, wound infection, infection, wound, orif, debridement, vacuum, Orthopedic Persistent left hip pain. Left hip avascular necrosis. Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing Hip Pain CHIEF COMPLAINT:, orthopedic, hip pain, radiculopathy, degenerative changes, avascular necrosis, hip resurfacing, arthrodesis, hip replacement, avn, Orthopedic Incision and drainage and removal of foreign body, right foot. The patient has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound. I&D & Foreign Body Removal PREOPERATIVE DIAGNOSIS:, Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body, right foot.,PROCEDURE PERFORMED:,1. Incision and drainage, right foot.,2. Removal of foreign body, right foot.,HISTORY: , This 7-year-old Caucasian male is an inpatient at ABCD General Hospital with a history of falling off his bike and having a root ________ angle inside of his foot. The patient has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.,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 the operating table in a supine position with a safety strap across his lap. General anesthesia was administered by the Department of Anesthesia. The foot was then prepped and draped in the usual sterile orthopedic fashion. The stockinette was reflected and the foot was cleansed with wet and dry sponge. There was noted to be some remaining periwound erythema. There was noted to be some mild crepitation about 2 cm proximal from the entry wound. The entry wound was noted to be over the third metatarsal head dorsally. Upon inspection of the wound, there was noted to be hard foreign filling substance deep within the wound. The entry site from the foreign body was extended proximally approximately about 0.5 cm. At this time, a large wooden foreign body was visualized and removed with a straight stat.,The area was carefully inspected for any remaining piece of foreign body. Several small pieces were noted and they were removed. The area was palpated and there was no more remaining foreign body noted. At this time, the wound was inspected thoroughly. There was noted to be an area along the third metatarsal head more distally that did probe to the bone. There was no purulent drainage expressed. Area was flushed with copious amounts of sterile saline. Pulse lavage was performed with 3 liters of plain sterile saline. Wound cultures were obtained, aerobic and aerobic. The wound was then again inspected for any remaining foreign body or purulent drainage. None was noticed. The wound was packed with sterile new gauze packing lately and dressings consisted of 4x4s, ABDs, Kling, and Kerlix.,The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to the PACU with vital signs stable and vascular status intact. The patient is to be readministered to the pediatrics where daily dressing changes will be performed by podiatry. The patient had a postoperative pain prescription written for Tylenol, Elixir with codeine as needed. orthopedic, incision and drainage, removal of foreign body, purulent drainage, foreign body, metatarsal head, metatarsal, i&d, incision, drainage, foot Orthopedic Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg. Hypergranulation - Consult 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. Orthopedic Painful ingrown toenail, left big toe. Removal of an ingrown part of the left big toenail with excision of the nail matrix. Ingrown Toenail Removal 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. orthopedic, toenail, nail matrix, ingrown toenail, painful, ingrown, Orthopedic Decreased ability to perform daily living activity secondary to recent right hip surgery. Hip Surgery - Discharge Summar CHIEF COMPLAINT:, Decreased ability to perform daily living activity secondary to recent right hip surgery.,HISTORY OF PRESENT ILLNESS: ,The patient is a 51-year-old white female who is status post right total hip replacement performed on 08/27/2007 at ABCD Hospital by Dr. A. The patient had an unremarkable postoperative course, except low-grade fever of 99 to 100 postoperatively. She was admitted to the Transitional Care Unit on 08/30/2007 at XYZ Services. Prior to her discharge from ABCD Hospital, she had received DVT prophylaxis utilizing Coumadin and Lovenox and the INR goal is 2.0 to 3.0. She presents reporting that her last bowel movement was on 08/26/2007 prior to surgery. Otherwise, she reports some intermittent right calf discomfort and some postoperative right hip pain.,ALLERGIES:, No known drug allergies.,PAST MEDICAL HISTORY:, Anxiety, depression, osteoarthritis, migraine headaches associated with menstrual cycle, history of sciatic pain in the distant past, history of herniated disc, and status post appendectomy.,MEDICATIONS: ,Medications taken at home are Paxil, MOBIC, and Klonopin.,MEDICATIONS ON TRANSFER: , Celebrex, Coumadin, Colace, Fiorinal, oxycodone, Klonopin, and Paxil.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY: , The patient is married. She lives with her husband and is employed as a school nurse for the School Department. She had quit smoking cigarettes some 25 years ago and is a nondrinker.,REVIEW OF SYSTEMS:, As mentioned above. She has a history of migraine headaches associated with her menstrual cycle. She wears glasses and has a history of floaters. She reports a low-grade temperature of 99 to 100 postoperatively, mild intermittent cough, scratchy throat, (the symptoms may be secondary to intubation during surgery), intermittent right calf pain, which was described as sharp, but momentary with a negative Homans sign. The patient denies any cardiopulmonary symptoms such as chest pain, palpitation, pain in the upper neck and down to her arm, difficulty breathing, shortness of breath, or hemoptysis. She denies any nausea, vomiting, or diarrhea, but reports as being constipated with the last bowel movement being on 08/26/2007 prior to surgery. She denies urinary symptoms such as dysuria, urinary frequency, incomplete bladder emptying or voiding difficulties. First day of her last menstrual cycle was 08/23/207 and she reports that she is most likely not pregnant since her husband had a vasectomy years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS: At the time of admission, temperature 97.7, blood pressure 108/52, heart rate 94, respirations 18, and 95% O2 saturation on room air.,GENERAL: No acute distress at the time of exam.,HEENT: Normocephalic. Sclerae are nonicteric. EOMI. Dentition is in good repair.,NECK: Trachea is at the midline.,LUNGS: Clear to auscultation.,HEART: Regular rate and rhythm.,ABDOMEN: Bowel sounds are heard throughout. Soft and nontender.,EXTREMITIES: Right hip incision is clean, intact, and no drainage is noted. There is diffuse edema, which extends distally. There is no calf tenderness per se bilaterally and Homans sign is negative. There is no pedal edema.,MENTAL STATUS: Alert and oriented x3, pleasant and cooperative during the exam.,LABORATORY DATA: , Initial workup included chemistry panel, which was unremarkable with the exception of a fasting glucose of 122 and an anion gap that was slightly decreased at 6. The BUN was normal at 8, creatinine was 0.9, INR was 1.49. CBC, had a white count of 5.7, hemoglobin was 9.2, hematocrit was 26.6, and platelets were 318,000.,IMPRESSION:,1. Status post right total hip replacement. The patient is admitted to the TCU at XYZ's Health Services and will be seen in consultation by Physical Therapy and Occupational Therapy.,2. Postoperative anemia, Feosol 325 mg one q.d.,3. Pain management. Oxycodone SR 20 mg b.i.d., and oxycodone IR 5 mg one to two tablets q.4h., p.r.n. pain. Additionally, she will utilize ice to help decrease edema.,4. Depression and anxiety, Paxil 40 mg daily, Klonopin 1 mg q.h.s.,5. Osteoarthritis, Celebrex 200 mg b.i.d.,6. GI prophylaxis, Protonix 40 mg b.i.d. Dulcolax suppository and lactulose will be used as a p.r.n. basis and Colace 100 mg b.i.d.,7. DVT prophylaxis will be maintained with Arixtra 2.5 mg subcutaneously daily until the INR is greater than 1.7 and Coumadin will be adjusted according to the INR. She will continue on 5 mg every day.,8. Right leg muscle spasm/calf pain is stable at this time and we will reevaluate on a regular basis. Monitor for any possibility of DVT. Orthopedic Status post left hip fracture and hemiarthroplasty. Rehab transfer as soon as medically cleared. Hip Fracture - Rehab Consult 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. Orthopedic Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement. Comminuted fracture, dislocation left proximal humerus. Hemiarthroplasty - Shoulder PREOPERATIVE DIAGNOSIS:, Comminuted fracture, dislocation left proximal humerus.,POSTOPERATIVE DIAGNOSIS:, Comminuted fracture, dislocation left proximal humerus.,PROCEDURE PERFORMED: , Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement.,PROCEDURE: ,The patient was taken to OR #2, administered general anesthetic. He was positioned in the modified beach chair position on the operative table utilizing the shoulder apparatus. The left shoulder and upper extremities were then prepped and draped in the usual manner. A longitudinal incision was made extending from a point just lateral to the coracoid down towards deltoid tuberosity of the humerus. This incision was taken down through the skin and subcutaneous tissues were split utilizing the coag cautery. Hemostasis was achieved with the cautery. The deltoid fascia were identified, skin flaps were then created. The deltopectoral interval was identified and the deltoid split just lateral to the cephalic vein. The deltoid was then retracted. There was marked hematoma and swelling within the subdeltoid bursa. This area was removed with rongeurs. The biceps tendon was identified which was the landmark for the rotator interval. Mayo scissors was utilized to split the remaining portion of the rotator interval. The greater tuberosity portion with the rotator cuff was identified. Excess bone was removed from the greater tuberosity side to allow for closure later. The lesser tuberosity portion with the subscapularis was still attached to the humeral head, therefore, osteotome was utilized to separate the lesser tuberosity from the humeral head fragment.,Excess bone was removed from the lesser tuberosity as well. Both of these were tagged with Ethibond sutures for later. The humeral head was delivered out of the wound. It was localized to the area of the anteroinferior glenoid region. The glenoid was then inspected, and noted to be intact. The fracture was at the level of the surgical neck on the proximal humerus. The canal was repaired with the broaches. An #8 stem was chosen as it was going to be cemented into place. The trial stem was impacted into position and the shaft of the bone marked with the cautery to the appropriate retroversion. Trial reduction was performed. The 48 x 21 mm head was the most appropriate size, matching the patient's as well as the soft tissue tension on the shoulder. At this point, the wound was copiously irrigated with gentamycin solution. The canal was copiously irrigated as well and suctioned dry. Methyl methacrylate cement was mixed. The cement gun was filled and the canal was filled with the cement. The #8 stem was then impacted into place and held in the position in the appropriate retroversion until the cement had cured. Excess cement was removed by sharp dissection. Prior to cementation of the stem, a hole was drilled in the shaft of proximal humerus and #2 fiber wires were placed through this hole for closure later. Once the cement was cured, the modular head was impacted on to the Morse taper. It was stable and the shoulder was reduced. The lesser tuberosity was then reapproximated back to the original site utilizing the #2 fiber wire suture that was placed in the humeral shaft as well as the holes in the humeral implant. The greater tuberosity portion with rotator cuff was also attached to the implant as well as the shaft of the humerus utilizing #2 fiber wires as well. The rotator interval was closed with #2 fiber wire in an interrupted fashion. The biceps tendon was ________ within this closure. The wound was copiously irrigated with gentamycin solution, suctioned dry. The deltoid fascia was then approximated with interrupted #2-0 Vicryl suture. Subcutaneous layer was approximated with interrupted #2-0 Vicryl and skin approximated with staples. Subcutaneous tissues were infiltrated with 0.25% Marcaine solution. A bulky dressing was applied to the wound followed by application of a large arm sling. Circulatory status was intact in the extremity at the completion of the case. The patient was then transferred to recovery room in apparent satisfactory condition. orthopedic, dislocation, proximal humerus, comminuted fracture, rotator interval, tuberosity portion, hemiarthroplasty, fracture, wound, proximal, deltoid, rotator, stem, humeral, humerus, tuberosity, cemented, Orthopedic Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root. Hemilaminotomy & Foraminotomy 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. orthopedic, foraminotomy with medial facetectomy, facetectomy for microscopic decompression, decompression of nerve root, hemilaminotomy and foraminotomy, decompression of nerve, microscopic decompression, medial facetectomy, kerrison rongeur, nerve root, spinous processes, facetectomy, kerrison, hemilaminotomy, foraminotomy, Orthopedic Left hip fracture. The patient is a 53-year-old female with probable pathological fracture of the left proximal femur. Hip Fracture - ER Consult REASON FOR CONSULTATION: , Left hip fracture.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 53-year-old female with a known history of sciatica, apparently presented to the emergency room due to severe pain in the left lower extremity and unable to bear weight. History was obtained from the patient. As per the history, she reported that she has been having back pain with left leg pain since past 4 weeks. She has been using a walker for ambulation due to disabling pain in her left thigh and lower back. She was seen by her primary care physician and was scheduled to go for MRI yesterday. However, she was walking and her right foot got caught on some type of rug leading to place excessive weight on her left lower extremity to prevent her fall. Since then, she was unable to ambulate. The patient called paramedics and was brought to the emergency room. She denied any history of fall. She reported that she stepped the wrong way causing the pain to become worse. She is complaining of severe pain in her lower extremity and back pain. Denies any tingling or numbness. Denies any neurological symptoms. Denies any bowel or bladder incontinence.,X-rays were obtained which were remarkable for left hip fracture. Orthopedic consultation was called for further evaluation and management. On further interview with the patient, it is noted that she has a history of malignant melanoma, which was diagnosed approximately 4 to 5 years ago. She underwent surgery at that time and subsequently, she was noted to have a spread to the lymphatic system and lymph nodes for which she underwent surgery in 3/2008.,PAST MEDICAL HISTORY: , Sciatica and melanoma.,PAST SURGICAL HISTORY: ,As discussed above, surgery for melanoma and hysterectomy.,ALLERGIES: , NONE.,SOCIAL HISTORY: , Denies any tobacco or alcohol use. She is divorced with 2 children. She lives with her son.,PHYSICAL EXAMINATION:,GENERAL: The patient is well developed, well nourished in mild distress secondary to left lower extremity and back pain.,MUSCULOSKELETAL: Examination of the left lower extremity, there is presence of apparent shortening and external rotation deformity. Tenderness to palpation is present. Leg rolling is positive for severe pain in the left proximal hip. Further examination of the spine is incomplete secondary to severe leg pain. She is unable to perform a straight leg raising. EHL/EDL 5/5. 2+ pulses are present distally. Calf is soft and nontender. Homans sign is negative. Sensation to light touch is intact.,IMAGING:, AP view of the hip is reviewed. Only 1 limited view is obtained. This is a poor quality x-ray with a lot of soft tissue shadow. This x-ray is significant for basicervical-type femoral neck fracture. Lesser trochanter is intact. This is a high intertrochanteric fracture/basicervical. There is presence of lytic lesion around the femoral neck, which is not well delineated on this particular x-ray. We need to order repeat x-rays including AP pelvis, femur, and knee.,LABS:, Have been reviewed.,ASSESSMENT: , The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.,DISCUSSION AND PLAN: , Nature and course of the diagnosis has been discussed with the patient. Based on her presentation without any history of obvious fall or trauma and past history of malignant melanoma, this appears to be a pathological fracture of the left proximal hip. At the present time, I would recommend obtaining a bone scan and repeat x-rays, which will include AP pelvis, femur, hip including knee. She denies any pain elsewhere. She does have a past history of back pain and sciatica, but at the present time, this appears to be a metastatic bone lesion with pathological fracture. I have discussed the case with Dr. X and recommended oncology consultation.,With the above fracture and presentation, she needs a left hip hemiarthroplasty versus calcar hemiarthroplasty, cemented type. Indication, risk, and benefits of left hip hemiarthroplasty has been discussed with the patient, which includes, but not limited to bleeding, infection, nerve injury, blood vessel injury, dislocation early and late, persistent pain, leg length discrepancy, myositis ossificans, intraoperative fracture, prosthetic fracture, need for conversion to total hip replacement surgery, revision surgery, DVT, pulmonary embolism, risk of anesthesia, need for blood transfusion, and cardiac arrest. She understands above and is willing to undergo further procedure. The goal and the functional outcome have been explained. Further plan will be discussed with her once we obtain the bone scan and the radiographic studies. We will also await for the oncology feedback and clearance.,Thank you very much for allowing me to participate in the care of this patient. I will continue to follow up. orthopedic, calcar, proximal femur, pathological fracture, hip, fracture, hemiarthroplasty, melanoma, Orthopedic Austin-Moore bipolar hemiarthroplasty, left hip. Subcapital left hip fracture. Hemiarthroplasty - Austin-Moore Bipolar 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. orthopedic, austin-moore bipolar hemiarthroplasty, subcapital left hip fracture, hip fracture, austin moore bipolar hemiarthroplasty, subcutaneous tissues, hip, hemiarthroplasty, austin, cemented, femur, subcapital, fracture, femoral, Orthopedic Hemiarthroplasty, right hip. Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip. Hemiarthroplasty - Discharge Summary ADMISSION DIAGNOSES: ,Fracture of the right femoral neck, also history of Alzheimer's dementia, and hypothyroidism.,DISCHARGE DIAGNOSES: , Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.,PROCEDURE PERFORMED: ,Hemiarthroplasty, right hip.,CONSULTATIONS: ,Medicine for management of multiple medical problems including Alzheimer's.,HOSPITAL COURSE: , The patient was admitted on 08/06/2007 after a fall with subsequent fracture of the right hip. The patient was admitted to Orthopedics and consulted Medicine. The patient was actually taken to the operating room, consent signed by durable power of attorney, taken on 08/06/2007, had right hip hemiarthroplasty, recovered without incidence. The patient had continued confusion and dementia, which is apparently his baseline secondary to his Alzheimer's. Brief elevation of white count following the surgery, which did subside. Studies, UA and blood culture were negative. The patient was stable and was discharged to Heartland.,CONDITION ON DISCHARGE: , Stable.,DISCHARGE INSTRUCTIONS:, Transfer to ABC for rehab and continued care. Diabetic diet. Activity, ambulate as tolerated with posterior hip precautions. Rehab potential fair. He will need nursing, Social Work, PT/OT, and nutrition consults. Resume home meds, DVT prophylaxis, aspirin, and compression stockings. Follow up Dr. X in one to two weeks; call 123-4567 for an appointment. orthopedic, femoral neck, orthopedics, rehab, femoral, neck, fracture, dementia, hemiarthroplasty, hip, Orthopedic Hardware removal in the left elbow. Hardware Removal - Elbow PREOPERATIVE DIAGNOSIS: , Retained hardware in left elbow.,POSTOPERATIVE DIAGNOSIS:, Retained hardware in left elbow.,PROCEDURE: , Hardware removal in the left elbow.,ANESTHESIA: , Procedure done under general anesthesia. The patient also received 4 mL of 0.25% Marcaine of local anesthetic.,TOURNIQUET: ,There is no tourniquet time.,ESTIMATED BLOOD LOSS: ,Minimal.,COMPLICATIONS: ,No intraoperative complications.,HISTORY AND PHYSICAL: ,The patient is a 5-year, 8-month-old male who presented to me direct from ED with distracted left lateral condyle fracture. He underwent screw compression for the fracture in October 2007. The fracture has subsequently healed and the patient presents for hardware removal. The risks and benefits of surgery were discussed. The risks of surgery include the risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure of removal of hardware, failure to relieve pain or improved range of motion. All questions were answered and the family agreed to the above plan.,PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table. General anesthesia was then administered. The patient's left upper extremity was then prepped and draped in standard surgical fashion. Using his previous incision, dissection was carried down through the screw. A guide wire was placed inside the screw and the screw was removed without incident. The patient had an extension lag of about 15 to 20 degrees. Elbow is manipulated and his arm was able to be extended to zero degrees dorsiflex. The washer was also removed without incident. Wound was then irrigated and closed using #2-0 Vicryl and #4-0 Monocryl. Wound was injected with 0.25% Marcaine. The wound was then dressed with Steri-Strips, Xeroform, 4 x4 and bias. The patient tolerated the procedure well and subsequently taken to the recovery in stable condition.,DISCHARGE NOTE: , The patient will be discharged on date of surgery. He is to follow up in one week's time for a wound check. This can be done at his primary care physician's office. The patient should keep his postop dressing for about 4 to 5 days. He may then wet the wound, but not scrub it. The patient may resume regular activities in about 2 weeks. The patient was given Tylenol with Codeine 10 mL p.o. every 3 to 4 hours p.r.n. orthopedic, retained hardware, hardware removal, tourniquet, elbow, hardware, Orthopedic New patient visit for right hand pain. Punched the wall 3 days prior to presentation, complained of ulnar-sided right hand pain, and was seen in the emergency room. Hand Pain - Consult REASON FOR VISIT: ,New patient visit for right hand pain.,HISTORY OF PRESENT ILLNESS: ,The patient is a 28-year-old right-hand dominant gentleman, who punched the wall 3 days prior to presentation. He complained of ulnar-sided right hand pain and was seen in the emergency room. Reportedly, he had some joints in his hand pushed back and placed by somebody in emergency room. Today, he admits that his pain is much better. Currently, since that time he has been in the splint with minimal pain. He has had no numbness, tingling or other concerning symptoms.,PAST MEDICAL HISTORY:, Negative.,SOCIAL HISTORY: ,The patient is a nonsmoker and does not use illegal drugs. Occasionally drinks.,REVIEW OF SYSTEMS: , A 12-point review of systems is negative.,MEDICATIONS:, None.,ALLERGIES: , No known drug allergies.,FINDINGS: , On physical exam, he has swelling and tenderness over the ulnar dorsum of his hand. He has a normal cascade. He has 70 degrees of MCP flexion and full IP flexion and extension. He has 3 to 5 strength in his grip and intrinsics. He has intact sensation to light touch in the radial, ulnar, and median nerve distribution. Two plus radial pulse.,X-rays taken from today were reviewed, include three views of the right hand. They show possible small fractures of the base of the fourth and third metacarpals. Joint appears to be located. A 45-degree oblique view was obtained and confirmed adduction of the CMC joints of the fourth and fifth metacarpals. His injury films from 09/15/07 were reviewed and demonstrated what appears to be CMC dislocations of the third and fourth metacarpals.,ASSESSMENT: , Status post right third and fourth metacarpal carpometacarpal dislocations.,PLANS: , The patient was placed into a short-arm cast and intrinsic plus. I would like him to wear this for 2 weeks and then follow up with us. At that time, we will transition him to an OT splint and begin range of motion activities of the fingers and wrist. We should see him back in 2 weeks' time at which time he should obtain three views of the right hand and a 45-degree oblique view out of cast. orthopedic, hand pain, pain, hand, metacarpals Orthopedic Removal of painful hardware, first left metatarsal. Excision of nonunion, first left metatarsal. Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal. Hardware Removal - Metatarsal TITLE OF OPERATION:,1. Removal of painful hardware, first left metatarsal.,2. Excision of nonunion, first left metatarsal.,3. Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.,PREOPERATIVE DIAGNOSES:,1. Nonunion of fractured first left metatarsal osteotomy.,2. Painful hardware, first left metatarsal.,POSTOPERATIVE DIAGNOSES:,1. Nonunion of fractured first left metatarsal osteotomy.,2. Painful hardware, first left metatarsal.,ANESTHESIA:, General anesthesia with local infiltration of 5 mL of 0.5% Marcaine and 1% lidocaine plain with 1:100,000 epinephrine preoperatively and 15 mL of 0.5% Marcaine postoperatively.,HEMOSTASIS: , Left ankle tourniquet set at 250 mmHg for 60 minutes.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,MATERIALS USED:, 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as one corticocancellous allograft consisting of ASIS and one T-type plate prebent with six screw holes and five 3.0 partially threaded cannulated screws and a single 3.0 noncannulated screw from the OsteoMed and Synthes System respectively for the fixation of the bone graft and the plate on the first left metatarsal.,INJECTABLES: , 1 g Ancef IV 30 minutes preoperatively and the afore-mentioned lidocaine.,DESCRIPTION OF THE PROCEDURE: ,The patient was brought to the operating room and placed on the operating table in the supine position. After general anesthesia 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 then inflated. Attention was then directed on the dorsal aspect of the first left metatarsal shaft where an 8-cm linear incision was placed directly parallel and medial to the course of the extensor hallucis longus tendon. The incision extended from the base of the first left metatarsal all the way to the first left metatarsophalangeal joint. 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 periosteum of the first left metatarsal. All the tendinous neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, the periosteal tissues were mobilized from their attachments on the first left metatarsal shaft. Dissection was carried down to the level of the lose screw fixation and the two screws were identified and removed intact. The screws were sent to pathology for examination. The nonunion was also identified closer to the base of the first left metatarsal and using the sagittal saw the nonunion and some of the healthy tissue on both ends of the previous osteotomy were resected and sent to pathology for identification. The remaining two ends of the previous osteotomy were then fenestrated with the use of a 0.045 Kirschner wire to induce bleeding. The corticocancellous bone graft was prepped according to the instructions in saline for at least 60 minutes and then interposed in the previous area of the osteotomy. Provisional fixation with K-wires was achieved and also correction of the bunion deformity of the first left metatarsophalangeal joint was also accomplished. The bone graft was then stabilized with the use of a T-type prebent plate with the use of fixed screws that were inserted using AO technique through the plate and the shaft of the first left metatarsal and compressed appropriately the graft. Removal of the K-wires and examination of fixation and graft incorporation into the previous nonunion area was found to be excellent. The area was flushed copiously flushed with saline. The periosteal and capsular tissues were approximated with 3-0 Vicryl and 2-0 Vicryl suture material. All the subcutaneous tissues were approximated with 4-0 Vicryl suture material and 5-0 Prolene was used to approximate the skin edges at this time. The left ankle tourniquet was deflated. Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff. The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage. The patient's left foot was placed in a surgical shoe.,The patient was then transferred to the postanesthesia care unit with his vital signs stable and the vascular status at appropriate levels. The patient was given specific instructions and education on how to continue caring for his left foot surgery. The patient was also given pain medications, instructions on how to control his 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 his first postoperative appointment. orthopedic, hardware removal, metatarsal osteotomy, painful hardware, osteotomy, excision of nonunion, corticocancellous bone graft, internal fixation, subcutaneous tissues, previous osteotomy, vicryl suture, suture material, corticocancellous bone, ankle tourniquet, bone graft, metatarsal, tourniquet, allograft, fixation, plates, ankle, vicryl, nonunion, screws, Orthopedic Hardware removal, right ulnar Hardware Removal - Ulnar PREOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar.,POSTOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar,PROCEDURE: , Hardware removal, right ulnar.,ANESTHESIA:, The patient received 2.5 mL of 0.25% Marcaine and local anesthetic.,COMPLICATIONS: , No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HISTORY AND PHYSICAL: ,The patient is a 5-year, 5-month-old male who sustained a both-bone forearm fracture in September 2007. The fracture healed uneventfully, but then the patient subsequently suffered a refracture one month ago. The patient had shortening in arms, noted in both bones. The parents opted for surgical stabilization with nailing. This was performed one month ago on return visit. His ulnar nail was quite prominent underneath the skin. It was decided to remove the ulnar nail early and place the patient in another cast for 3 weeks.,Risks and benefits of the surgery were discussed with the mother. Risk of surgery incudes risks of anesthesia, infection, bleeding, changes in sensation in most of the extremity, need for longer casting. All questions were answered and mother agreed to above plan.,PROCEDURE IN DETAIL: ,The patient was seen in the operative room, placed supine on operating room table. General anesthesia was then administered. The patient was given Ancef preoperatively. The left elbow was prepped and draped in a standard surgical fashion. A small incision was made over the palm with K-wire. This was removed without incident. The wound was irrigated. The bursitis was curetted. Wounds closed using #4-0 Monocryl. The wound was clean and dry, dressed with Xeroform 4 x 4s and Webril. Please note the area infiltrated with 0.25% Marcaine. The patient was then placed in a long-arm cast. The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: ,The patient will maintain the cast for 3 more weeks. Intraoperative nail was given to the mother. The patient to take Tylenol with Codeine as needed. All questions were answered., orthopedic, both-bone forearm fracture, retained hardware, hardware removal, hardware, forearm, ulnar, Orthopedic Left distal medial hamstring release. Hamstring Release PREOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,POSTOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,PROCEDURE: , Left distal medial hamstring release.,ANESTHESIA: , General anesthesia. Local anesthetic 10 mL of 0.25% Marcaine local.,TOURNIQUET TIME: , 15 minutes.,ESTIMATED BLOOD LOSS: ,Minimal.,COMPLICATIONS: ,There were no intraoperative complications.,DRAIN: ,None.,SPECIMENS: ,None.,HISTORY AND PHYSICAL: ,The patient is a 12-year-old boy born at a 32-week gestation and with drug exposure in utero. The patient has diagnosis of autism as well. The patient presented with bilateral knee flexion contractures, initially worse on right than left. He had right distal medial hamstring release performed in February 2007 and has done quite well and has noted significant improvement in his gait and his ability to play. The patient presents now with worsening left knee flexion contracture, and desires the same procedure to be performed. Risks and benefits of the surgery were discussed. The risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure to restore normal anatomy, continued contracture, possible need for other procedures. All questions were answered and mother and son agreed to above plan.,PROCEDURE NOTE: ,The patient was taken to operating room and placed supine on operating table. General anesthesia was administered. The patient received Ancef preoperatively. Nonsterile tourniquet was placed on the upper aspect of the patient's left thigh. The extremity was then prepped and draped in standard surgical fashion. The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg. Esmarch was then removed. A small 3 cm incision was made over the distal medial hamstring. Hamstring tendons were isolated and released in order of semitendinosus, semimembranosus, and sartorius. The wound was then irrigated with normal saline and closed used 2-0 Vicryl and then 4-0 Monocryl. The wound was cleaned and dried and dressed with Steri-Strips. The area was infiltrated with total 10 mL of 0.25% Marcaine. The wound was then covered with Xeroform, 4 x 4s, and Bias. Tourniquet was released at 15 minutes. The patient was then placed in knee immobilizer. The patient tolerated the procedure well and subsequently taken to recovery in stable condition.,POSTOPERATIVE PLAN: , The patient may weight bear as tolerated in his brace. He will start physical therapy in another week or two. The patient restricted from any PE for at least 6 week. He may return to school on 01/04/2008. He was given Vicodin for pain. orthopedic, medial hamstring release, distal medial hamstring release, bilateral knee flexion contractures, bilateral knee, hamstring release, knee flexion, tourniquet, flexion, contractures, hamstring, Orthopedic Excision of foreign body, right foot and surrounding tissue. This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. The wire entered his foot. Foreign Body Removal - Foot "PREOPERATIVE DIAGNOSIS: , Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body in the right foot.,PROCEDURE PERFORMED:, Excision of foreign body, right foot and surrounding tissue.,ANESTHESIA: , TIVA and local.,HISTORY:, This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. The wire entered his foot. His family physician attempted to remove the wire, but it only became deeper in the foot. The wound eventually healed, but a scar tissue was formed. The patient has had constant pain with ambulation intermittently since the incident occurred. He desires attempted surgical removal of the wire. The risks and benefits of the procedure have been explained to the patient in detail by Dr. X. The consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position with a safety strap placed across his waist for his protection.,A pneumatic ankle tourniquet was applied about the right ankle over copious amounts of Webril for the patient's protection. After adequate IV sedation was administered by the Department of Anesthesia, a total of 12 cc of 0.5% Marcaine plain was used to administer an ankle block. Next, the foot was prepped and draped in the usual aseptic fashion. An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered into the operative field and the sterile stockinet was reflected. Attention was directed to the plantar aspect of the foot where approximately a 5 mm long cicatrix was palpated and visualized. This was the origin and entry point of the previous puncture wound from the wire. This cicatrix was found lateral to the plantar aspect of the first metatarsal between the first and second metatarsals in a nonweightbearing area. Next, the Xi-scan was draped and brought into the operating room. A #25 gauge needles under fluoroscopy were inserted into the plantar aspect of the foot and three planes to triangulate the wire. Next, a #10 blade was used to make approximately a 3 cm curvilinear ""S""-shaped incision. Next, the #15 blade was used to carry the incision through the subcutaneous tissue. The medial and lateral margins of the incision were undermined. Due to the small nature of the foreign body and the large amount of fat on the plantar aspect of the foot, the wires seemed to serve no benefit other then helping with the incision planning. Therefore, they were removed. Once the wound was opened, a hemostat was used to locate the wire very quickly and the wire was clamped. A second hemostat was used to clamp the wire. A #15 blade was used to carefully transect the fatty tissue around the tip of the hemostats, which were visualized in the base of the wound. The wire quickly came into visualization. It measured approximately 4 mm in length and was approximately 1 mm in diameter. The wire was green colored and metallic in nature. It was removed with the hemostat and passed off as a specimen to be sent to Pathology for identification. The wire was found at the level of deep fascia at the capsular level just plantar to the deep transverse intermetatarsal ligament. Next, copious amounts of sterile gentamicin impregnated saline was instilled in the wound for irrigation and the wound base was thoroughly cleaned and inspected. Next, a #3-0 Vicryl was used to throw two simple interrupted deep sutures to remove the dead space. Next, #4-0 Ethibond was used to close the skin in a combination of simple interrupted and horizontal mattress suture technique. The standard postoperative dressing consisting of saline-soaked Owen silk, 4x4s, Kling, Kerlix, and Coban were applied. The pneumatic ankle tourniquet was released. There was immediate hyperemic flush to the digits noted. The patient's anesthesia was reversed. He tolerated the above anesthesia and procedure without complications. The patient was transported via cart to the Postanesthesia Care Unit.,Vital signs were stable and vascular status was intact to the right foot. He was given OrthoWedge shoe. Ice was applied behind the knee and his right lower extremity was elevated on to pillows. He was given standard postoperative instructions consisting of rest, ice and elevation to the right lower extremity. He is to be non-weightbearing for three weeks, at which time, the wound will be evaluated and sutures will be removed. He is to follow up with Dr. X on 08/22/2003 and was given emergency contact number to call if problems arise. He was given a prescription for Tylenol #4, #30 one p.o. q.4-6h. p.r.n., pain as well as Celebrex 200 mg #30 take two p.o. q.d. p.c., with 200 mg 12 hours later as a rescue dose. He was given crutches. He was discharged in stable condition." orthopedic, foreign body removal, excision of foreign body, ankle tourniquet, plantar aspect, foreign body, foot, ankle, plantar, wound, Orthopedic Excision of ganglion of the left wrist. A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist. Ganglion Excision 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. orthopedic, curved incision, superficial vessels, tourniquet, excision, dorsal, wrist, ganglion Orthopedic Consultation for left foot pain. Foot pain Consultation CHIEF COMPLAINT:, Left foot pain.,HISTORY:, XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to continue playing He was examined by John Houston, the trainer, and had tenderness around the navicular so was asked to come over and see me for evaluation. He has been in a walking boot. He has been taped firmly. Pain with weightbearing activities. He is limping a bit. No significant foot injuries in the past. Most of his pain is located around the dorsal aspect of the hindfoot and midfoot. ,PHYSICAL EXAM:, He does have some swelling from the hindfoot out toward the midfoot. His arch is maintained. His motion at the ankle and subtalar joints is preserved. Forefoot motion is intact. He has pain with adduction and abduction across the hindfoot. Most of this discomfort is laterally. His motor strength is grossly intact. His sensation is intact, and his pulses are palpable and strong. His ankle is not tender. He has minimal to no tenderness over the ATFL. He has no medial tenderness along the deltoid or the medial malleolus. His anterior drawer is solid. His external rotation stress is not painful at the ankle. His tarsometatarsal joints, specifically 1, 2 and 3, are nontender. His maximal tenderness is located laterally along the calcaneocuboid joint and along the anterior process of the calcaneus. Some tenderness over the dorsolateral side of the talonavicular joint as well. The medial talonavicular joint is not tender.,RADIOGRAPHS:, Those done of his foot weightbearing show some changes over the dorsal aspect of the navicular that appear chronic. I don't see a definite fracture. The tarsometarsal joints are anatomically aligned. Radiographs of his ankle again show changes along the dorsal talonavicular joint but no other fractures identified. Review of an MR scan of the ankle dated 12/01/05 shows what looks like some changes along the lateral side of the calcaneocuboid joint with disruption of the lateral ligament and capsular area. Also some changes along the dorsal talonavicular joint. I don't see any significant marrow edema or definitive fracture line. ,IMPRESSION:, Left Chopart joint sprain.,PLAN:, I have spoken to XYZ about this. Continue with ice and boot for weightbearing activities. We will start him on a functional rehab program and progress him back to activities when his symptoms allow. He is clear on the prolonged duration of recovery for these hindfoot type injuries. orthopedic, foot pain, calcaneocuboid joint, dorsal aspect, dorsal talonavicular joint, foot injuries, hindfoot, midfoot, rehab program, walking boot, weightbearing, talonavicular joint, dorsal, talonavicular, ankle, foot, tenderness Orthopedic Resection of infected bone, left hallux, proximal phalanx, and distal phalanx. Osteomyelitis, left hallux. Hallux Infected Bone Resection "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." orthopedic, osteomyelitis, proximal phalanx, distal phalanx, infected bone, proximal, bone, phalanx, healing, hallux, infected, tissue, distal, Orthopedic Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot. Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads. Foreign Body Removal - Foot - 1 PREOPERATIVE DIAGNOSES:,1. Cellulitis with associated abscess, right foot.,2. Foreign body, right foot.,POSTOPERATIVE DIAGNOSES:,1. Cellulitis with associated abscess, right foot.,2. Foreign body, right foot.,PROCEDURE PERFORMED:,1. Irrigation debridement.,2. Removal of foreign body of right foot.,ANESTHESIA:, Spinal with sedation.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,GROSS FINDINGS: , Include purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old Caucasian male with a history of uncontrolled diabetes mellitus. The patient states that he was working in his garage over the past few days when he noticed some redness and edema in his right foot. He notes some itching as well as increasing pain and redness in the right foot and presented to ABCD General Hospital Emergency Room. He was evaluated by the Emergency Room staff as well as the medical team and the Department of Orthopedics. It was noted upon x-ray a foreign body in his foot and he had significant amount of cellulitis as well ________ right lower extremity. After a long discussion held with the patient, it was elected to proceed with irrigation debridement and removal of the foreign body.,PROCEDURE: , After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained. The operative extremity was then confirmed with the patient, operative surgeon, the Department of Anesthesia and nursing staff. The patient was then transferred to preoperative area to Operative Suite #5 and placed on the operating table in supine position. All bony prominences were well padded at this time. The Department of Anesthesia was administered spinal anesthetic to the patient. Once this anesthesia was obtained, the patient's right lower extremity was sterilely prepped and draped in the usual sterile fashion. Upon viewing of the plantar aspect of the foot, there was noted to be a swollen ecchymotic area with a small hole in it, which purulent fluid was coming from. At this time, after all bony and soft tissue landmarks were identified as well as the localization of the pus, a 2 cm longitudinal incision was made directly over this area, which was located between the second and third metatarsal heads. Upon incising this, there was a foul smelling purulent fluid, which flowed from this region. Aerobic and anaerobic cultures were taken as well as gram stain. The area was explored and it ________ to the dorsum of the foot. There was no obvious joint involvement. After all loculations were broken, 3 liters antibiotic-impregnated fluid were pulse-evac through the wound. The wound was again inspected with no more gross purulent or necrotic appearing tissue. The wound was then packed with an iodoform gauge and a sterile dressing was applied consisting of 4x4s, floss, and Kerlix covered by an Ace bandage. At this time, the Department of Anesthesia reversed the sedation. The patient was transferred back to the hospital gurney to Postanesthesia Care Unit. The patient tolerated the procedure well and there were no complications.,DISPOSITION: ,The patient will be followed on a daily basis for possible repeat irrigation debridement. orthopedic, removal of foreign body, purulent material, metatarsal, cellulitis, abscess, kerlix, foreign body, foot, irrigation, debridement, purulent, Orthopedic Flexor carpi radialis and palmaris longus repair. Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration. Flexor Carpi Radialis & Palmaris Longus Repair PREOPERATIVE DIAGNOSIS:, Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.,POSTOPERATIVE DIAGNOSIS:, Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.,PROCEDURES PERFORMED: ,1. Repair flexor carpi radialis.,2. Repair palmaris longus.,ANESTHETIC: , General.,TOURNIQUET TIME: ,Less than 30 minutes.,CLINICAL NOTE: ,The patient is a 21-year-old who sustained a clean laceration off a teapot last night. She had lacerated her flexor carpi radialis completely and 90% of her palmaris longus. Both were repaired proximal to the carpal tunnel. The postoperative plans are for a dorsal splint and early range of motion passive and active assist. The wrist will be at approximately 30 degrees of flexion. The MPJ is at 30 degrees of flexion, the IP straight. Splinting will be used until the 4-week postoperative point.,PROCEDURE: , Under satisfactory general anesthesia, the right upper extremity was prepped and draped in the usual fashion. There were 2 transverse lacerations. Through the first laceration, the flexor carpi radialis was completely severed. The proximal end was found with a tendon retriever. The distal end was just beneath the subcutaneous tissue.,A primary core stitch was used with a Kessler stitch. This was with 4-0 FiberWire. A second core stitch was placed, again using 4-0 FiberWire. The repair was oversewn with locking, running, 6-0 Prolene stitch. Through the second incision, the palmaris longus was seen to be approximately 90% severed. It was an oblique laceration. It was repaired with a 4-0 FiberWire core stitch and with a Kessler-type stitch. A secure repair was obtained. She was dorsiflexed to 75 degrees of wrist extension without rupture of the repair. The fascia was released proximally and distally to give her more room for excursion of the repair.,The tourniquet was dropped, bleeders were cauterized. Closure was routine with interrupted 5-0 nylon. A bulky hand dressing as well as a dorsal splint with the wrist MPJ and IP as noted. The splint was dorsal. The patient was sent to the recovery room in good condition. orthopedic, kessler stitch, flexor carpi radialis, palmaris longus, radialis, laceration, fiberwire, flexor, carpi, palmaris, longus, repair Orthopedic Consultation for FCR tendinitis FCR tendinitis HISTORY OF PRESENT PROBLEM:, XYZ was seen by Dr. ABC for an FCR tendinitis. We do not have his reports, but by history she has had two cortisone shots. She plays musical instruments, and it does bother her from time to time. She was considering surgery, but she takes ibuprofen and it seems to be well-controlled. She is here now for consultation. ,CLINICAL/PHYSICAL EXAMINATION: , ,General: The patient is alert and oriented times three in no acute distress. ,Skin: No skin breakdown or hyperhidrosis.,Vascular: 2+ radial and ulnar artery pulses.,Musculoskeletal: Wrist, elbow, shoulder and neck exams reveal no focal findings except for some tenderness to palpation over the FCR tendon on the scaphoid tubercle, but there is no SL instability and no signs of lunotriquetral instability or midcarpal instability. The DRUJ is stable. Flexion/extension of the fingers is all intact. Forearm, elbow and shoulder exams reveal no other focal tenderness to palpation.,Neurologic: Negative Tinel's, Phalen's and compression median nerve test. APB, EPL and first dorsal interosseous have 5/5 strength. Forearm, elbow and shoulder exams reveal no neurologic compromise.,Gait: Normal.,Neck: Negative Spurling sign. Negative signs of thoracic outlet.,HEENT: Pupils equal and reactive with no asymmetry.,CLINICAL IMPRESSION:, By history, possible FCR tendinitis.,EVALUATION/TREATMENT PLAN: At this point, we have asked her some questions again. She is not that sore at this point, and she has had a couple of cortisone shots. Without being the initial treating physician, she has FCR tendinitis that fails to respond to cortisone shots. She is a candidate for an FCR tunnel release. It has been described and is effective for those patients with that problem. My only consideration would be, if the patient should choose, to get an MRI when she is symptomatic to confirm the FCR tendinitis. She will followup with Dr. ABC as needed or come back to us when she is thinking more along the lines of surgery. orthopedic, fcr tendinitis, fcr tunnel release, cortisone shot, tendinitis, tunnel release, signs, oriented, shoulder, fcr Orthopedic Sample Radiology report of knee (growth arrest lines). Five views of the right knee. 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. orthopedic, fractures dislocations or subluxations, femur and proximal, growth arrest lines, patella alta, fractures, dislocations, subluxations, distal, femur, patella Orthopedic Endoscopic carpal tunnel release. Left carpal tunnel syndrome. Endoscopic Carpal Tunnel Rlease PREOPERATIVE DIAGNOSIS:, Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Left carpal tunnel syndrome.,OPERATIONS PERFORMED:, Endoscopic carpal tunnel release.,ANESTHESIA:, I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:, Zero.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: , With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated. The tourniquet was elevated at 290 mm/Hg. Construction lines were made on the left palm to identify the ring ray. A transverse incision was made in the wrist, between FCR and FCU, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin. Blunt dissection exposed the antebrachial fascia. Hemostasis was obtained with bipolar cautery. A distal-based window in the antebrachial fascia was then fashioned. Care was taken to protect the underlying contents. A proximal forearm fasciotomy was performed under direct vision. A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface. Hamate sounds were then used to palpate the hook of hamate. The endoscopic instrument was then inserted into the proximal incision. The transverse carpal ligament was easily visualized through the portal. Using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,The distal end of the transverse carpal ligament was then identified in the window. The blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision. After complete division o the transverse carpal ligament, the instrument was reinserted. Radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,The wound was then closed with running subcuticular stitch. Steri-Strips were applied, and sterile dressing was applied over the Steri-Strips. The tourniquet was deflated. The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition, having tolerated the procedure well. orthopedic, fcr, fcu, antebrachial fascia, endoscopic carpal tunnel release, carpal tunnel release, carpal tunnel syndrome, carpal, endoscopic, ligament, tourniquet, transverse, Orthopedic Left little finger extensor tendon laceration. Repair of left little extensor tendon. Extensor Tendon Repair 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. orthopedic, extensor tendon laceration, bier block, pip joint, extensor tendon, tendon, repair, finger, laceration, extensor, Orthopedic Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty, total laminectomy C3, C4, C5, and C6, excision of scar tissue, and repair of dural tear with Prolene 6-0 and Tisseel. Facetectomy & Foraminotomy 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. Orthopedic Consultation for finger triggering and locking. Finger triggering and locking CHIEF COMPLAINT:, Right middle finger triggering and locking, as well as right index finger soreness at the PIP joint.,HISTORY OF OCCUPATIONAL INJURY OR ILLNESS:, The patient has been followed elsewhere, and we reviewed his records. Essentially, he has had a trigger finger and a mucocyst, and he has had injections. This has been going on for several months. He is now here for active treatment because the injections were not helpful, nonoperative treatment has not worked, and he would like to move forward in order to prevent this from keeping on locking and causing his pain. He is referred over here for evaluation regarding that.,SIGNIFICANT PAST MEDICAL AND SURGICAL HISTORY:,General health/review of systems: See H&P. ,Allergies: See H&P.,Medications: See H&P.,Social History: See H&P.,Family History: See H&P.,Previous Hospitalizations: See H&P.,CLINICAL ASSESSMENT AND FINDINGS:,Musculoskeletal: Shows point tenderness to palpation to the right middle finger A1 pulley. The right index finger has some small soreness at the PIP joint, but at this time no obvious mucocyst. He has flexion/extension of his fingers intact. There is no crepitation at the wrist, forearm, elbow or shoulder with full range of motion. Contralateral arm exam for comparison reveals no focal findings.,Neurological: APB, EPL and first dorsal interosseous 5/5.,LABORATORY, RADIOGRAPHIC, AND/OR IMAGING TESTS ORDERS & RESULTS:,Special lab studies: ,CLINICAL IMPRESSION:,1. Tendinitis, left middle finger.,2. PIP joint synovitis and mucocyst, but controlled on nonoperative treatment.,3. Middle finger trigger, failed nonoperative treatment, requiring a trigger finger release to the right middle finger.,EVALUATION/TREATMENT PLAN:, Risks, benefits and alternatives were discussed. All questions were answered. No guarantees were made. We will schedule for surgery. We would like to move forward in order to help him significantly improve since he has failed injections. All questions were answered. Followup appointment was given. orthopedic, finger triggering, a1 pulley, pip joint, tendinitis, crepitation, locking, mucocyst, synovitis, trigger finger, middle finger triggering, triggering and locking, index finger, finger, triggering, Orthopedic Endoscopic carpal tunnel release and de Quervain's release. Left carpal tunnel syndrome and de Quervain's tenosynovitis. Endoscopic Carpal Tunnel & de Quervain's Release PREOPERATIVE DIAGNOSIS: ,1. Left carpal tunnel syndrome.,2. de Quervain's tenosynovitis.,POSTOPERATIVE DIAGNOSIS:, ,1. Left carpal tunnel syndrome.,2. de Quervain's tenosynovitis.,OPERATIONS PERFORMED: ,1. Endoscopic carpal tunnel release.,2. de Quervain's release.,ANESTHESIA:, I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:, Zero.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: ,ENDOSCOPIC CARPAL TUNNEL RELEASE:, With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated. The tourniquet was elevated at 290 mm/Hg. Construction lines were made on the left palm to identify the ring ray. A transverse incision was made in the wrist, between FCR and FCU, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin. Blunt dissection exposed the antebrachial fascia. Hemostasis was obtained with bipolar cautery. A distal-based window in the antebrachial fascia was then fashioned. Care was taken to protect the underlying contents. A proximal forearm fasciotomy was performed under direct vision. A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface. Hamate sounds were then used to palpate the hook of hamate. The endoscopic instrument was then inserted into the proximal incision. The transverse carpal ligament was easily visualized through the portal. Using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,The distal end of the transverse carpal ligament was then identified in the window. The blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision. After complete division o the transverse carpal ligament, the instrument was reinserted. Radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,The wound was then closed with running subcuticular stitch. Steri-Strips were applied, and sterile dressing was applied over the Steri-Strips. The tourniquet was deflated. The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition, having tolerated the procedure well.,DE QUERVAIN'S RELEASE: , With the patient under adequate regional anesthesia applied by surgeon using 1% plain Xylocaine, the upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated. The tourniquet was elevated to 290 mm/Hg. A transverse incision was then made over the radial aspect of the wrist overlying the first dorsal tunnel. Using blunt dissection, the radial sensory nerve branches were dissected and retracted out of the operative field. The first dorsal tunnel was then identified. The first dorsal tunnel was incised along the dorsal ulnar border, completely freeing the stenosing tenosynovitis (de Quervain's release). EPB and APL tendons were inspected and found to be completely free. The radial sensory nerve was inspected and found to be without damage.,The skin was closed with a running 3-0 Prolene subcuticular stitch and Steri-Strips were applied and, over the Steri-Strips, a sterile dressing, and, over the sterile dressing, a volar splint with the hand in safe position. The tourniquet was deflated. The patient was returned to the holding area in satisfactory condition, having tolerated the procedure well. orthopedic, de quervain's tenosynovitis, de quervain's release, carpal tunnel syndrome, carpal tunnel release, endoscopic carpal tunnel release, tunnel, transverse, carpal, tourniquet, endoscopic, Orthopedic Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively. Followup Screw Fixation REASON FOR VISIT: ,Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,HISTORY OF PRESENT ILLNESS: ,The patient is a 59-year-old gentleman who is now approximately 4 months status post percutaneous screw fixation of Schatzker IV tibial plateau fracture and nonoperative management of second through fifth metatarsal head fractures. He is currently at home and has left nursing home facility. He states that his pain is well controlled. He has been working with physical therapy two to three times a week. He has had no drainage or fever. He has noticed some increasing paresthesias in his bilateral feet but has a history of spinal stenosis with lower extremity neuropathy.,FINDINGS: , On physical exam, his incision is near well healed. He has no effusion noted. His range of motion is 10 to 105 degrees. He has no pain or crepitance. On examination of his right foot, he is nontender to palpation of the metatarsal heads. He has 4 out of 5 strength in EHL, FHL, tibialis, and gastroc-soleus complex. He does have decreased sensation to light touch in the L4-L5 distribution of his feet bilaterally.,X-rays taken including AP and lateral of the right knee demonstrate a healed medial tibial plateau fracture status post percutaneous screw fixation. Examination of three views of the right foot demonstrates the second through fifth metatarsal head fractures. These appear to be extraarticular. They are all in a bayonet arrangement, but there appears to be bridging callus between the fragments on the oblique film.,ASSESSMENT: ,Four months status post percutaneous screw fixation of the right medial tibial plateau and second through fifth metatarsal head fractures.,PLANS: , I would like the patient to continue working with physical therapy. He may be weightbearing as tolerated on his right side. I would like him to try to continue to work to gain full extension of the right knee and increase his knee flexion. I also would like him to work on ambulation and strengthening.,I discussed with the patient his concerning symptoms of paresthesias. He said he has had the left thigh for a number of years and has been followed by a neurologist for this. He states that he has had some right-sided paresthesias now for a number of weeks. He claims he has no other symptoms of any worsening stenosis. I told him that I would see his neurologist for evaluation or possibly a spinal surgeon if his symptoms progress.,The patient should follow up in 2 months at which time he should have AP and lateral of the right knee and three views of the right foot. orthopedic, metatarsal head fractures, tibial plateau fracture, schatzker, percutaneous screw fixation, tibial plateau, metatarsal head, screw fixation, head, screw, fixation, metatarsal Orthopedic Left elbow manipulation and hardware removal of left elbow. Elbow Manipulation PREOPERATIVE DIAGNOSIS:, Left elbow with retained hardware.,POSTOPERATIVE DIAGNOSIS: , Left elbow with retained hardware.,PROCEDURE: , ,1. Left elbow manipulation.,2. Hardware removal of left elbow.,ANESTHESIA: ,Surgery was performed under general anesthesia.,COMPLICATIONS:, There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,INTRAOPERATIVE FINDING: , Preoperatively, the patient is 40 to 100 degrees range of motion with limited supination and pronation of about 20 degrees. We increased his extension and flexion to about 20 to 120 degrees and the pronation and supination to about 40 degrees.,LOCAL ANESTHETIC: ,10 mL of 0.25% Marcaine.,HISTORY AND PHYSICAL: , The patient is a 10-year-old right-hand dominant male, who threw himself off a quad on 10/10/2007. The patient underwent open reduction and internal fixation of his left elbow fracture dislocation. The patient also sustained a nondisplaced right glenoid neck fracture. The patient's fracture has healed without incident, although he had significant postoperative stiffness for which he is undergoing physical therapy, as well as use of a Dynasplint. The patient is neurologically intact distally. Given the fact that his fracture has healed, surgery was recommended for hardware removal to decrease his irritation with elbow extension from the hardware. Risks and benefits of the surgery were discussed. The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to remove hardware, failure to relieve pain, continued postoperative stiffness. All questions were answered and the parents agreed to the above plan.,PROCEDURE: ,The patient was taken to the operating room and placed supine on the operating table. General anesthesia was then administered. The patient's left upper extremity was then prepped and draped in a standard surgical fashion. Using fluoroscopy, the patient's K-wire was located. An incision was made over his previous scar. A subcutaneous dissection then took place in the plane between the subcutaneous fat and muscles. The K-wires were easily palpable. A small incision was made into the triceps, which allowed for visualization of the two pins, which were removed without incident. The wound was then irrigated. The triceps split was now closed using #2-0 Vicryl. The subcutaneous tissue was also closed using #2-0 Vicryl and the skin with #4-0 Monocryl. The wound was clean and dry and dressed with Steri-Strips, Xeroform, and 4 x 4s, as well as bias. A total of 10 mL of 0.25% Marcaine was injected into the incision, as well as the joint line. At the beginning of the case, prior to removal of the hardware, the arm was taken through some strenuous manipulations with improvement of his extension to 20 degrees, flexion to 130 degrees and pronation supination to about 40 degrees.,DIAGNOSTIC IMPRESSION: ,The postoperative films demonstrated no fracture, no retained hardware. The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: , The patient will restart physical therapy and Dynasplint in 3 days. The patient is to follow up in 1 week's time for a wound check. The patient was given Tylenol No. 3 for pain. orthopedic, k-wires, dynasplint, elbow manipulation, hardware removal, retained hardware, elbow, hardware, Orthopedic Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger. 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. Dupuytren Disease Excision 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. orthopedic, excision of dupuytren disease, proximal interphalangeal joint, dupuytren disease, bier block, pip joint, disease, dupuytren, contractions, metacarpophalangeal, neurovascular, bundles, interphalangeal, finger Orthopedic Excision dorsal ganglion, right wrist. The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field. Dorsal Ganglion - Excision 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. orthopedic, excision dorsal ganglion, extensor tendon, extensor retinaculum, dorsal ganglion, retinaculum, ganglion Orthopedic Left elbow pain. Fracture of the humerus, spiral. Possible nerve injuries to the radial and median nerve, possibly neurapraxia. Elbow Pain - Consult 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. Orthopedic A 47-year-old female with a posttraumatic AV in the right femoral head. Discharge Summary - Hip Surgery ADMITTING DIAGNOSIS:, Posttraumatic AV in right femoral head.,DISCHARGE DIAGNOSIS:, Posttraumatic AV in right femoral head.,SECONDARY DIAGNOSES PRIOR TO HOSPITALIZATION:,1. Opioid use.,2. Right hip surgery.,3. Appendectomy.,4. Gastroesophageal reflux disease.,5. Hepatitis diagnosed by liver biopsy.,6. Blood transfusion.,6. Smoker.,7. Trauma with multiple orthopedic procedures.,8. Hip arthroscopy.,POSTOP COMORBIDITIES: , Postop acute blood loss anemia requiring transfusion and postop pain.,PROCEDURES DURING THIS HOSPITALIZATION:, Right total hip arthroplasty and removal of hardware.,CONSULTS:, Acute pain team consult.,DISPOSITION: , Home.,HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE:, For details, please refer to clinic notes and OP notes. In brief, the patient is a 47-year-old female with a posttraumatic AV in the right femoral head. She came in consult with Dr. X who after reviewing the clinical and radiological findings recommended she undergo a right total hip arthroplasty and removal of old hardware. After being explained the risks, benefits, alternative options, and possible outcomes of surgery, she was agreeable and consented to proceed and therefore on the day of her admission, she was sent to the operating room where she underwent a right total hip arthroplasty and removal of hardware without any complications. She was then transferred to PACU for recovery and postop orthopedic floor for convalescence, physical therapy, and discharge planning. DVT prophylaxis was initiated with Lovenox. Postop pain was adequately managed with the aid of Acute Pain team. Postop acute blood loss anemia was treated with blood transfusions to an adequate level of hemoglobin. Physical therapy and occupational therapy were initiated and continued to work with her towards discharge clearance on the day of her discharge.,DISPOSITION:, Home. On the day of her discharge, she was afebrile, vital signs were stable. She was in no acute distress. Her right hip incision was clean, dry, and intact. Extremity was warm and well perfused. Compartments were soft. Capillary refill less than two seconds. Distal pulses were present.,PREDISCHARGE LABORATORY FINDINGS: , White count of 10.9, hemoglobin of 9.5, and BMP is pending.,DISCHARGE INSTRUCTIONS: , Continue diet as before.,ACTIVITY: , Weightbearing as tolerated in the right lower extremity as instructed. Do not lift, drive, move furniture, do strenuous activity for six weeks. Call Dr. X if there is increased temperature greater than 101.5, increased redness, swelling, drainage, increased pain that is not relieved by current pain regimen as per postop orthopedic discharge instruction sheet.,FOLLOW-UP APPOINTMENT: Follow up with Dr. X in two weeks. Orthopedic Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs Discectomy, Osteophytectomy, & Foraminotomy 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. Orthopedic Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis. Release of first dorsal extensor compartment. Dorsal Extensor Compartment Release PREOPERATIVE DIAGNOSIS: , Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.,POSTOPERATIVE DIAGNOSIS: , Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.,PROCEDURE PERFORMED:, Release of first dorsal extensor compartment.,ASSISTANT: , None.,ANESTHESIA: , Bier block.,TOURNIQUET TIME: , 30 minutes.,COMPLICATIONS: , None.,INDICATIONS: ,The above patient is a 47-year-old right hand dominant black female who has signs and symptomology of de Quervain's stenosing tenosynovitis. She was treated conservatively with steroid injections, splinting, and nonsteroidal anti-inflammatory agents without relief. She is presenting today for release of the first dorsal extensor compartment. She is aware of the risks, benefits, alternatives and has consented to this operation.,PROCEDURE: , The patient was given intravenous prophylactic antibiotics. She was taken to the operating suite under the auspices of Anesthesiology. She was given a left upper extremity bier block. Her left upper extremity was then prepped and draped in the normal fashion with Betadine solution. Afterwards, a transverse incision was made over the extensor retinaculum of the first dorsal extensor compartment. Dissection was carried down through the dermis into the subcutaneous tissue. The dorsal radial sensory branches were kept out of harm's way. They were retracted gently to the ulnar side of the wrist. The retinaculum was incised with a #15 scalpel blade in the longitudinal fashion and the retinaculum was released completely both proximally and distally. Both the extensor pollices brevis and abductor pollices longus tendons were identified. There was no pathology noted within the first dorsal extensor compartment. The wound was irrigated. Hemostasis was obtained with bipolar cautery. The wound was infiltrated with _0.25% Marcaine solution and then closure performed with #6-0 nylon suture utilizing a horizontal mattress stitch. Sterile occlusive dressing was applied along with the thumb spica splint. The tourniquet was released and the patient was transported to the recovery area in stable and satisfactory condition. orthopedic, dorsal extensor compartment, de quervain tendonitis, dorsal, extensor, quervain, tendonitis, retinaculum, tenosynovitis, tourniquet, Orthopedic Trauma/ATV accident resulting in left open humerus fracture. Discharge Summary - ATV Accident ADMITTING DIAGNOSIS: , Trauma/ATV accident resulting in left open humerus fracture.,DISCHARGE DIAGNOSIS:, Trauma/ATV accident resulting in left open humerus fracture.,SECONDARY DIAGNOSIS:, None.,HISTORY OF PRESENT ILLNESS: , For complete details, please see dictated history and physical by Dr. X dated July 23, 2008. Briefly, the patient is a 10-year-old male who presented to the Hospital Emergency Department following an ATV accident. He was an unhelmeted passenger on ATV when the driver lost control and the ATV rolled over throwing the passenger and the driver approximately 5 to 10 meters. The patient denies any loss of consciousness. He was not amnestic to the event. He was taken by family members to the Iredell County Hospital, where he was initially evaluated. Due to the extent of his injuries, he was immediately transferred to Hospital Emergency Department for further evaluation.,HOSPITAL COURSE: , Upon arrival in the Hospital Emergency Department, he was noted to have an open left humerus fracture. No other apparent injuries. This was confirmed with radiographic imaging showing that the chest and pelvis x-rays were negative for any acute injury and that the cervical spine x-ray was negative for fracture malalignment. The left upper extremity x-ray did demonstrate an open left distal humerus fracture. The orthopedic surgery team was then consulted and upon their evaluation, the patient was taken emergently to the operating room for surgical repair of his left humerus fracture. In the operating room, the patient was prepared for an irrigation and debridement of what was determined to be an open type 3 subcondylar left distal humerus fracture. In the operating room, his upper extremity was evaluated for neurovascular status and great care was taken to preserve these structures. Throughout the duration of the procedure, the patient had a palpable distal radial pulse. The orthopedic team then completed an open reduction and internal fixation of the left supracondylar humerus fracture. A wound VAC was then placed over the wound at the conclusion of the procedure. The patient tolerated this procedure well and was returned to the Pediatric Intensive Care Unit for postsurgical followup and monitoring. His diet was advanced and his pain was controlled with pain medication. The day following his surgery, the patient was evaluated for a potential for closed head injury given the nature of his accident and the fact that he was not wearing a helmet during his accident. A CT of the brain without contrast showed no acute intracranial abnormalities moreover his cervical spine was radiographically and clinically cleared and his C-collar was removed at that point. Once his C spine had been cleared and the absence of a closed head injury was confirmed. The patient was then transferred from the Intensive Care Unit to the General Floor bed. His clinical status continued to improve and on July 26, 2008, he was taken back to the operating room for removal of the wound VAC and closure of his left upper extremity wound. He again tolerated this procedure well on his return to the General Pediatrics Floor. Throughout his stay, there was concern for compartment syndrome due to the nature and extent of his injuries. However, frequent checks of his distal pulses indicated that he had strong peripheral pulses in the left upper extremity. Moreover, the patient had no complaints of paresthesia. There was no demonstration of pallor or pain on passive motion. There was good capillary refill to the digits of the left hand. By the date of the discharge, the patient was on a full pediatric select diet and was tolerating this well. He had no abdominal tenderness and there were no abdominal injuries on exam or radiographic studies. He was afebrile and his vital signs were stable and once cleared by Orthopedics, he was deemed appropriate for discharge.,PROCEDURES DURING THIS HOSPITALIZATION:,1. Irrigation and debridement of open type 3 subcondylar left distal humerus fracture (July 23, 2008).,2. Open reduction and internal fixation of the left supracondylar humerus fracture (July 23, 2008).,3. Negative pressure wound dressing (July 23, 2008).,4. Irrigation and debridement of left elbow fracture (July 26, 2008).,5. CT of the brain without contrast (July 24, 2008).,DISPOSITION: ,Home with parents.,INVASIVE LINES: , None.,DISCHARGE INSTRUCTIONS: ,The patient was instructed that he can return home with his regular diet and he was asked not to do any strenuous activities, move furniture, lift heavy objects, or use his left upper extremity. He was asked to followup with return appointment in one week to see Dr. Y in Orthopedics. Additionally, he was told to call his pediatrician, if he develops any fevers, pain, loss of sensation, loss of pulse, or discoloration of his fingers, or paleness to his hand. orthopedic, humerus fracture, trauma, irrigation and debridement, atv accident, upper extremity, humerus, fracture, Orthopedic Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block for sacroiliac joint pain. Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine. Dorsal Ramus & Branch Block PROCEDURE: , Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible vascular entry of medications. I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing. The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE: ,Oxygen saturation and vital signs were monitored continuously throughout the procedure. The patient remained awake throughout the procedure in order to interact and give feedback. The X-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in the prone position on the treatment table, pillow under the chest, and head rotated contralateral to the side being treated. The skin over and surrounding the treatment area was cleaned with Betadine. The area was covered with sterile drapes, leaving a small window opening for needle placement. Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 25-gauge 3.5-inch spinal needle was gently guided into the groove between the SAP and sacrum through the dorsal ramus of the L5 and the lateral and superior border of the posterior sacral foramen with the lateral branches of S1, S2, and S3. Multiple fluoroscopic views were used to ensure proper needle placement. Approximately 0.25 mL of nonionic contrast agent was injected showing no concurrent vascular dye pattern. Finally, the treatment solution, consisting of 0.5% of bupivacaine was injected to each area. All injected medications were preservative free. Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS: , This was then repeated on the left side.,COMPLICATIONS: , None.,DISCUSSION: ,Postprocedure vital signs and oximetry were stable. The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day. The patient was told to resume all medications. The patient was told to resume normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes or changes in bowel or bladder function.,Follow up appointment was made at the PM&R Spine Clinic in approximately 1 week. orthopedic, sacroiliac, lateral branch block, ramus block, branch block, sacroiliac joint, dorsal ramus, fluoroscopic, branch, dorsal, ramus, bilateral, needle, block, Orthopedic Redo L4-5 diskectomy, left - recurrent herniation L4-5 disk with left radiculopathy. Diskectomy PREOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,POSTOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,PROCEDURE:, Redo L4-5 diskectomy left.,COMPLICATIONS:, None.,ANTIBIOTIC (S),: Vancomycin given preoperatively.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, 10 mL.,BLOOD REPLACED:, None.,CRYSTALLOID GIVEN:, 800 mL.,DRAIN (S):, None.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room in supine position. General endotracheal anesthesia was administered. He was turned into the prone position on the operating table and positioned in the modified knee-chest position with Andrews frame being used. Care was taken to protect pressure points. The back was shaved, scrubbed with Betadine scrub, rinsed with alcohol, and prepped with DuraPrep, and draped in the usual sterile fashion with Ioban drape being used. A midline skin incision was made, excising scar from previous surgery. Dissection was carried down through the subcutaneous tissue with electrocautery technique. The lumbosacral fascia was split to the left of the spinous process, and subperiosteal dissection of the spinous process and lamina, area of previous laminotomy was identified. Cross-table lateral was also made to confirm position. The scar was then loosened from the inferior portion of 4, superior of L5 lamina, and a portion of the lamina was removed. I did identify normal dura. The scar was then lysed from the medial wall. Dura and nerve root were identified and protected with nerve root retractor. The bulging disk fragment was still contained under the longitudinal ligament. A rent was made with the Penfield and a moderately large fragment was removed. The disk space was then entered with a cruciate cut in the annulus, with additional nuclear material being received. When no other fragments could be removed from the disk space, no other fragments were felt in the central canal under the longitudinal ligament, and a Murphy ball could be passed through the foramen without evidence of compression, the decompression was complete. Check was made for CSF leakage, and no evidence of significant epidural bleeding was present. The wound was irrigated with antibiotic solution. Twenty milligrams of Depo-Medrol was placed over the dura and nerve root. A free fat graft from the subcutaneous tissue was then placed over the dura. Closure was obtained with the lumbosacral fascia being reapproximated with #1, running, Vicryl suture. Subcutaneous closure was obtained in layers with 2-0, running, Vicryl suture. Skin closure was obtained with 3-0 Vicryl subcuticular suture. Proxi-Strips and sterile dressing was applied. The skin had been infiltrated with 8 mL of 0.5% Marcaine with epinephrine.,After a sterile dressing was applied, the patient was turned into the supine position on the waiting recovery room stretcher, brought from under the effects of anesthesia, and taken to the recovery room. orthopedic, herniation, andrews frame, csf leakage, depo-medrol, l4-5, proxi-strips, diskectomy, endotracheal anesthesia, lumbosacral fascia, modified knee-chest position, radiculopathy, supine position, nerve root, duraprep, Orthopedic 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 ClickX System. Decompressive Laminectomy 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. orthopedic, facetectomies, decompression, posterolateral fusion, synthes click'x system, decompressive laminectomy, leksell rongeur, kerrison rongeur, transverse processes, thecal sac, nerve roots, pedicle screws, spinous process, pedicle, process, screws, rods, laminectomy, decompressive, spinous, Orthopedic Wrist de Quervain stenosing tenosynovitis. de Quervain release. Fascial lengthening flap of the 1st dorsal compartment. de Quervain Release - Wrist PREOPERATIVE DIAGNOSIS:, Wrist de Quervain stenosing tenosynovitis.,POSTOPERATIVE DIAGNOSIS: , Wrist de Quervain stenosing tenosynovitis.,TITLE OF PROCEDURES,1. de Quervain release.,2. Fascial lengthening flap of the 1st dorsal compartment.,ANESTHESIA:, MAC.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: , After MAC anesthesia and appropriate antibiotics were administered, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with an Esmarch and the tourniquet inflated to 250 mmHg.,I made a transverse incision just distal to the radial styloid. Dissection was carried down directly to the 1st dorsal compartment with the superficial radial nerve identified and protected. Meticulous hemostasis was maintained with bipolar electrocautery.,I dissected the sheath superficially free of any other structures, specifically the superficial radial nerve. I then incised it under direct vision dorsal to its axis and incised it both proximally and distally. The EPB subsheath was likewise released.,I irrigated the wound thoroughly. In order to prevent tendon subluxation, I then back-cut both the dorsal and volar leafs of the sheath so that I could close them in an extended and lengthened position. I did this with 3-0 Vicryl. I then passed an instrument underneath to check and make sure that the sheath was not too tight. I then irrigated it and closed the skin, and then I dressed and splinted the wrist appropriately. The patient was sent to the recovery room in good condition, having tolerated the procedure well. orthopedic, de quervain, tenosynovitis, de quervain release, fascial lengthening flap, dorsal compartment, sheath, wrist, dorsal, tourniquet, Orthopedic Degenerative disk disease at L4-L5 and L5-S1. Anterior exposure diskectomy and fusion at L4-L5 and L5-S1. Diskectomy & Fusion PREOPERATIVE DIAGNOSIS: , Degenerative disk disease at L4-L5 and L5-S1.,POSTOPERATIVE DIAGNOSIS:, Degenerative disk disease at L4-L5 and L5-S1.,PROCEDURE PERFORMED: ,Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.,ANESTHESIA: , General.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , 150 mL.,PROCEDURE IN DETAIL: ,Patient was prepped and draped in sterile fashion. Left lower quadrant incision was performed and taken down to the preperitoneal space with the use of the Bovie, and then preperitoneal space was opened. The iliac veins were carefully mobilized medially, and then the L4-L5 disk space was confirmed by fluoroscopy, and diskectomy fusion, which will be separately dictated by Dr. X, was performed after the adequate exposure was gained, and then after this L4-L5 disk space was fused and the L5-S1 disk space was carefully identified between the iliac vessels and the presacral veins and vessels were ligated with clips, disk was carefully exposed. Diskectomy and fusion, which will be separately dictated by Dr. X, were performed. Once this was completed, all hemostasis was confirmed. The preperitoneal space was reduced. X-ray confirmed adequate positioning and fusion. Then the fascia was closed with #1 Vicryl sutures, and then the skin was closed in 2 layers, the first layer being 2-0 Vicryl subcutaneous tissues and then a 4-0 Monocryl subcuticular stitch, then dressed with Steri-Strips and 4 x 4's. Then patient was placed in the prone position after vascular checks of the lower extremity confirmed patency of the arteries with warm bilateral lower extremities. orthopedic, anterior exposure, degenerative disk disease, disk disease, disk space, diskectomy, fusion, Orthopedic Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment as well as medial malleolar fragment. Delayed ORIF PREOPERATIVE DIAGNOSES:,1. Right ankle trimalleolar fracture.,2. Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,OPERATIVE PROCEDURE: ,Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment, as well as medial malleolar fragment.,POSTOPERATIVE DIAGNOSES:,1. Right ankle trimalleolar fracture.,2. Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,TOURNIQUET TIME: , 80 minutes.,HISTORY: , This 50-year-old gentleman was from the area and riding his motorcycle in Kentucky.,The patient lost control of his motorcycle when he was traveling approximately 40 mile per hour. He was on a curve and lost control. He is unsure what exactly happened, but he thinks his right ankle was pinned underneath the motorcycle while he was sliding. There were no other injuries. He was treated in Kentucky. A close reduction was performed and splint applied. Orthopedic surgeon called myself with regards to this patient's fracture management and suggested a CT scan. The patient returned to Ohio and his friend drove him all the way from Kentucky to Northwest Ohio overnight. The patient showed up in the emergency department where a CT scan was asked to be performed. This was performed and reviewed. The patient, however, had significant amount of soft tissue swelling and therefore he was asked to follow up in 2 days. At this time, he still had significant swelling, but because of the amount of swelling that he had particularly with the long car ride for many hours with his leg dependent, it was felt to be best to wait.,Indeed after 7 days, the patient started to develop fracture blisters on the posterior medial aspect of his ankle with large blisters measuring approximately 2 to 3 inches. The patient was x-rayed in the office. He had lost some of his reduction. Therefore, he was re-reduced at approximately 7 days and then each time the patient had examination of tissues, he was re-reduced just to keep the pressure off the skin.,An x-ray showed the distal fibular fracture starting at the mortise region laterally. It appeared as an abduction type injury with minimal rotation. This was comminuted, fragmented, and impacted.,The medial malleolus fracture was an avulsion type. The syndesmosis appeared to be intact. This appeared as an AO type B fracture. However, this was not a rotational injury.,There is a posterior malleolar fragment attached to the distal fibular fragment, which appeared to be avulsed as well, but comminuted. CT scan revealed a more serious fracture with an anterior as well as posterior plafond fracture of an anterior fragment, which was undisplaced in the posterior medial corner. A posterior Tillaux fragment appeared to be separate. However, in this area, there was significant comminution in the mid portion of the ankle joint.,There were many fragments and defects in this region.,The medial mortise however appeared to be intact with regards to the tibial plafond even though there was an anterior undisplaced fragment.,We discussed delayed open reduction internal fixation with the patient. He understood the risk of surgery including infection, decreased range of motion, stiffness, neurovascular injury, weakness, and numbness. We discussed seriously the risk of osteoarthritis because of the comminution in the intraarticular surface shown on the CT scan. We discussed deep vein thrombosis, pulmonary embolism, skin slough, skin necrosis, infection, and need for second surgery. We discussed shortening, decreased strength, limited use, disability of operative extremity, malunion, nonunion, compartment syndrome, stiffness of the operative extremity, numbness, and weakness. Examination of the patient revealed that he had slightly decreased sensation on the dorsum of his foot.,The patient was able to flex and extend his toes, had good capillary refill, good dorsalis pedis, and posterior tibial pulse.,The patient's tissues were edematous and we has waited approximately 10 days before performing the surgery when the skin could be wrinkled anteriorly. We discussed his incision, the medial incision as well as lateral incision and the lateral incision would be more posterolateral to maintain a bridge of at least 6 to 8 cm between the 2 incisions. We did discuss the skin slough as well as skin necrosis, particularly medially where the most skin pressure was because of displacement laterally. He understood the posterolateral comminution of the tibial plafond, which would be reduced by aligning up the cortex posteriorly.,We discussed the posterolateral approach with reduction of the fibula. We discussed that likely the distal fibula would not be removed completely to assess the articular surface as this would likely comminute the fibula, even more fragmentation would occur, and would not be able to obtain an anatomic reduction. He understood this distal fibular fracture was comminuted and there were missing fragments of bone because they were impacted into intramedullary cancellous space. With this, the patient understood that the hardware may necessitate removal as well in the future. We discussed hardware irritation. We also discussed risk of osteoarthritis, which was nearly 100% particularly because of comminution of this area posteriorly. With these risks discussed and listed on the consent, the patient wanted the procedure.,OPERATIVE NOTE:, The patient was brought to operating theater and given successful general anesthetic. His right leg was prepped and draped in the usual fashion. Before prep and drape was performed, a close reduction was tried to be obtained to see whether there was any obstruction to reduction. It was felt that at one point the posterior tibialis tendon may be intraarticular.,The reduction appeared to line up. However, there was significant gap of approximately 1.5 to 2 cm between the avulsed medial malleolus fragment and distal tibia.,A lateral incision was made over the fracture site approximately 8 cm long and was taken to subcutaneous tissue. The superficial peroneal nerve was seen and this was avoided. The incision was placed posterolateral to fibula.,This was to ensure good flap of tissue between the 2 incisions medial and laterally. The fracture was seen. The fracture was elevated and medialized and de-rotated. The anterior portion of the distal fibula was significantly comminuted with defect. The posterior aspect was still intact. However, there were multiple fracture lines demonstrating a crush-type injury. This was reduced manually. At this point, dissection was performed bluntly behind the peroneal tendons in between this and flexor hallucis longus tendon. No sharp dissection was performed. The posterior malleolar fragment was palpated with the distal fibula reduced. The posterior malleolar fragment appeared to be reduced as well.,X-ray views confirmed this.,An incision was made, standard incision, curvilinear, medially distal to the medial corner of the mortise and curving anterior and posteriorly around the tip of the medial malleolus. This was taken only through subcutaneous tissue. The saphenous vein was found, dissected out. Its branches were cauterized. Penrose drain was placed around this.,Dissection was undertaken. The periosteal tissue was seen and was invaginated into the joint.,This was recovered and flipped back on both sides. Next, the towel clip was used. Ends were freshened up using irrigation. The joint surface appeared to be congruent anteriorly and posteriorly medially.,Anatomic reduction was performed in the medial malleolus using 2 mm K-wires and exchanging these for a 35 mm and a 40 mm, anterior and posterior respectively, partially threaded cancellous screws. Anatomic reduction was gained. X-rays were taken showing excellent anatomic reduction. Next, attention was drawn towards the fibula. Standard 6-hole one-third tubular plate was applied to this. Again, this was more of a transverse impacted fracture. Therefore, interfragmentary screw on an angle could not be used.,The posterior cortex was used to assess anatomic reduction. Screws were placed. It was used as a spring plate pushing the distal fibular fragment medially.,Screw holes were filled. They were double-checked. Screws had excellent purchase and were tightened up. At this point, lateral views were taken as well as palpation of posterior lateral fragment was performed in the plafond. This appeared to show anatomic reduction and did not appear to be a step on the articular surface or the posterior cortex of the distal tibia.,The screw was then placed from anterior medial to posterior lateral into this comminuted fragment.,A 2 mm K-wire was used. Finger was placed on this fragment and the pin was advanced even before the finger. X-ray views could show the posterior cortex and location of the pin. This was then exchanged for a 55 mm partially threaded cancellous screw after tapping was performed. This was double checked to ensure good positioning and this was so. On the lateral view, we could see this was not in the joint. AP views and mortise views showed this was not in the joint. One could palpate this as well. The screw was placed slightly proximal to distal in the anteroposterior plane. At the distal tip of it, it was just in the subchondral bone but not in the joint. There was slight to excellent purchase of this posterior lateral fragment. Wounds were copiously irrigated followed by closing using 2-0 Vicryl in inverted fashion followed by staples to skin. Adaptic, 4 x 4s, abdominal pad was placed on wound, held in place with Kerlix followed by an extensor bandage. Posterior splint was placed on the patient. The patient's leg was placed in neutral position. Significant amount of cast padding were used and large bulky trauma ABD type dressings. The heel was padded and leg was padded with approximately 2 inches of padding. Tourniquet was deflated. The patient had good capillary refill, good pulses, and the patient returned to recovery room in stable condition with no complications. Physician assistant assisted during the case with retracting as well as holding the medial malleolar fragment and fragments in position while placement screws were applied. Positioning of the leg was accomplished by the physician assistant. As well, physician assistant assisted in transport of patient to and from the recovery room, assisted in cautery as well as dissection and retraction of tissue. The patient is expected to do well overall. He does have an area of comminution shown on the CT scan. However, by x-rays, it appears that there is anatomic reduction gained at this posterolateral fragment. Nonetheless, this area was crushed and the patient will have degenerative changes in the future caused by this crushing area. Orthopedic Torn rotator cuff and subacromial spur with impingement syndrome, right shoulder. Diagnostic arthroscopy with subacromial decompression and open repair of rotator cuff using three Panalok suture anchors. Diagnostic Arthroscopy 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. orthopedic, subacromial decompression, panalok suture, repair of rotator cuff, torn rotator cuff, diagnostic arthroscopy, subacromial space, subacromial spur, arthroscopy, panalok, shoulder, subacromial, Orthopedic Incision and drainage with extensive debridement, left shoulder. Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component). Implantation of antibiotic beads, left shoulder. Debridement - Shoulder TITLE OF OPERATION: ,1. Incision and drainage with extensive debridement, left shoulder.,2. Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component).,3. Implantation of antibiotic beads, left shoulder.,INDICATION FOR SURGERY: , The patient was seen multiple times preoperatively and found to have findings consistent with a chronic and indolent infections. Risks and benefits have been discussed with him and his family at length including but not exclusive of continued infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, fractures, loss of bone, medical complications, surgical complications, transfusion related complications, etc. The patient understood and wished to proceed.,PREOP DIAGNOSIS: , Presumed infection, left total shoulder arthroplasty.,POSTOP DIAGNOSES: ,1. Deep extensive infection, left total shoulder arthroplasty.,2. Biceps tenosynovitis.,3. Massive rotator cuff tear in left shoulder (full thickness subscapularis tendon rupture 3 cm x 4 cm; supraspinatus tendon rupture 3 cm x 3 cm; infraspinatus tear 2 cm x 2 cm).,DESCRIPTION OF PROCEDURE: ,The patient was anesthetized in the supine position, a Foley catheter was placed in his bladder. He was then placed Beach chair position and all bony prominences were well padded. Pillows were placed around his knees to protect his sciatic nerve. He was brought to the side of the table and secured with towels and tape. The head was placed in neutral position with no lateral bending or extension to protect the brachioplexus from any stretch. Left upper extremity was then prepped and draped in usual sterile fashion. Unfortunately, preoperative antibiotics were given prior to the procedure. This occurred due to lack of communication between the surgical staff and the anesthesia staff. The patient's extremity, however, was prepped a second time with a chlorhexidine prep after he had been draped. Also, Ioban bandages were placed securely to the skin to prevent any further introduction of infection into his shoulder.,Deltopectoral incision was then made. The patient's had a cephalic vein, it was identified and protected throughout the case. It was retracted laterally and once this has been completed, the deltopectoral interval was developed as carefully as possible. The patient did have significant scar from this point on and did bleed from many surfaces throughout the case. As a result, he was transfused 1 unit postoperatively. He did not have any problems during the case except for one small drop of blood pressure. However this was due primarily because of the extensive scarring of his proximal humerus. He had scar between the anterior capsular structures and the conjoint tendon. Also there was significant scar between the deltoid and the proximal humerus. The deltoid was very carefully and tediously removed from the proximal humerus in order not to damage the axillary nerve. Once the plane between the deltoid and underlying tissue was found, the proximal humerus was discovered to have a large defect, approximately 4 x 3. This was covered by rimmed fibrous tissue which was fairly compressible, which felt to be purulent, however, when the needle was stuck into this area, there was no return of fluid. As a result, this was finally opened and found to have fibrinous exudates which appeared to be old congealed, purulent material. There was some suggestion of a synovitis type reaction also inside this cystic area. This was all debrided but was found to track all the way into the proximal humerus from the lateral femoral component and also tracked posteriorly through and around the posterior cortex of the proximal humerus indicating that the infraspinatus probably had some tearing and detachment. This later proved to be the case and infraspinatus did indeed have a tear 2 cm x 2 cm. All of the mucinous material and fibrinous material was removed from the proximal humerus. This was fairly extensive debridement. All of this was sent to pathology and also sent for culture and sensitivity. It should be noted that Gram stain became as multiple white blood cells but no organism seen. The pathology came back as fibrinous material with multiple white cells, also with signs of chronic inflammation consistent with an infection.,Attention was then directed towards the anterior structures to gain access to the joint so that we could dislocate the prosthesis and remove it. There was also cystic area in the anterior aspect of the shoulder which was fairly fibrinous. This was also removed. Once this was removed, though the capsule was found to be very thin, there was essentially no subscapularis tendon whatsoever. It should also noted the patient's proximal humerus was subluxed superiorly so that there was no supraspinatus tendon present whatsoever. As a result, the biceps tendon was finally identified just below the pectoralis tendon insertion. The upper 1 or 2 cm of the pectoralis insertion was released in order to find the biceps. It was tracked proximally and transverse ligament released. The biceps tendon was flat and somewhat erythematous. As a result, it released and tagged with an 0 Vicryl suture. It was later tenodesed to the conjoint tendon using 2-0 Prolene sutures. The joint was then entered and noted significant synovitis throughout the entire glenoid. This was all very carefully removed using a rongeur and sharp dissection.,Next, the humeral component was removed and this was done by attempting to remove it with the slap hammer and device which comes with the Biomet set. Unfortunately, this device would not hold the proximal humerus and we could not get the component to release. As a result, bone contact of the metal proximally was released using a straight osteotome. Once this was completed, another attempt was made to remove the prosthesis but this only resulted in fracture of the proximal humerus through the areas of erosion of the infection and once this has been completed, we abandoned use of that particular device and using a __________ , we were able to hit the prosthesis lip from beneath and essentially remove it. There was no cement. There was exudate within the canal which was removed using a curette.,Using fluoroscopy, sequential reamers were placed to a size of 11 distally down the shaft to remove the exudate. This was also thoroughly irrigated with irrigation antibiotic, and impregnated irrigation to decrease any risk of infection. It should be noted that the reaming was done fluoroscopically to make sure that there was no penetration of the canal at any point.,The attention was then directed to the glenoid. The glenoid component was very carefully dissected free and found to be very loose. It was essentially removed with digital dissection. There was no remaining cement in the cavity itself. The patient's glenoid was very carefully debrided. The glenoid itself was found to be very cup shaped with significant amount of bone loss in the central portion of the canal itself. This was debrided using rongeurs and curette until there was no purulent exudate present anywhere in the glenoid itself.,Next, the entire wound was irrigated thoroughly with 9 liters of antibiotic impregnated irrigation. Rather than place a spacer, it was elected to use antiobiotic beads. This was with antibiotic impregnated cement with one package with 3 gram of vancomycin. These beads were then connected using Prolene and placed into the glenoid cavity itself, also some were placed in the greater tuberosity region. These three did not have a Prolene attached to them. The ones placed down the canal did have a Prolene used as did the ones placed in the cavity of the glenoid itself.,The biceps tendon was then tenodesed under tension to the conjoint tendon. There was essentially no capsule left purely to close over the proximal humerus. It was electively the proximal humerus. A portion of bone intact because it did have some bleeding surfaces. Deltopectoral was then closed with 0-Vicryl sutures, the deep subcutaneous tissues with 0-Vicryl sutures, superficial subcutaneous tissues with 2-0 Vicryl sutures. Skin was closed with staples. A sterile bandage was applied along with a cold therapy device and shoulder immobilizer. The patient was sent to recovery room in stable and satisfactory condition.,It should be noted that __________ is being requested for this case. This was a significantly scarred patient which required extra dissection and attention. Even though this was a standard revision case due to infection, there was a significant more decision making and technical challenges in this case and this was present for typical revision case. Similarly, this case took approximately 30 to 40% more length of time due to bleeding and the attention to hemostasis. The blood loss and operative findings indicates that this case was at least 30 to 40% more challenging than a standard total shoulder or revision case. This is being dictated for insurance purposes only and reflects no inherent difficulties with the case whatsoever. orthopedic, incision and drainage, shoulder arthroplasty, extensive debridement, uncemented humeral, biomet, cemented, antibiotic beads, biceps tenosynovitis, rotator cuff tear, total shoulder arthroplasty, proximal humerus, vicryl sutures, glenoid, tendon, proximal, humerus, beads, shoulder, incision, Orthopedic Carpal tunnel syndrome and de Quervain's stenosing tenosynovitis. Carpal tunnel release and de Quervain's release. A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. The dissection was carried down to the superficial aponeurosis. de Quervain Release - Carpal PREOPERATIVE DIAGNOSIS,1. Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,POSTOPERATIVE DIAGNOSIS,1. Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,TITLE OF PROCEDURE,1. Carpal tunnel release.,2. de Quervain's release.,ANESTHESIA: , MAC,COMPLICATIONS: , None.,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 longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. The dissection was carried down to the superficial aponeurosis. The subcutaneous fat was dissected radially from 2-3 mm and the superficial aponeurosis cut on this side to leave a longer ulnar leaf.,The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly, and 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 radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4-0 Vicryl. Care was taken to avoid entrapping the motor branch of the median nerve in the suture. A hemostat was placed under the repair to ensure that the median nerve was not compressed. The skin was repaired with 5-0 nylon interrupted stitches.,The first dorsal compartment was addressed through a transverse incision at the level of the radial styloid tip. Dissection was carried down with care taken to avoid and protect the superficial radial nerve branches. I released the compartment in a separate subsheath for the EPB on the dorsal side. Both ends of the sheath were released to lengthen them, and then these were repaired with 4-0 Vicryl. It was checked to make sure that there was significant room remaining for the tendons. This was done to prevent postoperative subluxation.,I then irrigated and closed the wounds in layers. Marcaine with epinephrine was placed into all wounds, and dressings and splint were placed. The patient was sent to the recovery room in good condition, having tolerated the procedure well. orthopedic, de quervain's release, carpal tunnel syndrome, tenosynovitis, carpal, incision, aponeurosis, tunnel, cut, Orthopedic CT REPORT - Soft Tissue Neck CT Neck - 1 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. orthopedic, deep cervical node, epiglottic mass, epiglottic space, aryepiglottic folds, jugulodigastric nodes, level deep, cervical node, deep cervical, node, jugulodigastric, aryepiglottic, deep, cervical Orthopedic Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested. CT Lumbar Spine EXAM:, Noncontrast CT scan of the lumbar spine,REASON FOR EXAM: , Left lower extremity muscle spasm.,COMPARISONS: , None.,FINDINGS: , Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.,No abnormal paraspinal masses are identified.,There are sclerotic changes with anterior effusion of the sacroiliac joints bilaterally.,There is marked intervertebral disk space narrowing at the L5-S1 level with intervertebral disk vacuum phenomenon and advanced endplate degenerative changes. Posterior disk osteophyte complex is present, most marked in the left paracentral to lateral region extending into the lateral recess on the left. This most likely will affect the S1 nerve root on the left. There are posterior hypertrophic changes extending into the neural foramina bilaterally inferiorly. There is mild neural foraminal stenosis present. Small amount of extruded disk vacuum phenomenon is present on the left in the region of the exiting nerve root. There is facet sclerosis bilaterally. Mild lateral recess stenosis just on the right, there is prominent anterior spondylosis.,At the L4-5 level, mild bilateral facet arthrosis is present. There is broad based posterior annular disk bulging or protrusion, which mildly effaces the anterior aspect of the thecal sac and extends into the inferior aspect of the neural foramina bilaterally. No moderate or high-grade central canal or neural foraminal stenosis is identified.,At the L3-4 level anterior spondylosis is present. There are endplate degenerative changes with mild posterior annular disk bulging, but no evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the L2-3 level, there is mild bilateral ligamentum flavum hypertrophy. Mild posterior annular disk bulging is present without evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the T12-L1 and L1-2 levels, there is no evidence of herniated disk protrusion, central canal, or neural foraminal stenosis.,There is arteriosclerotic vascular calcification of the abdominal aorta and iliac arteries without evidence of aneurysm or dilatation. No bony destructive changes or acute fractures are identified.,CONCLUSIONS:,1. Advanced degenerative disk disease at the L5-S1 level.,2. Probable chronic asymmetric herniated disk protrusion with peripheral calcification at the L5-S1 level, laterally in the left paracentral region extending into the lateral recess causing lateral recess stenosis.,3. Mild bilateral neural foraminal stenosis at the L5-S1 level.,4. Posterior disk bulging at the L2-3, L3-4, and L4-5 levels without evidence of moderate or high-grade central canal stenosis.,5. Facet arthrosis to the lower lumbar spine.,6. Arteriosclerotic vascular disease. orthopedic, noncontrast ct scan, lower extremity muscle spasm, neural foraminal stenosis, lumbar spine, spine, disk, lumbar, ct, intervertebral, canal, foraminal, noncontrast, stenosis, Orthopedic CT of Lumbar Spine without Contrast. Patient with history of back pain after a fall. CT of Lumbar Spine w/o Contrast 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., orthopedic, lumbar spine, back pain, ct, coronal, atherosclerotic, axial images, central canal, compression, deformity, degenerative, disk space, fracture, intervertebral, neuroforamen, sagittal, spondylolisthesis, spondylolysis, subluxation, wedge, without contrast, contrast, spine, lumbar, noncontrast, Orthopedic This is a middle-aged female with low back pain radiating down the left leg and foot for one and a half years. CT Lumbar Spine - 1 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. orthopedic, posterior annular disc, circumferential annular disc, normal central canal, annular disc bulging, lumbar spine, posterior annular, facet joints, annular disc, disc bulging, tomography, disc, lumbar, postsurgical, spine, annular, bulging, Orthopedic This is a middle-aged female with two month history of low back pain and leg pain. CT Lumbar Spine - 2 FINDINGS:,Axial scans were performed from L1 to S2 and reformatted images were obtained in the sagittal and coronal planes.,Preliminary scout film demonstrates anterior end plate spondylosis at T11-12 and T12-L1.,L1-2: There is normal disc height, anterior end plate spondylosis, very minimal vacuum change with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints (image #4).,L2-3: There is mild decreased disc height, anterior end plate spondylosis, circumferential disc protrusion measuring 4.6mm (AP) and right extraforaminal osteophyte disc complex. There is mild non-compressive right neural foraminal narrowing, minimal facet arthrosis, normal central canal and left neural foramen (image #13).,L3-4: There is normal disc height, anterior end plate spondylosis, and circumferential non-compressive annular disc bulging. The disc bulging flattens the ventral thecal sac and there is minimal non-compressive right neural foraminal narrowing, minimal to mild facet arthrosis with vacuum change on the right, normal central canal and left neural foramen (image #25).,L4-5: orthopedic, anterior end plate spondylosis, compressive right neural foraminal, compressive annular disc bulging, anterior end plate, annular disc bulging, normal central canal, plate spondylosis, central canal, vacuum change, disc bulging, neural foraminal, facet arthrosis, anterior, spondylosis, neural, lumbar, disc, bulging, foraminal, arthrosis, facet Orthopedic CT REPORT - Soft Tissue Neck CT Neck - 2 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. orthopedic, cervical nodal, mass lesion, deep lobe, deep lateral, lateral cervical, parotid gland, cervical, lesion, gland, parotid, deep Orthopedic Motor vehicle collision. CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast. CT Head, Facial Bones, Cervical Spine - 1 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. orthopedic, intracranial disease, motor vehicle collision, orbital nerves, extra-ocular muscles, cervical spine, ct cervical spine, ct facial bones, ct head, axial ct images, facial bone fracture, facial bones, ct, noncontrast, intracranial, axial, spine, fracture, cervical, contrast, facial, bones, Orthopedic Common CT C-Spine template CT C-Spine 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. orthopedic, sequential axial ct images, atlanto-dens interval, dens, ct c spine, cervical spineNOTE Orthopedic Motor vehicle collision. CT head without contrast and CT cervical spine without contrast. Noncontrast axial CT images of the head were obtained. CT Head and C Spine 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. orthopedic, muscle spasms, cervical lordosis, intracranial hemorrhage, motor vehicle collision, axial ct images, ct head, ct, anterior, cyst, polyp, maxillary, contrast, intracranial, sinuses, spine, axial, head, cervical, noncontrast Orthopedic CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast. CT Head, Facial Bones, Cervical Spine 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. orthopedic, sagittal, coronal, soft tissue swelling, paranasal sinuses, mastoid air, acute fracture, maxillary sinuses, tissue swelling, underlying fracture, multilevel degenerative, ct head, soft tissue, facial bones, cervical spine, ct, facial, bones, spine, cervical Orthopedic The patient has been suffering from intractable back and leg pain. Consult - Back & Leg Pain Her axial back pain is greatly improved, but not completely eradicated. There is absolutely no surgery at this point in time that would be beneficial for her axial back pain due to her lumbar internal disc disruption.,PAST MEDICAL HISTORY:, Significant for anxiety disorder.,PAST SURGICAL HISTORY: , Foot surgery, abdominal surgery, and knee surgery.,CURRENT MEDICATIONS:, Lipitor and Lexapro.,ALLERGIES: , She is allergic to sulfa medications.,SOCIAL HISTORY: , She is married, retired. Denies tobacco or ethanol use.,FAMILY HISTORY:, Father died of mesothelioma. Mother gastric problems.,REVIEW OF SYSTEMS: , No recent history of night sweats, fevers, weight loss, visual changes, loss of consciousness, convulsion, or dysphagia. Otherwise, review of systems is unremarkable, and a detailed history can be found in the patient's chart.,PHYSICAL EXAMINATION:, Physical exam can be found in great detail in the patient's chart.,ASSESSMENT AND PLAN: ,The patient is suffering from multilevel lumbar internal disc disruption as well as an element of lumbar facet joint syndrome. Her lumbar facet joints were denervated approximately 6 months ago. The denervation procedure helped her axial back pain approximately 40% when standing. With extension and rotation it helped her axial back pain approximately 70%. She is now able to swing a golf club. She was unable to swing a golf club due to the rotational movements before her rhizotomy. She is currently playing golf. Her L4 radicular symptoms have resolved since her therapeutic transforaminal injection.,I am going to have her fitted with a low profile back brace and I am starting her on diclofenac 75 mg p.o. b.i.d. We will follow her up in 1 month's time., orthopedic, multilevel lumbar internal disc disruption, denervation procedure, lumbar facet joint syndrome, swing a golf, lumbar internal disc, internal disc disruption, lumbar internal, internal disc, disc disruption, intractable, surgery, disc, lumbar Orthopedic Lateral and plantar condylectomy, fifth left metatarsal. Condylectomy TITLE OF OPERATION:, Lateral and plantar condylectomy, fifth left metatarsal.,PREOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,POSTOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,ANESTHESIA: ,Monitored anesthesia care with 10 mL of 1:1 mixture of both 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:, 30 minutes, left ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,MATERIALS USED: , 3-0 Vicryl and 4-0 Vicryl.,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 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 a normal sterile technique. The left ankle tourniquet was inflated. Attention was then directed on the dorsolateral aspect of the fifth left metatarsophalangeal joint where a 4-cm linear incision was placed over the fifth left metatarsophalangeal joint parallel and lateral to the course of the extensor digitorum longus to the fifth left 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 fifth left metatarsophalangeal joint. All the tendinous and neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, the soft tissue attachments through the fifth left metatarsal head were mobilized. The lateral and plantar aspect of the fifth left metatarsal head were adequately exposed and using the sagittal saw a lateral and plantar condylectomy of the fifth left metatarsal head were then achieved. The bony prominences were removed and passed off the operating table to be sent to pathology for identification. The remaining sharp edges of the fifth left metatarsal head were then smoothened with the use of a dental rasp. The area was copiously flushed with saline. Then, 3-0 Vicryl and 4-0 Vicryl suture materials were used to approximate the periosteal, capsular, and subcutaneous tissues respectively. The incision was reinforced with Steri-Strips. Range of motion of the fifth left metatarsophalangeal joint was tested and was found to be excellent and uninhibited. The patient's left ankle tourniquet at this time was deflated. Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff. The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage and the patient's left foot was placed in a surgical shoe. The patient was then transferred to the recovery 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 medications and instructions on how to control her postoperative course. She was discharged from Hospital according to nursing protocol and was will follow up with Dr. X in one week's time for her first postoperative appointment. orthopedic, plantar condyle hypertrophy, condyle hypertrophy, subcutaneous tissues, ankle tourniquet, metatarsophalangeal joint, metatarsal head, plantar condylectomy, tourniquet, condylectomy, plantar, ankle, metatarsal, Orthopedic Closed reduction percutaneous pinning, left distal humerus. Closed type-III supracondylar fracture, left distal humerus. Tethered brachial artery, left elbow. Closed Reduction Percutaneous Pinning 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. orthopedic, closed reduction, percutaneous pinning, distal humeru, supracondylar fracture, tethered brachial artery, artery, supracondylar, brachial, pinning, reduction, fracture, humerus, elbow, Orthopedic Patient with complaint of left knee pain. Patient is obese and will be starting Medifast Diet. Consult - Knee Pain CHIEF COMPLAINT:, Left knee pain.,SUBJECTIVE: , This is a 36-year-old white female who presents to the office today with a complaint of left knee pain. She is approximately five days after a third Synvisc injection. She states that the knee is 35% to 40 % better, but continues to have a constant pinching pain when she full weight bears, cannot handle having her knee in flexion, has decreased range of motion with extension. Rates her pain in her knee as a 10/10. She does alternate ice and heat. She is using Tylenol No. 3 p.r.n. and ibuprofen OTC p.r.n. with minimal relief.,ALLERGIES,1. PENICILLIN.,2. KEFLEX.,3. BACTRIM.,4. SULFA.,5. ACE BANDAGES.,MEDICATIONS,1. Toprol.,2. Xanax.,3. Advair.,4. Ventolin.,5. Tylenol No. 3.,6. Advil.,REVIEW OF SYSTEMS:, Will be starting the Medifast diet, has discussed this with her PCP, who encouraged her to have gastric bypass, but the patient would like to try this Medifast diet first. Other than this, denies any further problems with her eyes, ears, nose, throat, heart, lungs, GI, GU, musculoskeletal, nervous system, except what is noted above and below.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse 72, blood pressure 130/88, respirations 16, height 5 feet 6.5 inches.,GENERAL: This is a 36-year-old white female who is A&O x3, in no apparent distress with a pleasant affect. She is well developed, well nourished, appears her stated age.,EXTREMITIES: Orthopedic evaluation of the left knee reveals there to be well-healed portholes. She does have some medial joint line swelling. Negative ballottement. She has significant pain to palpation of the medial joint line, none of the lateral joint line. She has no pain to palpation on the popliteal fossa. Range of motion is approximately -5 degrees to 95 degrees of flexion. It should be noted that she has extreme hyperextension on the right with 95+ degrees of flexion on the right. She has a click with McMurray. Negative anterior-posterior drawer. No varus or valgus instability noted. Positive patellar grind test. Calf is soft and nontender. Gait is stable and antalgic on the left.,ASSESSMENT,1. Osteochondral defect, torn meniscus, left knee.,2. Obesity.,PLAN: , I have encouraged the patient to work on weight reduction, as this will only benefit her knee. I did discuss treatment options at length with the patient, but I think the best plan for her would be to work on weight reduction. She questions whether she needs a total knee; I don't believe she needs total knee replacement. She may, however, at some point need an arthroscopy. I have encouraged her to start formal physical therapy and a home exercise program. Will use ice or heat p.r.n. I have given her refills on Tylenol No. 3, Flector patch, and Relafen not to be taken with any other anti-inflammatory. She does have some abdominal discomfort with the anti-inflammatories, was started on Nexium 20 mg one p.o. daily. She will follow up in our office in four weeks. If she has not gotten any relief with formal physical therapy and the above-noted treatments, we will discuss with Dr. X whether she would benefit from another knee arthroscopy. The patient shows a good understanding of this treatment plan and agrees. orthopedic, medifast, medifast diet, obesity, gastric bypass, knee pain, weight reduction, knee, Orthopedic Axial images through the cervical spine with coronal and sagittal reconstructions. CT C-Spine - 1 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. orthopedic, c-spine, axial images, sagittal reconstructions, cervical spine, sagittal, fracture, coronal, spine, axial, cervical, ct, Orthopedic CT cervical spine for trauma. CT examination of the cervical spine was performed without contrast. Coronal and sagittal reformats were obtained for better anatomical localization. CT C-Spine - 2 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. orthopedic, c-spine, anatomical, degenerative endplate, ct examination, cervical spine, coronal, ct, spine, cervicalNOTE Orthopedic Trimalleolar ankle fracture and dislocation right ankle. A comminuted fracture involving the lateral malleolus, as well as a medial and posterior malleolus fracture as well. Closed open reduction and internal fixation of right ankle. Closed ORIF - Ankle 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. orthopedic, ankle fracture, dislocation, open reduction, internal fixation, orif, trimalleolar ankle fracture, cortical screw, cancellous screws, fracture site, fracture, ankle, malleolus, Orthopedic Right distal both-bone forearm fracture. Closed reduction under conscious sedation and application of a splint was warranted. Closed Reduction - 1 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. orthopedic, closed reduction, distal both bone forearm, emergency department, pollicis longus, bone forearm, forearm fracture, conscious sedation, emergency, department, pollicis, longus, splint, distal, bone, forearm, conscious, sedation, fracture, reduction, Orthopedic Postoperative followup note - Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate. Cervicalgia FAMILY HISTORY: , Her father died at the age of 80 from prostate cancer. Her mother died at the age of 67. She did abuse alcohol. She had a brother died at the age of 70 from bone and throat cancer. She has two sons, ages 37 and 38 years old who are healthy. She has two daughters, ages 60 and 58 years old, both with cancer. She describes cancer hypertension, nervous condition, kidney disease, lung disease, and depression in her family.,SOCIAL HISTORY: , She is married and has support at home. Denies tobacco, alcohol, and illicit drug use.,ALLERGIES: , Aspirin.,MEDICATIONS: ,The patient does not list any current medications.,PAST MEDICAL HISTORY: , Hypertension, depression, and osteoporosis.,PAST SURGICAL HISTORY: , She has had over her over her lifetime four back surgeries and in 2005 she had anterior cervical discectomy and fusion of C3 through C7 by Dr. L. She is G10, P7, no cesarean sections.,REVIEW OF SYSTEMS: , HEENT: Headaches, vision changes, dizziness, and sore throat. GI: Difficulty swallowing. Musculoskeletal: She is right-handed with joint pain, stiffness, decreased range of motion, and arthritis. Respiratory: Shortness of breath and cough. Cardiac: Chest pain and swelling in her feet and ankle. Psychiatric: Anxiety and depression. Urinary: Negative and noncontributory. Hem-Onc: Negative and noncontributory. Vascular: Negative and noncontributory. Genital: Negative and noncontributory.,PHYSICAL EXAMINATION:, On physical exam, she is 5 feet tall and currently weighs 110 pounds; weight one year ago was 145 pounds. BP 138/78, pulse is 64. General: A well-developed, well-nourished female, in no acute distress. HEENT exam, head is atraumatic and normocephalic. Eyes, sclerae are anicteric. Teeth, she does have some poor dentition. She does say that she needs some of her teeth pulled on her lower mouth. Cranial nerves II, III, IV, and VI, vision is intact and visual fields are full to confrontation. EOMs are full bilaterally. Pupils are equal, round, and reactive to light. Cranial nerves V and VII, normal facial sensation and symmetrical facial movements. Cranial nerve VIII, hearing is intact, although decreased bilaterally right worse than left. Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically. Cranial nerve XI, strong and symmetrical shoulder shrugs against resistance. Cardiac, regular rate and rhythm. Chest and lungs are clear bilaterally. Skin is warm and dry. Normal turgor and texture. No rashes or lesions are noted. General musculoskeletal exam reveals no gross deformity, fasciculations, and atrophy. Peripheral vascular, no cyanosis, clubbing, or edema. She does have some tremoring of her bilateral upper arms as she said. Strength testing reveals difficulty when testing due to the fact that the patient does have a lot of pain, but she seems to be pretty equal in the bilateral upper extremities with no obvious weakness noted. She is about 4+/5 in the deltoids, biceps, triceps, wrist flexors, wrist extensors, dorsal interossei, and grip strength.,It is much more painful for her on the left. Deep tendon reflexes are 2+ bilaterally only at biceps, triceps, and brachioradialis, knees, and ankles. No ankle clonus is elicited. Hoffmann's is negative bilaterally. Sensation is intact. She ambulates with slow short steps. No spastic gait is noted. She has appropriate station and gait with no assisted devices, although she states that she is supposed to be using a cane. She does not bring one in with her today.,FINDINGS: , Patient brings in cervical spine x-rays and she has had an MRI taken but does not bring that in with her today. She will obtain that and x rays, which showed at cervical plate C3, C4, C5, C6, and C7 anteriorly with some lifting with the most lifted area at the C3 level. No fractures are noted.,ASSESSMENT: , Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate.,PLAN:, We went ahead and obtained an EKG in the office today, which demonstrated normal sinus rhythm. She went ahead and obtained her x-rays and will pick her MRI and return to the office for surgical consultation with Dr. L first available. She would like the plate removed, so that she can eat and drink better, so that she can proceed with her shoulder surgery. All questions and concerns were addressed with her. Warning signs and symptoms were gone over with her. If she should have any further questions, concerns, or complications, she will contact our office immediately; otherwise, we will see her as scheduled. I am quite worried about the pain that she is having in her arms, so I would like to see the MRI as well. Case was reviewed and discussed with Dr. L. orthopedic, c3 through c7, pain scale, mris, x-rays, cervical discectomy and fusion, cervical radiculopathy, cervical fusion, cervical discectomy, cervical plate, difficulty swallowing, cranial nerves, radiculopathy, discectomy, cervicalgia, postoperative, fusion, swallowing, Orthopedic Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot. Closing Wedge Osteotomy PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,PROCEDURE: , Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.,ANESTHESIA: , Local infiltrate with IV sedation.,INDICATIONS FOR SURGERY: , The patient has had a longstanding history of foot problems. The problem has been progressive in nature. The preoperative discussion with the patient included alternative treatment options, the procedure was explained, and the risk factors such as infection, swelling, scar tissue, numbness, continued pain, recurrence, and the postoperative management were discussed. The patient has been advised, although no guarantee for success could be given, most of the patient have less pain and improved function, all questions were thoroughly answered. The patient requested for surgical repair since the problem has reached a point that interfere with normal daily activity. The purpose of the surgery is to alleviate pain and discomfort.,DETAILS OF PROCEDURE: ,The patient was given 1 g of Ancef IV for antibiotic prophylaxis 30 minutes prior to the procedure. The patient was brought to the operating room and placed in the supine position. No tourniquet was utilized. IV sedation was achieved followed by a local anesthetic consisting of approximately 10 mL total in 1:1 mixture of 0.25% Marcaine and 1% lidocaine with epinephrine was locally infiltrated proximal to the operative site. The lower extremity was prepped and draped in the usual sterile manner. Balanced anesthesia was obtained.,PROCEDURE:, Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot. A dorsal curvilinear incision was made extending from the base of the proximal phalanx fifth digit to a point 1.5 cm from the base of the fifth metatarsal. Care was taken to identify and retract all vital structures and when necessary, vessels were ligated via electrocautery. The extensor tendon was identified and retracted medially. Sharp and blunt dissection was carried down through the subcutaneous tissue down to the periosteal layer. A linear periosteal capsular incision was made in line with the skin incision. The capsular tissue and periosteal layer was underscored, free from its underlying osseous attachment, and then reflected to expose the osseous surface. Inspection of the fifth metatarsophalangeal joint revealed articular cartilage to be perverse and hypertrophic changes to the lateral and dorsolateral aspect of the fifth metatarsal head. An oscillating saw was utilized to carefully resect the hypertrophic portion of the fifth metatarsal head to a more normal configuration. The both edges were rasped smooth.,Attention was then focused on the fifth metatarsal. The periosteal layer proximal to the fifth metatarsal head was underscored, free from its underlying attachment, and then reflected to expose the osseous surface. An excess guide position perpendicular to the weightbearing surface was placed to define apex of the osteotomy.,Using an oscillating saw, a vertically placed, wedge-shaped oblique ostomy was made with the apex being proximal, lateral, and the base medial and distal. Generous amounts of lateral cortex were preserved for the lateral hinge. The wedge was removed from the surgical field. The fifth metatarsal was placed in the appropriate position and stabilized with a guide pin, which was then countersunk and a 3-0 x 40 mm cannulated cortical screw was placed over the guide pin and secured into position. Good purchase was noted at the osteotomy site. Inspection revealed satisfactory reduction of the fourth intermetatarsal angle with the fifth metatarsal in good alignment and position. The surgical site was flushed with copious amounts of normal saline irrigation. The periosteal and capsular layers were closed with running sutures of 3-0 Vicryl. The subcutaneous tissues were closed with 4-0 Vicryl, and the skin edges were closed with 4-0 nylon in a running interrupted fashion. A dressing consisting of Adaptic, 4 x 4, confirming bandages, and ACE wrap to provide mild compression was applied. The patient tolerated the procedure and anesthesia well and left the operating room to the recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by normal capillary refill time, and all digits were warm and pink.,A walker boot was dispensed and applied. The patient should wear that all the time when standing or walking and be nonweightbearing with crutches and to clear by me.,Office visit will be in 4 days. The patient was given prescriptions for Keflex 500 mg one p.o. t.i.d. for 10 days and Ultram ER, #15 one p.o. daily along with written and oral home instructions including a number on which I can be reached 24 hours a day if any problem arises.,After short recuperative period, the patient was discharged home with a vital sign stable in no acute distress. orthopedic, internal screw fixation, osteotomy, closing wedge osteotomy, tailor's bunion, screw fixation, periosteal layer, metatarsal head, wedge osteotomy, metatarsal, anesthesia Orthopedic Left hip cemented hemiarthroplasty and biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment. Cemented Hemiarthroplasty & Biopsy PREOPERATIVE DIAGNOSIS:, Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,POSTOPERATIVE DIAGNOSIS: , Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,PROCEDURES PERFORMED:,1. Left hip cemented hemiarthroplasty.,2. Biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.,IMPLANTS USED:,1. DePuy Ultima calcar stem, size 3 x 45.,2. Bipolar head 28 x 43.,3. Head with +0 neck length.,4. Distal centralizer and cement restrictor.,5. SmartSet antibiotic cement x2.,ANESTHESIA: , General.,NEEDLE AND SPONGE COUNT: , Correct.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: , 300 mL.,SPECIMEN: , Resected femoral head and tissue from the fracture site as well as the marrow from the canal.,FINDINGS: ,On exposure, the fracture was noted to be basicervical pattern with no presence of calcar about the lesser trochanter. The lesser trochanter was intact. The fracture site was noted to show abnormal pathological tissue with grayish discoloration. The quality of the bone was also pathologically abnormal with soft trabecular bone. The abnormal pathological tissues were sent along with the femoral head to pathology for assessment. Articular cartilage of the acetabulum was intact and well preserved.,INDICATION: , The patient is a 53-year-old female with a history of malignant melanoma, who apparently had severe pain in her left lower extremity and was noted to have a basicervical femoral neck fracture. She denied any history of fall or trauma. The presentation was consistent with pathological fracture pending tissue assessment. Indication, risks, and benefits were discussed. Treatment options were reviewed. No guarantees have been made or implied.,PROCEDURE: ,The patient was brought to the operating room and once an adequate general anesthesia was achieved, she was positioned on a pegboard with the left side up. The left lower extremity was prepped and draped in a standard sterile fashion. Time-out procedure was called. Antibiotics were infused.,A standard posterolateral approach was made. Subcutaneous dissection was performed and the dissection was carried down to expose the fascia of the gluteus maximus. This was then incised along the line of the incision. Hemostasis was achieved. Charnley retractor was positioned. The trochanter was intact. The gluteus medius was well protected with retractor. The piriformis and minimus junction was identified. The minimus was also reflected along with the medius. Using Bovie and knife, the piriformis and external rotators were detached from its trochanteric insertion. Similarly, L-shaped capsulotomy was performed. A #5 Ethibond was utilized to tag the piriformis and the capsule for late repair. Fracture site was exposed. The femoral neck fracture was noted to be very low-lying basicervical type. Femoral head was retrieved without any difficulty with the help of a corkscrew. The head size was measured to be 43 mm. Bony fragments were removed. The acetabular socket was thoroughly irrigated. A 43-mm bipolar trial head was inserted and this was noted to give a satisfactory fit with good stability. The specimens submitted to pathology included the resected femoral head and the tissue at the fracture site, which was abnormal with grayish discoloration. This was sent to the pathology. The fracture was noted to be basicervical and preoperatively, decision was made to consider cemented calcar stem. An L-shaped osteotomy was performed in order to accept the calcar prosthesis. The basicervical fracture was noted to be just at the level of superior border of the lesser trochanter. There was no calcar superior to the lesser trochanter. The L-shaped osteotomy was performed to refine the bony edges and accept the calcar prosthesis. Hemostasis was achieved. Now, the medullary canal was entered with a canal finder. The fracture site was well exposed. Satisfactory lateralization was performed. Attention was for the reaming process. Using a size 1 reamer, the medullary canal was entered and reamed up to size 3, which gave us a satisfactory fit into the canal. At this point, a trial prosthesis size 3 with 45 mm calcar body was inserted. Appropriate anteversion was positioned. The anteversion was marked with a Bovie to identify subsequent anteversion during implantation. The bony edges were trimmed. The calcar implant with 45 mm neck length was fit in the host femur very well. There was no evidence of any subsidence. At this point, trial reduction was performed using a bipolar trial head with 0 neck length. The relationship between the central femoral head and the greater trochanter was satisfactory. The hip was well reduced without any difficulty. The stability and range of motion in extension and external rotation as well as flexion-adduction, internal rotation was satisfactory. The shuck was less than 1 mm. Leg length was satisfactory in reference to the contralateral leg. Stability was satisfactory at 90 degrees of flexion and hip at 75-80 degrees of internal rotation. Similarly, keeping the leg completely adducted, I was able to internally rotate the hip to 45 degrees. After verifying the stability and range of motion in all direction, trial components were removed. The canal was thoroughly irrigated and dry sponge was inserted and canal was dried completely. At this point, 2 batches of SmartSet cement with antibiotics were mixed. The definitive Ultima calcar stem size 3 with 45 mm calcar body was selected. Centralizer was positioned. The cement restrictor was inserted. Retrograde cementing technique was applied once the canal was dried. Using cement gun, retrograde cementing was performed. The stem was then inserted into cemented canal with appropriate anteversion, which was maintained until the cement was set hard and cured. The excess cement was removed with the help of a curette and Freer elevator. All the cement debris was removed.,Attention was now placed for the insertion of the trial femoral head. Once again, 0 neck length trial bipolar head was inserted over the trunnion. It was reduced and range of motion and stability was satisfactory. I also attempted with a -3 trial head, but the 0 gave us a satisfactory stability, range of motion, as well as the length and the shuck was also minimal. The hip was raised to 90 degrees of flexion and 95 degrees of internal rotation. There was no evidence of any impingement on extension and external rotation as well as flexion-adduction, internal rotation. I also tested the hip at 90 degrees of flexion with 10 degrees adduction and internal rotation and further progressive flexion of the hip beyond 90 degrees, which was noted to be very stable. At this point, a definitive component using +0 neck length and bipolar 43 head were placed over the trunnion and the hip was reduced. Range of motion and stability was as above. Now, the attention was placed for the repair of the capsule and the external rotators and the piriformis. This was repaired to the trochanteric insertion using #5 Ethibond and suture plaster. Satisfactory reinforcement was achieved with the #5 Ethibond. The wound was thoroughly irrigated. Hemostasis was achieved. The fascia was closed with #1 Vicryl followed by subcutaneous closure using 2-0 Vicryl. The wound was thoroughly washed and a local injection with mixture of morphine and Toradol was infiltrated including the capsule and the pericapsular structures. Skin was approximated with staples. Sterile dressings were placed. Abduction pillow was positioned and the patient was then extubated and transferred to the recovery room in a stable condition. There were no intraoperative complications noted. Orthopedic Cervical spondylosis and kyphotic deformity. She had a nerve conduction study and a diagnosis of radiculopathy was made. She had an MRI of lumbosacral spine, which was within normal limits. She then developed a tingling sensation in the right middle toe. Cervical Spondylosis - Neuro Consult REASON FOR NEUROLOGICAL CONSULTATION: , Cervical spondylosis and kyphotic deformity. The patient was seen in conjunction with medical resident Dr. X. I personally obtained the history, performed examination, and generated the impression and plan.,HISTORY OF PRESENT ILLNESS: ,The patient is a 45-year-old African-American female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain. This has subsequently resolved. She started vigorous workouts in November 2005. In March of this year, she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician. By her report, she had a nerve conduction study and a diagnosis of radiculopathy was made. She had an MRI of lumbosacral spine, which was within normal limits. She then developed a tingling sensation in the right middle toe. Symptoms progressed to sensory symptoms of her knees, elbows, and left middle toe. She then started getting sensory sensations in the left hand and arm. She states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg. Symptoms have been mildly progressive. She is unaware of any trigger other than the vigorous workouts as mentioned above. She has no associated bowel or bladder symptoms. No particular position relieves her symptoms.,Workup has included two MRIs of the C-spine, which were personally reviewed and are discussed below. She saw you for consultation and the possibility of surgical decompression was raised. At this time, she is somewhat reluctant to go through any surgical procedure.,PAST MEDICAL HISTORY:,1. Ocular migraines.,2. Myomectomy.,3. Infertility.,4. Hyperglycemia.,5. Asthma.,6. Hypercholesterolemia.,MEDICATIONS: , Lipitor, Pulmicort, Allegra, Xopenex, Patanol, Duac topical gel, Loprox cream, and Rhinocort.,ALLERGIES: , Penicillin and aspirin.,Family history, social history, and review of systems are discussed above as well as documented in the new patient information sheet. Of note, she does not drink or smoke. She is married with two adopted children. She is a paralegal specialist. She used to exercise vigorously, but of late has been advised to stop exercising and is currently only walking.,REVIEW OF SYSTEMS: , She does complain of mild blurred vision, but these have occurred before and seem associated with headaches.,PHYSICAL EXAMINATION: , On examination, blood pressure 138/82, pulse 90, respiratory rate 14, and weight 176.5 pounds. Pain scale is 0. A full general and neurological examination was personally performed and is documented on the chart. Of note, she has a normal general examination. Neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk. She has mild postural tremor in both arms. She has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities. Motor examination reveals no weakness to individual muscle testing, but on gait she does have a very subtle left hemiparesis. She has hyperreflexia in her lower extremities, worse on the left. Babinski's are downgoing.,PERTINENT DATA: ,MRI of the brain from 05/02/06 and MRI of the C-spine from 05/02/06 and 07/25/06 were personally reviewed. MRI of the brain is broadly within normal limits. MRI of the C-spine reveals large central disc herniation at C6-C7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema. There is also a fairly large disc at C3-C4 with cord deformity and partial effacement of the subarachnoid space. I do not appreciate any cord edema at this level.,IMPRESSION AND PLAN: ,The patient is a 45-year-old female with cervical spondylosis with a large C6-C7 herniated disc with mild cord compression and signal change at that level. She has a small disc at C3-C4 with less severe and only subtle cord compression. History and examination are consistent with signs of a myelopathy.,Results were discussed with the patient and her mother. I am concerned about progressive symptoms. Although she only has subtle symptoms now, we made her aware that with progression of this process, she may have paralysis. If she is involved in any type of trauma to the neck such as motor vehicle accident, she could have an acute paralysis. I strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation. I agree with the previous physicians who have told her not to exercise as I am sure that her vigorous workouts and weight training since November 2005 have contributed to this problem. I have recommended that she wear a hard collar while driving. The results of my consultation were discussed with you telephonically. orthopedic, kyphotic, cervical, radiculopathy, myelopathy, kyphotic deformity, cord compression, cervical spondylosis, toe, spondylosis, cord, Orthopedic Left distal both-bone forearm fracture. Closed reduction with splint application with use of image intensifier. Closed Reduction - 2 PREOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,PROCEDURE:, Closed reduction with splint application with use of image intensifier.,INDICATIONS: , Mr. ABC is an 11-year-old boy who sustained a fall on 07/26/2008. Evaluation in the emergency department revealed both-bone forearm fracture. Considering the amount of angulation, it was determined that we should proceed with conscious sedation and closed reduction. After discussion with parents, verbal and written consent was obtained.,DESCRIPTION OF PROCEDURE: ,The patient was induced with propofol for conscious sedation via the emergency department staff. After it was confirmed that appropriate sedation had been reached, a longitudinal traction in conjunction with re-creation of the injury maneuver was applied reducing the fracture. Subsequently, this was confirmed with image intensification, a sugar-tong splint was applied and again reduction was confirmed with image intensifier. The patient was aroused from anesthesia and tolerated the procedure well. Post-reduction plain films revealed some anterior displacement of the distal fragment. At this time, it was determined this fracture proved to be unstable.,DISPOSITION: , After review of the reduction films, it appears that there is some element of fracture causing displacement. We will proceed to the operating room for open reduction and internal fixation versus closed reduction and percutaneous pinning as our operative schedule allows., orthopedic, closed reduction, reduction with splint application, distal both bone forearm, distal both bone, splint application, emergency department, conscious sedation, image intensifier, bone forearm, forearm fracture, reduction, emergency, department, conscious, displacement, splint, sedation, tong, distal, bone, image, intensifier, forearm, fracture Orthopedic Carpal tunnel syndrome. Endoscopic carpal tunnel release. 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. Carpal Tunnel Release - Endoscopic 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. orthopedic, endoscopic, carpal tunnel syndrome, carpal tunnel release, carpal ligament, tourniquet, carpal, esmarch, tunnel, transverse, ligament Orthopedic Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty. Cartilage Loose Body Removal PREOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,POSTOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,PROCEDURES:, Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.,ANESTHESIA: , General.,TOURNIQUET TIME: ,Thirty-seven minutes.,MEDICATIONS: , The patient also received 30 mL of 0.5% Marcaine local anesthetic at the end of the case.,COMPLICATIONS: , No intraoperative complications.,DRAINS AND SPECIMENS: , None.,INTRAOPERATIVE FINDINGS: , The patient had a loose body that was found in the suprapatellar pouch upon entry of the camera. This loose body was then subsequently removed. It measured 24 x 14 mm. This was actually the OCD lesion seen on the MRI that had come from the weightbearing surface of just the lateral posterior aspect of the medial femoral condyle,HISTORY AND PHYSICAL: , The patient is 13-year-old male with persistent left knee pain. He was initially seen at Sierra Pacific Orthopedic Group where an MRI demonstrated unstable OCD lesion of the left knee. The patient presented here for a second opinion. Surgery was recommended grossly due to the instability of the fragment. Risks and benefits of surgery were discussed. The risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure to relieve pain or restore the articular cartilage, possible need for other surgical procedures, and possible early arthritis. All questions were answered and parents agreed to the above 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 nonsterile tourniquet was placed on the upper aspect of the patient's left thigh. The extremity was then prepped and draped in standard surgical fashion. The standard portals were marked on the skin. The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg. The portal incisions were then made by an #11 blade. Camera was inserted into the lateral joint line. There was a noted large cartilage loose body in the suprapatellar pouch. This was subsequently removed with extension of the anterolateral portal. Visualization of the rest of the knee revealed significant synovitis. The patient had a large cartilage defect in the posterolateral aspect of the medial femoral condyle. The remainder of the knee demonstrated no other significant cartilage lesions, loose bodies, plica or meniscal pathology. ACL was also visualized to be intact in the intracondylar notch.,Attention was then turned back to the large defect. The loose cartilage was debrided using a shaver. Microfracture technique was then performed to 4 mm depth at 2 to 3 mm distances. Tourniquet was released at the end of the case to ensure that there was fat and bleeding at the microfracture sites. All instruments were then removed. The portals were closed using #4-0 Monocryl. A total of 30 mL of 0.5% Marcaine was injected into the knee. Wounds were then cleaned and dried, and dressed in Steri-Strips, Xeroform, 4 x 4s, and bias. The patient was then placed in a knee immobilizer. The patient tolerated the procedure well. The tourniquet was released at 37 minutes. He was taken to recovery in stable condition.,POSTOPERATIVE PLAN: , The loose cartilage fragment was given to the family. The intraoperative findings were relayed with intraoperative photos. There was a large deficit in the weightbearing portion of medial femoral condyle. His prognosis is guarded given the fact of the fragile lesion and location, but in advantages of his age and his rehab potential down the road, if the patient still has symptoms, he may be a candidate for osteochondral autograft, a procedure which is not performed at Children's or possible cartilaginous transplant. All questions were answered. The patient will follow up in 10 days, may wet the wound in 5 days. orthopedic, knee arthroscopy, chondroplasty, medial femoral condyle, cartilage loose body, loose cartilage, knee, arthroscopy, tourniquet, microfracture, femoral, cartilage, Orthopedic Carpal tunnel syndrome. Open carpal tunnel release. 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. Carpal Tunnel Release - Open 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. orthopedic, carpal ligament, carpal tunnel release, carpal tunnel syndrome, transverse carpal ligament, transverse, ligament, hemostat, tunnel, incision Orthopedic Followup cervical spinal stenosis. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects. Cervical Spinal Stenosis REASON FOR VISIT: ,Followup cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS: ,Ms. ABC returns today for followup regarding her cervical spinal stenosis. I have last seen her on 06/19/07. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on 06/04/07, when she thought she had exacerbated her conditions while lifting several objects.,I referred her to obtain a cervical spine MRI.,She returns today stating that she continues to have right upper extremity pain, paresthesias, weakness, which she believes radiates from her neck. She had some physical therapy, which has been helping with the neck pain. The right hand weakness continues. She states she has a difficult time opening jars, and doors, and often drops items from her right greater than left upper extremity. She states she have several occasions when she is sleeping at night, she has had sharp shooting radicular pain and weakness down her left upper extremity and she feels that these symptoms somewhat scare her.,She has been undergoing nonoperative management by Dr. X and feels this has been helping her neck pain, but not the upper extremity symptoms.,She denies any bowel and bladder dysfunction. No lower back pain, no lower extremity pain, and no instability with ambulation.,REVIEW OF SYSTEMS:, Negative for fevers, chills, chest pain, and shortness of breath.,FINDINGS: ,On examination, Ms. ABC is a very pleasant well-developed, well-nourished female in no apparent distress. Alert and oriented x3. Normocephalic and atraumatic. Afebrile to touch.,She ambulates with a normal gait.,Motor strength is 4 plus out of 5 in the bilateral deltoids, biceps, triceps muscle groups, 4 out of 5 in the bilateral hand intrinsic muscle groups, grip strength 4 out of 5, 4 plus out of 5 bilateral wrist extension and wrist flexion.,Light touch sensation decreased in the right greater than left C6 distribution. Biceps and brachioradialis reflexes are 3 plus. Hoffman sign normal bilaterally.,Lower extremity strength is 5 out of 5 in all muscle groups. Patellar reflex is 3 plus. No clonus.,Cervical spine radiographs dated 06/21/07 are reviewed.,They demonstrate evidence of spondylosis including degenerative disk disease and anterior and posterior osteophyte formation at C4-5, C5-6, C6-7, and C3-4 demonstrates only minimal if any degenerative disk disease. There is no significant instability seen on flexion-extension views.,Updated cervical spine MRI dated 06/21/07 is reviewed.,It demonstrates evidence of moderate stenosis at C4-5, C5-6. These stenosis is in the bilateral neural foramina and there is also significant disk herniation noted at the C6-7 level. Minimal degenerative disk disease is seen at the C6-7. This stenosis is greater than C5-6 and the next level is more significantly involved at C4-5.,Effacement of the ventral and dorsal CSF space is seen at C4-5, C5-6.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination, and radiographic findings are compatible with C4-5, C5-6 cervical spinal stenosis with associated right greater than left upper extremity radiculopathy including weakness.,I spent a significant amount of time today with the patient discussing the diagnosis, prognosis, natural history, nonoperative, and operative treatment options.,I laid out the options as continued nonoperative management with physical therapy, the same with the addition of cervical epidural steroid injections and surgical interventions.,The patient states she would like to avoid injections and is somewhat afraid of having these done. I explained to her that they may help to improve her symptoms, although they may not help with the weakness.,She feels that she is failing maximum nonoperative management and would like to consider surgical intervention.,I described the procedure consisting of C4-5, C5-6 anterior cervical decompression and fusion to the patient in detail on a spine model.,I explained the rationale for doing so including the decompression of the spinal cord and improvement of her upper extremity weakness and pain. She understands.,I discussed the risks, benefits, and alternative of the procedure including material risks of bleeding, infection, neurovascular injury, dural tear, singular or multiple muscle weakness, paralysis, hoarseness of voice, difficulty swallowing, pseudoarthrosis, adjacent segment disease, and the risk of this given the patient's relatively young age. Of note, the patient does have a hoarse voice right now, given the fact that she feels she has allergies.,I also discussed the option of disk arthroplasty. She understands.,She would like to proceed with the surgery, relatively soon. She has her birthday coming up on 07/20/07 and would like to hold off, until after then. Our tentative date for the surgery is 08/01/07. She will go ahead and continue the preoperative testing process. Orthopedic Left total knee cemented arthroplasty. Severe tricompartmental osteoarthritis, left knee with varus deformity. Cemented Arthroplasty 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. Orthopedic Right carpal tunnel release. Right carpal tunnel syndrome. 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. Carpal Tunnel Release - 9 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. orthopedic, carpal tunnel release, carpal tunnel syndrome, median nerve, bier block, carpal ligament, tunnel, carpal, transverse, median, Orthopedic Left carpal tunnel release. Left carpal tunnel syndrome. Severe compression of the median nerve on the left at the wrist. Carpal Tunnel Release - 6 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. orthopedic, compression, wrist, carpal tunnel release, carpal tunnel syndrome, median nerve, tunnel, carpal, Orthopedic Right carpal tunnel syndrome. Right carpal tunnel release. Carpal Tunnel Release - 7 PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE PERFORMED: , Right carpal tunnel release.,PROCEDURE NOTE: ,The right upper extremity was prepped and draped in the usual fashion. IV sedation was supplied by the anesthesiologist. A local block using 6 cc of 0.5% Marcaine was used at the transverse wrist crease using a 25 gauge needle, superficial to the transverse carpal ligament.,The upper extremity was exsanguinated with a 6 inch ace wrap.,Tourniquet time was less than 10 minutes at 250 mmHg.,An incision was used in line with the third web space just to the ulnar side of the thenar crease. It was carried sharply down to the transverse wrist crease. The transverse carpal ligament was identified and released under direct vision. Proximal to the transverse wrist crease it was released subcutaneously. During the entire procedure care was taken to avoid injury to the median nerve proper, the recurrent median, the palmar cutaneous branch, the ulnar neurovascular bundle and the superficial palmar arch. The nerve appeared to be mildly constricted. Closure was routine with running 5-0 nylon. A bulky hand dressing as well as a volar splint was applied and the patient was sent to the outpatient surgery area in good condition. orthopedic, superficial palmar arch, carpal tunnel release, carpal tunnel syndrome, transverse wrist crease, superficial, ligament, Orthopedic Right carpal tunnel release and right index and middle fingers release A1 pulley. Right carpal tunnel syndrome and right index finger and middle fingers tenosynovitis. Carpal Tunnel Release - 8 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. orthopedic, compressed median nerve, stenosing tenosynovitis, carpal tunnel release, carpal tunnel syndrome, middle fingers, carpal tunnel, littler scissors, median nerve, copious irrigation, volar aspect, tunnel, pulley, carpal, fingers, index, tourniquet, ligament, tenosynovitis, superficialis, tendons, Orthopedic Bilateral open carpal tunnel release. Carpal Tunnel Release - 5 PREOPERATIVE DIAGNOSIS: ,Carpal tunnel syndrome, bilateral.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome, bilateral.,ANESTHESIA:, General,NAME OF OPERATION: , Bilateral open carpal tunnel release.,FINDINGS AT OPERATION: , The patient had identical, very thick, transverse carpal ligaments, with dull synovium.,PROCEDURE: ,Under satisfactory anesthesia, the patient was prepped and draped in a routine manner on both upper extremities. The right upper extremity was exsanguinated, and the tourniquet inflated. A curved incision was made at the the ulnar base, carried through the subcutaneous tissue and superficial fascia, down to the transverse carpal ligament. This was divided under direct vision along its ulnar border, and wound closed with interrupted nylon. The wound was injected, and a dry, sterile dressing was applied. An identical procedure was done to the opposite side. The patient left the operating room in satisfactory condition. orthopedic, bilateral open carpal tunnel, carpal tunnel syndrome, carpal tunnel release, carpal tunnel, release, tourniquet, bilateral, tunnel, carpal Orthopedic Left endoscopic carpal tunnel release and endotracheal fasciotomy. Carpal Tunnel Release - 2 PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,OPERATIVE PROCEDURE:,1. Left endoscopic carpal tunnel release.,2. Endotracheal fasciotomy.,ANESTHESIA:, General.,COMPLICATIONS: , None.,INDICATION: , The patient is a 62-year-old lady with the aforementioned diagnosis refractory to nonoperative management. All risks and benefits were explained. Questions answered. Options discussed. No guarantees were made. She wished to proceed with surgery.,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. orthopedic, carpal tunnel syndrome, antebrachial fascia, antebrachial fasciotomy, carpal tunnel release, electrocautery, fasciotomy, hamate, wrist crease, endoscopic carpal tunnel release, transverse carpal ligament, carpal tunnel, transverse carpal, carpal ligament, carpal, antebrachial, transverse, ligament Orthopedic Right open carpal tunnel release and cortisone injection, left carpal tunnel. Carpal Tunnel Release - 4 PREOPERATIVE DIAGNOSIS: ,Bilateral carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Bilateral carpal tunnel syndrome.,PROCEDURES:,1. Right open carpal tunnel release.,2. Cortisone injection, left carpal tunnel.,ANESTHESIA: , General LMA.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:, None.,INDICATIONS:, This patient is a 50-year-old male with bilateral carpal tunnel syndrome, which is measured out as severe. He is scheduled for the above-mentioned procedures. The planned procedures were discussed with the patient including the associated risks. The risks included but are not limited to bleeding, infection, nerve damage, failure to heal, possible need for reoperation, possible recurrence, or any associated risk of the anesthesia. He voiced understanding and agreed to proceed as planned.,DESCRIPTION OF PROCEDURE: , The patient was identified in the holding area and correct operative site was identified by the surgeon's mark. Informed consent was obtained. The patient was then brought to the operating room and transferred to the operating table in supine position. Time-out was then performed at which point the surgeon, nursing staff, and anesthesia staff all confirmed the correct identification.,After adequate general LMA anesthesia was obtained, a well-padded tourniquet was placed on the patient's right upper arm. The right upper extremity was then prepped and draped in the usual sterile fashion. Planned skin incision was marked along the base of the patient's right palm. Right upper extremity was then exsanguinated using Esmarch. The tourniquet was then inflated to 250 mmHg. Skin incision was then made and dissection was carried down with scalpel to the level of the palmar fascia which was sharply divided by the skin incision. Bleeding points were identified with electrocautery using bipolar electrocautery. Retractors were then placed to allow visualization of the distal extent of the transverse carpal ligament, and this was then divided longitudinally under direct vision. Baby Metzenbaum scissors were used to dissect distal to this area to confirm the absence of any remaining crossing obstructing fibrous band. Retractors were then replaced proximally to allow visualization of proximal extent of the transverse carpal ligament and the release was continued proximally until complete release was performed. This was confirmed by visually and palpably. Next, baby Metzenbaum scissors were used to dissect anteroposterior adjacent antebrachial fascia, and this was divided longitudinally under direct vision using baby Metzenbaum scissors to a level of approximately 3 cm proximal to the proximal extent of the skin incision. Carpal canal was then inspected. The median nerve was flattened and injected. No other abnormalities were noted. Wounds were then irrigated with normal saline and antibiotic additive. Decadron 4 mg was then placed adjacent to the median nerve. Skin incision was then closed with interrupted 5-0 nylon suture. The wound was then dressed with Adaptic, 4 x 4s, Kling, and Coban. The tourniquet was then deflated. Attention was then directed to the left side. Using sterile technique, the left carpal canal was injected with a mixture of 40 mg of Depo-Medrol, 1 cc of 1% lidocaine, and 1 cc of 0.25% Marcaine. Band-Aid was then placed over the injection site. The patient was then awakened, extubated, and transferred over to his hospital bed. He was transported to recovery room in stable condition. There were no intraoperative or immediate postoperative complications. All counts were reported as correct. orthopedic, carpal tunnel syndrome, 4 x 4s, adaptic, carpal canal, coban, cortisone injection, esmarch, kling, metzenbaum, carpal tunnel release, electrocautery, fibrous band, palmar fascia, tourniquet, transverse carpal ligament, bilateral carpal tunnel, baby metzenbaum scissors, carpal ligament, bilateral carpal, metzenbaum scissors, carpal tunnel, carpal, tunnel, Orthopedic Right carpal tunnel release. Carpal Tunnel Release - 1 PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,TITLE OF THE PROCEDURE: , Right carpal tunnel release.,COMPLICATIONS:, There were no complications during the procedure.,SPECIMEN: ,The specimen was sent to pathology.,INSTRUMENTS: , All counts were correct at the end of the case and no complications were encountered.,INDICATIONS: ,This is a 69-year-old female who have been complaining of right hand pain, which was steadily getting worse over a prolonged period of time. The patient had tried nonoperative therapy, which did not assist the patient. The patient had previous diagnosis of carpal tunnel and EMG showed compression of the right median nerve. As a result of these findings, the patient was sent to my office presenting with this history and was carefully evaluated. On initial evaluation, the patient had the symptomology of carpal tunnel syndrome. The patient at the time had the risks, benefits, and alternatives thoroughly explained to her. All questions were answered. No guarantees were given. The patient had agreed to the surgical procedure and the postoperative rehabilitation as needed.,DETAILS OF THE PROCEDURE: ,The patient was brought to the operating room, placed supine on the operating room table, prepped and draped in the sterile fashion and was given sedation. The patient was then given sedation. Once this was complete, the area overlying the carpal ligament was carefully injected with 1% lidocaine with epinephrine. The patient had this area carefully and thoroughly injected with approximately 10 mL of lidocaine with epinephrine and once this was complete, a 15-blade knife was then used to incise the skin opposite the radial aspect of the fourth ray. Careful dissection under direct visualization was performed through the subcutaneous fat as well as through the palmar fascia. A Weitlaner retractor was then used to retract the skin and careful dissection through the palmar fascia would then revealed the transverse carpal ligament. This was then carefully incised using a 15-blade knife and once entry was again into the carpal canal, a Freer elevator was then inserted and under direct visualization, the carpal ligament was then released. The transverse carpal ligament was carefully released first in the distal direction until palmar fat could be visualized and by palpation no further ligament could be felt. The area was well hemostased with the 1% lidocaine with epinephrine and both proximal and distal dissection along the nerve was performed. Visualization of the transverse carpal ligament was maintained with Weitlaner retractor as well as centric. Both the centric and the Ragnell were used to retract both proximal and distal corners of the incision and the entirety of the area was under direct visualization at all times. Palmar fascia was released both proximally and distally as well as the transverse carpal ligament. Direct palpation of the carpal canal demonstrated a full and complete release. Observation of the median nerve revealed an area of hyperemia in the distal two-thirds of the nerve, which demonstrated the likely area of compression. Once this was complete, hemostasis was established using bipolar cautery and some small surface bleeders and irrigation of the area was performed and then the closure was achieved with 4-0 chromic suture in a horizontal mattress and interrupted stitch. Xeroform was then applied to the incision. A bulky dressing was then applied consisting of Kerlix and Ace wrap, and the patient was taken to the recovery room in stable condition without any complications. orthopedic, carpal tunnel syndrome, ace wrap, emg, freer elevator, kerlix, weitlaner retractor, bulky dressing, carpal tunnel, carpal tunnel release, palmar fascia, subcutaneous fat, lidocaine with epinephrine, transverse carpal ligament, carpal ligament, carpal, tunnel, ligament, Orthopedic Carpal tunnel release with transverse carpal ligament reconstruction. A longitudinal incision was made in line with the fourth ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. The dissection was carried down to the superficial aponeurosis. Carpal Ligament Reconstruction PROCEDURE:, Carpal tunnel release with transverse carpal ligament reconstruction.,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 longitudinal incision was made in line with the fourth ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. The dissection was carried down to the superficial aponeurosis. The subcutaneous fat was dissected radially for 2-3 mm, and the superficial aponeurosis cut on this side to leave a longer ulnar leaf.,The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly, and 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 a scissor.,After irrigating the wound with copious amounts of normal saline, the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4-0 Vicryl. Care was taken to avoid entrapping the motor branch of the median nerve in the suture. A hemostat was placed under the repair to ensure that the median nerve was not compressed. The skin was repaired with 5-0 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. orthopedic, carpal tunnel, carpal ligament reconstruction, transverse carpal ligament, ulnar, hemostat, transverse, superficial, ligament, carpal Orthopedic Endoscopic release of left transverse carpal ligament. Carpal Ligament Release - 1 PREOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,PROCEDURE: , Endoscopic release of left transverse carpal ligament.,ANESTHESIA:, Monitored anesthesia care with regional anesthesia provided by surgeon. ,TOURNIQUET TIME: , 12 minutes.,OPERATIVE PROCEDURE IN DETAIL: , With the patient under adequate monitored anesthesia, the left upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated. The tourniquet was elevated at 290 mmHg. Construction lines were made on the left palm to identify the ring ray. A transverse incision was made in the palm between FCR and FCU, one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin. Blunt dissection exposed the antebrachial fascia. Hemostasis was obtained with bipolar cautery. A distal based window in the antebrachial fascia was then fashioned. Care was taken to protect the underlying contents. A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.,Hamate sounds were then used to palpate the Hood of Hamate. The Agee Inside Job was then inserted into the proximal incision. The transverse carpal ligament was easily visualized through the portal. Using palmar pressure, transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end. The distal end of the transverse carpal ligament was then identified in the window. The blade was then elevated, and the Agee Inside Job was withdrawn, dividing transverse carpal ligament under direct vision. After complete division of transverse carpal ligament, the Agee Inside Job was reinserted. Radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished. One cc of Celestone was then introduced into the carpal tunnel and irrigated free. ,The wound was then closed with a running 3-0 Prolene subcuticular stitch. Steri-strips were applied and a sterile dressing was applied over the Steri-strips. The tourniquet was deflated. The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well. orthopedic, carpal tunnel syndrome, antebrachial fascia, carpal, ligament, palmar, synovium, tourniquet, transverse carpal ligament, transverse incision, agee inside job, transverse carpal, carpal ligament, carpal tunnel, antebrachial, release, endoscopic, Orthopedic Left carpal tunnel release, left ulnar nerve anterior submuscular transposition at the elbow, lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve. Carpal Tunnel Release - 3 "PREOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome (354.0).,2. Left ulnar nerve entrapment at the elbow (354.2).,POSTOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome (354.0).,2. Left ulnar nerve entrapment at the elbow (354.2).,OPERATIONS PERFORMED:,1. Left carpal tunnel release (64721).,2. Left ulnar nerve anterior submuscular transposition at the elbow (64718).,3. Lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve (25280).,ANESTHESIA: , General anesthesia with intubation.,INDICATIONS OF PROCEDURE: , This patient is insulin-dependant diabetic. He is also has end-stage renal failure and has chronic hemodialysis. Additionally, the patient has had prior heart transplantation. He has been evaluated for ischemic problems to both lower extremities and also potentially to the left upper extremity. However, it is our contention that this patient's prime problem of the left upper extremity is probably neuropathic ulcers from total lack of sensation along the ulnar border of the left little finger. These started initially as unrecognized paper cuts. Additionally, the patient appears to have a neurogenic pain affecting predominantly the areas innovated by the median nerve, but also to the little finger. Finally, this patient does indeed have occlusive arterial disease to the left upper extremity in that he has a short segment radial artery occlusion and he does appear to have a narrowed segment in the ulnar artery, but the arteriogram shows distal perfusion down the ulnar border of the hand and into the little finger. Thus, we have planned to proceed first with nerve entrapment releases and potentially at the later date do arterial reconstruction if deemed necessary. Thirdly, this patient does have chronic distal ischemic problems with evidence of ""ping-pong ball sign"" due to fat atrophy at the finger tips and some periodic cracking and ulceration at the tips of the fingers. However, this patient has no clinical sign at all of tissue necrosis at the finger tips at this time.,The patient has also previously had an arteriovenous shunt in the forearm, which has been deactivated within the last 3 weeks. Thus, we planned to bring this patient to the operating room for left carpal tunnel release as well as anterior submuscular transposition of the ulnar nerve. This patient had electro diagnostic studies performed, which showed severe involvement of both the ulnar nerve at the elbow and the medial nerve at the carpal tunnel.,DESCRIPTION OF PROCEDURE: , After general anesthesia being induced and the patient intubated, he is given intravenous Ancef. The entire left upper extremity is prepped with Betadine all the way to the axilla and draped in a sterile fashion. A sterile tourniquet and webril are placed higher on the arm. The arm is then exsanguinated with Ace bandage and tourniquet inflated to 250 mmHg. I started first at the carpal tunnel release and a longitudinal curvilinear incision is made parallel to the thenar crease and stopping short of the wrist flexion crease. Dissection continued through subcutaneous tissue to the palmer aponeurosis, which is divided longitudinally from distal to proximal. I next encountered the transverse carpal ligament, which in turn is also divided longitudinally from distal to proximal, and the proximal most division of the transverse carpal ligament is done under direct vision into the distal forearm. Having confirmed a complete release of the transverse carpal ligament, I next evaluated the contents of the carpal tunnel. The synovium was somewhat thickened, but not unduly so. There was some erythema along the length of the median nerve, indicating chronic compression. The motor branch of the median nerve was clearly identified. The contents of the carpal canal were retracted in a radial direction and the floor of the canal evaluated and no other extrinsic compressive pathology was identified. The wound was then irrigated with normal saline and wound edges were reapproximated with interrupted 5-0 nylon sutures.,I next turned my attention to the cubital tunnel problem and a longitudinal curvilinear incision is made on the medial aspect of the arm extending into the forearm with the incision passing directly between the olecranon and the medial epicondyle. Dissection continues through fascia and then skin clamps are elevated to the level of the fascia on the flexor pronator muscle mass. In the process of elevating this skin flap I elevated and deactivated shunt together with the skin flap. I now gained access to the radial border of the flexor pronator muscle mass, dissected down the radial side, until I identified the median nerve.,I turned my attention back to the ulnar nerve and it is located immediately posterior to the medial intramuscular septum in the upper arm, and I dissected it all the way proximally until I encountered the location with ulnar the nerve passed from the anterior to the posterior compartments in the upper portion of the arm. The entire medial intramuscular septum is now excised. The ulnar nerve is mobilized between vessel loops and includes with it is accompanying vascular structures. Larger penetrating vascular tributaries to the muscle ligated between hemoclips. I continued to mobilize the nerve around the medial epicondyle and then took down the aponeurosis between the two heads of the flexor carpi ulnaris and continued to dissect the nerve between the FCU muscle fibers. The nerve is now mobilized and I had retained the large muscular branches and dissected them out into the muscle and also proximally using microvascular surgical techniques. In this way, the nerve was able to be mobilized between vessiloops and easily transposed anterior to the flexor pronator muscle mass in tension free manner.,I now made an oblique division of the entire flexor pronator muscle mass proximally in the forearm and the ulnar nerve was able to be transposed deep to the muscle in a nonkinking and tension-free manner. Because of the oblique incision into the flexor pronator muscle mass the muscle edges were now able to slide on each other. So that in effect a lengthening is performed. Fascial repair is done with interrupted figure-of-eight 0-Ethibond sutures. I now ranged the arm through the full range of flexion and extension at the elbow and there was no significant kinking on the nerve and there was a tension-free coverage of the muscle without any impingement on the nerve. The entire arm is next wrapped with a Kerlix wrap and I released the tourniquet and after allowing the reactive hyperemia to subside, I then unwrap the arm and check for hemostasis. Wound is copiously irrigated with normal saline and then a 15-French Round Blake drainage placed through a separate stab incision and laid along the length of the wound. A layered wound closure is done with interrupted Vicryl subcutaneously, and a running subcuticular Monocryl to the skin. A 0.25% plain Marcaine then used to infiltrate all the wound edges to help with post operative analgesia and dressings take the form of Adaptic impregnated Bacitracin ointment, followed by a well-fluffed gauze and a Kerlix dressing and confirming Kerlix and webril, and an above elbow sugar-tong splint is applied extending to the support of the wrist. Fingers and femoral were free to move. The splint is well padded with webril and is in turn held in place with Kerlix and Ace bandage. Meanwhile the patient is awakened and extubated in the operating room and returned to the recovery room in good condition. Sponge and needle counts reported as correct at the end of the procedure." orthopedic, carpal tunnel syndrome, ace bandage, kerlix, carpal tunnel release, curvilinear incision, flexor pronator muscle, ping-pong ball sign, synovium, ulnar artery, ulnar nerve, ulnar nerve entrapment, pronator muscle mass, transverse carpal, carpal ligament, tunnel release, flexor pronator, pronator muscle, carpal tunnel, tunnel, carpal, nerve, pronator, forearm, Orthopedic Left calcaneal lengthening osteotomy with allograft, partial plantar fasciotomy, posterior subtalar and tibiotalar capsulotomy, and short leg cast placed. Calcaneal Lengthening Osteotomy 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. orthopedic, calcaneal lengthening, osteotomy, allograft, plantar fasciotomy, capsulotomy, calcaneal valgus split, partial plantar fasciotomy, short leg cast, achilles lengthening, calcaneal valgus, tourniquet, plantar, valgus, achilles, calcaneal, Orthopedic Carpal tunnel release. 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. Carpal Tunnel Release 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. orthopedic, carpal tunnel syndrome, carpal ligament, nerve conduction study, carpal tunnel release, bier block, carpal tunnel, tunnel, carpal, Orthopedic Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe. Bunion left foot and hammertoe, left second toe. Bunionectomy & Metatarsal Osteotomy PREOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,POSTOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,PROCEDURE PERFORMED:,1. Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left.,2. Arthroplasty left second toe.,HISTORY: ,This 39-year-old female presents to ABCD General Hospital with the above chief complaint. The patient states that she has had bunion for many months. It has been progressively getting more painful at this time. The patient attempted conservative treatment including wider shoe gear without long-term relief of symptoms and desires surgical treatment.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preop holding area. The patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap. Copious amount of Webril were placed around the left ankle followed by a blood pressure cuff. After adequate sedation was achieved by the Department of Anesthesia, a total of 15 cc of 0.5% Marcaine plain was injected in a Mayo and digital block to the left foot. 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 table. The stockinette was reflected. The foot was cleansed with wet and dry sponge. Attention was then directed to the first metatarsophalangeal joint of the left foot. An incision was created over this area approximately 6 cm in length. The incision was deepened with a #15 blade. All vessels encountered were ligated for hemostasis. The skin and subcutaneous tissue was then dissected from the capsule. Care was taken to preserve the neurovascular bundle. Dorsal linear capsular incision was then created. The capsule was then reflected from the head of the first metatarsal. Attention was then directed to the first interspace where a lateral release was performed. A combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected. A lateral capsulotomy was performed. Attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence. The incision was then extended proximally with further dissection down to the level of the bone. Two 0.45 K-wires were then inserted as access guides for the SCARF osteotomy. A standard SCARF osteotomy was then performed. The head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle. After adequate reduction of the bunion deformity was noted, the bone was temporarily fixated with a 0.45 K-wire. A 3.0 x 12 mm screw was then inserted in the standard AO fashion with compression noted. A second 3.0 x 14 mm screw was also inserted with tight compression noted. The remaining prominent medial eminence medially was then resected with a sagittal saw. Reciprocating rasps were then used to smooth any sharp bony edges. The temporary fixation wires were then removed. The screws were again checked for tightness, which was noted. Attention was directed to the medial capsule where a medial capsulorrhaphy was performed. A straight stat was used to assist in removing a portion of the capsule. The capsule was then reapproximated with #2-0 Vicryl medially. Dorsal capsule was then reapproximated with #3-0 Vicryl in a running fashion. The subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular stitch with #5-0 Vicryl. The skin was then closed with #4-0 nylon in a horizontal mattress type fashion.,Attention was then directed to the left second toe. A dorsal linear incision was then created over the proximal phalangeal joint of the left second toe. The incision was deepened with a #15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally. An incision was made on either side of the extensor digitorum longus tendon. A curved mosquito stat was then used to reflex the tendon laterally. The joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx. A sagittal saw was then used to resect the head of the proximal head. The bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto. The extensor digitorum longus tendon was inspected and noted to be intact. Any sharp edges were then smoothed with reciprocating rasp. The area was then flushed with copious amounts of sterile saline. The skin was then reapproximated with #4-0 nylon. Dressings consisted of Owen silk, 4x4s, Kling, Kerlix, and Coban. Pneumatic ankle tourniquet was released and an 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 to the left foot. The patient is to follow up with Dr. X in his clinic as directed. orthopedic, hammertoe, osteotomy, internal screw fixation, scarf type, extensor digitorum, metatarsal osteotomy, foot, toe, metatarsal, bunionectomy, Orthopedic Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Akin bunionectomy, right toe with internal wire fixation. Bunionectomy & Osteotomy 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. orthopedic, hallux interphalangeus, osteotomy, bunionectomy, akin, wire fixation, screw fixation, painful bunion, metatarsophalangeal joint, pneumatic ankle, metatarsal head, foot, toe, sagittal, metatarsal Orthopedic Endoscopic release of left transverse carpal ligament. Steroid injection, stenosing tenosynovitis of right middle finger. Carpal Ligament Release - 2 PREOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome.,2. Stenosing tenosynovitis of right middle finger (trigger finger).,POSTOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome.,2. Stenosing tenosynovitis of right middle finger (trigger finger).,PROCEDURES:,1. Endoscopic release of left transverse carpal ligament.,2. Steroid injection, stenosing tenosynovitis of right middle finger.,ANESTHESIA: ,Monitored anesthesia care with regional anesthesia applied by surgeon.,TOURNIQUET TIME: , Left upper extremity was 15 minutes.,OPERATIVE PROCEDURE IN DETAIL:, With the patient under adequate monitored anesthesia, the left upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated. The tourniquet was elevated at 290 mmHg. Construction lines were made on the left palm to identify the ring ray. A transverse incision was made in the palm between FCR and FCU, one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin. Blunt dissection exposed the antebrachial fascia. Hemostasis was obtained with bipolar cautery. A distal based window in the antebrachial fascia was then fashioned. Care was taken to protect the underlying contents. A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.,Hamate sounds were then used to palpate the Hood of Hamate. The Agee Inside Job was then inserted into the proximal incision. The transverse carpal ligament was easily visualized through the portal. Using palmar pressure, transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end. The distal end of the transverse carpal ligament was then identified in the window. The blade was then elevated, and the Agee Inside Job was withdrawn, dividing transverse carpal ligament under direct vision. After complete division of transverse carpal ligament, the Agee Inside Job was reinserted. Radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished. One mL of Celestone was then introduced into the carpal tunnel and irrigated free. ,The wound was then closed with a running 3-0 Prolene subcuticular stitch. Steri-strips were applied and a sterile dressing was applied over the Steri-strips. The tourniquet was deflated. The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.,Attention was turned to the right palm where after a sterile prep, the right middle finger flexor sheath was injected with 0.5 mL of 1% plain Xylocaine and 0.5 mL of Depo-Medrol 40 mg/mL. A Band-Aid dressing was then applied.,The patient was then awakened from the anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well. orthopedic, carpal tunnel syndrome, agee inside job, steroid injection, antebrachial fascia, forearm, ring ray, synovial elevator, tenosynovitis, tourniquet, transverse incision, trigger finger, tenosynovitis of right middle, transverse carpal ligament, transverse carpal, carpal ligament, steri strips, stenosing tenosynovitis, middle finger, ligament, carpal, endoscopic, finger Orthopedic Bunion, left foot. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot. Bunionectomy & Akin Osteotomy 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. orthopedic, bunionectomy, akin osteotomy, internal wire fixation, internal screw fixation, osteotomy, metatarsal, metatarsal osteotomy, extensor digitorum, drill hole, osteotomy site, foot Orthopedic " Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint. Arthrodesis, right second, third, and fourth toes with external rod fixation. Hammertoe repair, right fifth toe. Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint. Modified Tailor's bunionectomy, right fifth metatarsal. " Bunionectomy & Arthrodesis 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. Orthopedic Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Proximal interphalangeal joint arthroplasty, bilateral fifth toes. Distal interphalangeal joint arthroplasty, bilateral third and fourth toes. Flexor tenotomy, bilateral third toes. Bunionectomy & Flexor Tenotomy PREOPERATIVE DIAGNOSES:,1. Hallux abductovalgus, right foot.,2. Hammertoe, bilateral third, fourth, and fifth toes.,POSTOPERATIVE DIAGNOSES:,1. Hallux abductovalgus, right foot.,2. Hammertoe, bilateral third, fourth, and fifth toes.,PROCEDURE PERFORMED:,1. Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2. Proximal interphalangeal joint arthroplasty, bilateral fifth toes.,3. Distal interphalangeal joint arthroplasty, bilateral third and fourth toes.,4. Flexor tenotomy, bilateral third toes.,HISTORY:, This is a 36-year-old female who presented to ABCD preoperative holding area after keeping herself n.p.o. since mid night for surgery on her painful bunion to her right foot and her painful hammertoes to both feet. The patient has a history of sharp pain, which is aggravated by wearing shoes and ambulation. She has tried multiple conservative methods and treatment such as wide shoes and accommodative padding, all of which provided inadequate relief. At this time, she desires attempted surgical correction. The risks versus benefits of the procedure have been discussed in detail by Dr. Kaczander with the patient and the consent is available on the chart.,PROCEDURE IN DETAIL:, 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 a safety strap placed across her waist for her protection.,Copious amounts of Webril were applied about both ankles and a pneumatic ankle tourniquet was applied over the Webril. After adequate IV sedation was administered, a total of 18 cc of a 0.5% Marcaine plain was used to anesthetize the right foot, performing a Mayo block and a bilateral third, fourth, and fifth digital block. Next, the foot was prepped and draped in the usual aseptic fashion bilaterally. The foot was elevated off the table and an Esmarch bandage was used to exsanguinate the right foot. The pneumatic ankle tourniquet was elevated on the right foot to 200 mmHg. The foot was lowered into operative field and the sterile stockinet was reflected proximally. Attention was directed to the right first metatarsophalangeal joint, it was found to be contracted and there was lateral deviation of the hallux. There was decreased range of motion of the first metatarsophalangeal joint. A dorsolinear incision was made with a #10 blade, approximately 4 cm in length. The incision was deepened to the subcutaneous layer with a #15 blade. Any small veins traversing the subcutaneous layer were ligated with electrocautery. Next, the medial and lateral wound margins were undermined sharply. Care was taken to avoid the medial neurovascular bundle and the lateral extensor hallucis longus tendon. Next, the first metatarsal joint capsule was identified. A #15 blade was used to make a linear capsular incision down to the bone. The capsular periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound. The PASA was found to be within normal limits. There was a hypertrophic medial eminence noted. A sagittal saw was used to remove the hypertrophic medial eminence. A 0.045 inch Kirschner wire was placed into the central medial aspect of the metatarsal head as an access guide. A standard lateral release was performed. The fibular sesamoid was found to be in the interspace, but was relocated onto the metatarsal head properly. Next, a sagittal saw was used to perform a long arm Austin osteotomy. The K-wire was removed. The capital fragment was shifted laterally and impacted into the head. A 0.045 inch Kirschner wire was used to temporarily fixate the osteotomy. A 2.7 x 16 mm Synthes, fully threaded cortical screw was throne using standard AO technique. A second screw was throne, which was a 2.0 x 12 mm Synthes cortical screw. Excellent fixation was achieved and the screws tightly perched the bone. Next, the medial overhanging wedge was removed with a sagittal saw. A reciprocating rasp was used to smooth all bony prominences. The 0.045 inch Kirschner wire was removed. The screws were checked again for tightness and found to be very tight. The joint was flushed with copious amounts of sterile saline. A #3-0 Vicryl was used to close the capsular periosteal tissues with simple interrupted suture technique. A #4-0 Vicryl was used to close the subcutaneous layer in a simple interrupted technique. A #5-0 Monocryl was used to close the skin in a running subcuticular fashion.,Attention was directed to the right third digit, which was found to be markedly contracted at the distal interphalangeal joint. A #15 blade was used to make two convergent semi-elliptical incisions over the distal interphalangeal joint. The incision was deepened with a #15 blade. The wedge of skin was removed in full thickness. The long extensor tendon was identified and the distal and proximal borders of the wound were undermined. The #15 blade was used to transect the long extensor tendon, which was reflected proximally. The distal interphalangeal joint was identified and the #15 blade was placed in the joint and the medial and lateral collateral ligaments were released. Crown and collar scissors were used to release the planar attachment to the head of the middle phalanx. Next, a double action bone cutter was used to resect the head of the middle phalanx. The toe was dorsiflexed and was found to have an excellent rectus position. A hand rasp was used to smooth all bony surfaces. The joint was flushed with copious amounts of sterile saline. The flexor tendon was found to be contracted, therefore, a flexor tenotomy was performed through the dorsal incision. Next, #3-0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures. A #4-0 nylon was used to close the skin and excellent cosmetic result was achieved.,Attention was directed to the fourth toe, which was found to be contracted at the distal interphalangeal joint and abducted and varus rotated. An oblique skin incision with two converging semi-elliptical incisions was created using #15 blade. The rest of the procedure was repeated exactly the same as the above paragraph to the third toe on the right foot. All the same suture materials were used. However, there was no flexor tenotomy performed on this toe, only on the third toe bilaterally.,Attention was directed to the fifth right digit, which was found to be contracted at the proximal interphalangeal joint. A linear incision approximately 2 cm in length was made with a #15 blade over the proximal interphalangeal joint. Next, a #15 blade was used to deepen the incision to the subcutaneous layer. The medial and lateral margins were undermined sharply to the level of the long extensor tendon. The proximal interphalangeal joint was identified and the tendon was transected with the #15 blade. The tendon was reflected proximally, off the head of the proximal phalanx. The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound. A double action bone nibbler was used to remove the head of the proximal phalanx. A hand rasp was used to smooth residual bone. The joint was flushed with copious amounts of saline. A #3-0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures. A #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress sutures.,A standard postoperative dressing consisting of saline-soaked #0-1 silk, 4 x 4s, Kerlix, Kling, and Coban were applied. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.,Attention was directed to the left foot. The foot was elevated off the table and exsanguinated with an Esmarch bandage and the pneumatic ankle tourniquet was elevated to 200 mmHg. Attention was directed to the left fifth toe, which was found to be contracted at the proximal interphalangeal joint. The exact same procedure, performed to the right fifth digit, was performed on this toe, with the same materials being used for suture and closure.,Attention was then directed to the left fourth digit, which was found to contracted and slightly abducted and varus rotated. The exact same procedure as performed to the right fourth toe was performed, consisting of two semi-elliptical skin incisions in an oblique angle. The same suture material were used to close the incision.,Attention was directed to the left third digit, which was found to be contracted at the distal interphalangeal joint. The same procedure performed on the right third digit was also performed. The same suture materials were used to close the wound and the flexor tenotomy was also performed at this digit. A standard postoperative dressing was also applied to the left foot consisting of the same materials as described for the right foot. The pneumatic 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 foot. She was given postoperative shoes and will be partial weighbearing with crutches. She was admitted short-stay to Dr. Kaczander for pain control. She was placed on Demerol 50 and Vistaril 25 mg IM q3-4h. p.r.n. for pain. She will have Vicodin 5/500 one to two p.o. q.4-6h. p.r.n. for moderate pain. She was placed on Subq. heparin and given incentive spirometry 10 times an hour. She will be discharged tomorrow. She is to ice and elevate both feet today and rest as much as possible.,Physical Therapy will teach her crutch training today. X-rays were taken in the postoperative area and revealed excellent position of the screws and correction of bunion deformity as well as the hammertoe deformities. orthopedic, hallux abductovalgus, hammertoe, bunionectomy, flexor, tenotomy, interphalangeal, arthroplasty, screw fixation, osteotomy, interphalangeal joint arthroplasty, distal interphalangeal joint, interphalangeal joint, flexor tenotomy, proximal interphalangeal, joint arthroplasty, distal interphalangeal, distal, blade, proximal, foot, joint, toes, tendon, Orthopedic Evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet - recurrent bunion deformity, right forefoot & pes planovalgus deformity, bilateral feet. Bunion & Pes Planovalgus Deformity HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old female being seen today for evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet, right greater than left. The patient states she is having increasing symptoms of pain and discomfort associated with recurrence of bunion deformity on the right foot and pain localized to the second toe and MTP joint of the right foot as well. The patient had prior surgery performed approximately 13 years ago. She states that since the time of the original surgery the deformity has slowly recurred, and she has noticed progressive deformity in the lesser toes at the second and third toes of the left foot and involving the second toe of the right foot. The patient is employed on her feet as a hospital employee and states that she does wear a functional orthotic which does provide some relief of forefoot pain although not complete.,PAST MEDICAL HISTORY, FAMILY HISTORY, SOCIAL HISTORY & REVIEW OF SYSTEMS:, See Patient History sheet, which was reviewed with the patient and is signed in the chart. Past medical history on the patient, past surgical history, current medications, drug-related allergies and social history have all been updated and reviewed, and enclosed in the chart.,PHYSICAL EXAMINATION: , Physical exam reveals a pleasant, 57-year-old female who is 5 feet 4 inches and 150 pounds. She has palpable pulses. Neurologic sensation is intact. Examination of the extremities shows the patient as having well-healed surgical sites from her arthroplasty, second digits bilaterally and prior bunionectomy. There is a recurrence of bunion deformity noted on both great toes although the patient notes to have reasonably good range of movement. She has particular pain in the second MTP joint of the right foot and demonstrates a mild claw-toe deformity of the second and third toes to the left foot, and to a lesser degree the second toe to the right. Gait analysis: The patient stands and walks with a rather severe pes planus and has generalized hypermobility noted in the feet.,X-RAY INTERPRETATION:, X-rays taken today; three views to the right foot shows presence of internal K-wire and wire from prior bunionectomy. Biomechanical analysis shows 15 degree intermetatarsal angle and approximately 45 degree hallux abducto valgus angle. No evidence of arthrosis in the joint is noted. Significant shift to the fibular sesamoid is present.,ASSESSMENT:,1. Recurrent bunion deformity, right forefoot.,2. Pes planovalgus deformity, bilateral feet.,PLAN/TREATMENT:,1. Today, we did review remaining treatment options with the patient including the feasibility of conservative versus surgical treatment. The patient would require an open wedge osteotomy to reduce the intermetatarsal angle with the lateral release and a decompression osteotomy at the second metatarsal. Anticipated length of healing was noted for the patient as were potential risks and complications. The patient ultimately would probably require surgery on her left foot at a later date as well.,2. The patient will explore her ability to get out of work for the above-mentioned period of time and will be in touch with regards regarding scheduling at a later date.,3. All questions were answered. orthopedic, x-rays, pain, mtp joint, pes planovalgus deformity, pes planovalgus, bunion deformity, planovalgus, forefoot, foot, deformity, bunionectomy, bunion Orthopedic Austin/akin bunionectomy, right foot. Bunion, right foot. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful. Bunionectomy - Austin - Akin PREOPERATIVE DIAGNOSIS:, Bunion, right foot.,POSTOPERATIVE DIAGNOSIS:, Bunion, right foot.,PROCEDURE PERFORMED:, Austin/akin bunionectomy, right foot.,HISTORY: , This 77-year-old African-American female presents to ABCD General Hospital with the above chief complaint. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful. The patient has attempted conservative treatment without long-term relief of symptoms and desires surgical treatment.,PROCEDURE DETAILS:, An IV was instituted by Department of Anesthesia in the preop holding area. The patient was transported to the operating room and placed on the operating table in the supine position with a safety strap across her lap. Copious amounts of Webril were placed around the right ankle followed by blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain was injected in a Mayo block type fashion. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated to the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was inflated to 250 mmHg. The foot was lowered to the operating field and the stockinet was reflected. The foot was cleansed with wet and dry sponge.,Attention was directed to the bunion deformity on the right foot. An approximately 6 cm dorsal medial incision was created over the first metatarsophalangeal joint. The incision was then deepened with a #15 blade. All vessels encountered were ligated with hemostasis. The skin and subcutaneous tissue were then undermined off of the capsule medially. A dorsal linear capsular incision was then created over the first metatarsophalangeal joint. The periosteum and capsule were then reflected off of the first metatarsal. There was noted to be a prominent medial eminence. The articular cartilage was healthy for patient's age and race. Attention was then directed to the first interspace where a lateral release was performed.. A combination of sharp and blunt dissection was carried out until the adductor tendon insertions were identified. The adductor tendons were transected as well as a lateral capsulotomy was performed. The extensor digitorum brevis tendon was identified and transected. Care was taken to preserve the extensor hallucis longus to make sure that tendon that was transected was the extensor hallucis brevis at the _______ digitorum. Extensor hallucis brevis tendon was transected and care was taken to preserve the extensor halucis longus tendon. Attention was then directed to medial eminence, which was resected with a sagittal saw. Sagittal was then used to create a long dorsal arm outside the Austin type osteotomy and the first metatarsal. The head of the first metatarsal was then translocated laterally until correction of the intermetatarsal angle was noted. The head was intact. A 0.45 K-wire was inserted through subcutaneously from proximal medial to distal lateral. A second K-wire was then inserted from distal lateral to proximal plantar medial. Adequate fixation was noted at the osteotomy site. The K-wires were bent, cut, and pin caps were placed. Attention was then directed to the proximal phalanx of the hallux. The capsular periostem was reflected off of the base of the proximal phalanx. A sagittal was then used to create an akin osteotomy closing wedge. The apex was lateral and the base of the wedge was medial. The wedge was removed in the total and the osteotomy site was then feathered until closure was achieved without compression. Two 0.45 K-wires were then inserted, one from distal medial to proximal lateral and the second from distal lateral to proximal medial across the osteotomy site. Adequate fixation was noted at the osteotomy site and the osteotomy was closed. The toe was noted to be in a markedly more rectus position. Sagittal saw was then used to resect the remaining prominent medial eminence. The area was then smoothed with a reciprocating rasp. There was noted to be a small osteophytic formation laterally over first metatarsal head that was removed with a rongeur and smoothed with a reciprocating rasp. The area was then inspected for any remaining short bony edges, none were noted.,Copious amounts of sterile saline was then used to flush the surgical site. The capsule was closed with #3-0 Vicryl. Subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular #5-0 Vicryl. Steri-Strips were applied and 1 cc of dexamethasone phosphate was injected into the surgical site.,Dressings consisted of #0-1 silk, copious Betadine, 4 x 4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the right foot. A _______ cast was then applied postoperatively. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported from the operating room to the PACU with vital signs stable and vascular status intact to the right foot. The patient was given postoperative pain prescription for Tylenol #3 and instructed to take one q4-6h. p.o. p.r.n. for pain. The patient is to follow up with Dr. X in his office as directed. orthopedic, austin/akin bunionectomy, hallucis brevis, bunion deformity, extensor hallucis, osteotomy site, foot, austin, bunionectomy Orthopedic A 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 pain is located laterally as well as anteriorly into the groin. Bilateral Hip Pain 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. orthopedic, bilateral hip pain, femoroacetabular, impingement, hip, Orthopedic Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain. Back Pain - Discharge Summary "CHIEF COMPLAINT: , Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 45-year-old white male who was admitted with acute back pain. The patient reports that he had chronic problem with back pain for approximately 20 years, but it has gotten progressively worse over the last 3 years. On 08/29/2007, the patient had awoken and started his day as he normally does, but midday, he reports that he was in such severe back pain and he was unable to walk or stand upright. He was seen at ABCD Hospital Emergency Room, was evaluated and admitted. He was treated with IV analgesics as well as Decadron, after being evaluated by Dr. A. It was decided that the patient could benefit from physical therapy, since he was unable to perform ADLs, and was transferred to TCU at St. Joseph Health Services on 08/30/2007. He had been transferred with diagnosis of a back pain secondary to intravertebral lumbar disk disease, secondary to degenerative changes. The patient reports that he has had a "" bulging disk"" for approximately 1 year. He reports that he has history of testicular cancer in the distant past and the most recent bone scan was negative. The bone scan was done at XYZ Hospital, ordered by Dr. B, the patient's oncologist.,ALLERGIES: , PENICILLIN, AMOXICILLIN, CEPHALOSPORIN, DOXYCYCLINE, IVP DYE, IODINE, and SULFA, all cause HIVES.,Additionally, the patient reports that he has HIVES when he comes in contact with SAP FROM THE MANGO TREE, and therefore, he avoids any mango product at all.,PAST MEDICAL HISTORY: , Status post right orchiectomy secondary to his testicular cancer 18 years ago approximately 1989, GERD, irritable bowel syndrome, seasonal asthma (fall and spring) triggered by postnasal drip, history of bilateral carpal tunnel syndrome, and status post excision of abdominal teratoma and incisional hernia.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY: , The patient is employed in the finance department. He is a nonsmoker. He does consume alcohol on the weekend as much as 3 to 4 alcoholic beverages per day on the weekends. He denies any IV drug use or abuse.,REVIEW OF SYSTEMS: , No chills, fever, shakes or tremors. Denies chest pain palpitations, hemoptysis, shortness of breath, nausea, vomiting, diarrhea, constipation or hematemesis. The patient reports that his last bowel movement was on 08/30/2007. No urological symptoms such as dysuria, frequency, incomplete bladder emptying or voiding difficulties. The patient does report that he has occasional intermittent ""numbness and tingling"" of his hands bilaterally as he has a history of bilateral carpal tunnel syndrome. He denies any history of seizure disorders, but he did report that he had some momentary dizziness earlier, but that has since resolved.,PHYSICAL EXAMINATION:,VITAL SIGNS: At the time of admission, temperature 98, blood pressure 176/97, pulse 86, respirations 20, and 95% O2 saturation on room air. The patient weighs 260 pounds and is 5 feet and 10 inches tall by his report.,GENERAL: The patient appears to be comfortable, in no acute distress.,HEENT: Normocephalic. Sclerae are nonicteric. EOMI. Tongue is at midline and no evidence of thrush.,NECK: Trachea is at the midline.,LYMPHATICS: No cervical or axillary nodes palpable.,LUNGS: Clear to auscultation bilaterally.,HEART: Regular rate and rhythm. Normal S1 and S2.,ABDOMEN: Obese, softly protuberant, and nontender.,EXTREMITIES: There is no clubbing, cyanosis or edema. There is no calf tenderness bilaterally. Bilateral strength is 5/5 for the upper extremities bilaterally and he has 5/5 of left lower extremity. The right lower extremity is 4-5/5.,MENTAL STATUS: He is alert and oriented. He was pleasant and cooperative during the examination.,ASSESSMENT:,1. Acute on chronic back pain. The patient is admitted to the TCU at St. Joseph Health Services for rehabilitation therapy. He will be seen in consultation by Physical Therapy and Occupational Therapy. He will continue a tapering dose of Decadron over the next 10 to 14 days and a tapering schedule has been provided, also Percocet 5/325 mg 1 to 2 tablets q.i.d. p.r.n. for pain.,2. Status post right orchiectomy secondary to testicular cancer, stable at this time. We will attempt to obtain copy of the most recent bone scan performed at XYZ Hospital ordered by Dr. B.,3. Gastroesophageal reflux disease, irritable bowel syndrome, and gastrointestinal prophylaxis. Colace 100 mg b.i.d., lactulose will be used on a p.r.n. basis, and Protonix 40 mg daily.,4. Deep vein thrombosis prophylaxis will be maintained by the patient, continue to engage in his therapies including ambulating in the halls and doing leg exercises as well.,5. Obesity. As mentioned above, the patient's weighs 260 pounds with a height of 5 feet and 10 inches, and we had discussed possible weight loss plan, which he is interested in pursuing and a dietary consult has been requested." Orthopedic " Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal. Excision of nerve lesion with implantation of the muscle belly of the left second interspace. Excision of nerve lesion in the left third interspace. " Bbunionectomy & Metatarsal Osteotomy PREOPERATIVE DIAGNOSIS: ,Tailor's bunion and neuroma of the second and third interspace of the left foot.,POSTOPERATIVE DIAGNOSIS:, Tailor's bunion and neuroma of the second and third interspace, left foot.,PROCEDURE PERFORMED:,1. Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal.,2. Excision of nerve lesion with implantation of the muscle belly of the left second interspace.,3. Excision of nerve lesion in the left third interspace.,ANESTHESIA: ,Monitored IV sedation with local.,HISTORY: ,This is a 37-year-old female who presents to ABCD's preoperative holding area, n.p.o. since mid night, last night for surgery of her painful left second and third interspaces and her left fifth metatarsal. The patient has attempted conservative correction and injections with minimal improvement. The patient desires surgical correction at this time. The patient states that her pain has been increasingly worsening with activity and with time and it is currently difficult for her to ambulate and wear shoes. At this time, the patient desires surgical intervention and correction. The risks versus benefits of the procedure have been explained to the patient in detail by Dr. X and consent was obtained.,PROCEDURE IN DETAIL: , After an IV was instituted by the Department of Anesthesia in the preoperative holding area, the patient was taken to the Operating Suite via cart and placed on the operating table in the supine position. A safety strap was placed across her waist for protection.,Next, a pneumatic ankle tourniquet was applied around her left ankle over copious amounts of Webril for the patient's protection. After adequate IV sedation was administered by the Department of Anesthesia, a total of 20 cc of a mixture of 4.5 cc of 1% lidocaine plain, 4.5 cc of 0.5% Marcaine plain, and 1 cc of Solu-Medrol per 10 cc dose was administered to the patient for local anesthesia. The foot was then prepped and draped in the usual sterile orthopedic manner. The foot was then elevated and a tourniquet was then placed at 230 mmHg after applying Esmarch bandage. The foot was then lowered down the operative field and sterile stockinet was draped. The stockinet was then reflected. Attention was then directed to the second intermetatarsal interspace. After testing the anesthesia, a 4 cm incision was placed using a #10 blade over the dorsal surface of the foot in the second intermetatarsal space beginning from proximal third of the metatarsals distally to and beyond the metatarsal head. Then, using #15 blade the incision was deepened through the skin into the subcutaneous tissue. Care was taken to identify and avoid or to cauterize any local encountered vascular structures. Incision was deepened using the combination of blunt and dull dissection using Mayo scissors, hemostat, and a #15 blade. The incision was deepened distally down to the level of the deep transverse metatarsal ligament which was reflected and exposure of the intermetatarsal space was appreciated. The individual branches of the plantar digital nerve were identified extending into the second and third digits plantarly. These endings were dissected distally and cut at their most distal portions. Following this, the nerve was dissected proximally into the common nerve and dissected proximally into the proximal portion of the intermetatarsal space. Using careful meticulous dissection, there was noted to a be a enlarged bulbous mass of fibers and nerve tissue embedded with the adipose tissue. This was also cut and removed. The proximal portion of the nerve stump was identified and care was taken to suture this into the lumbrical muscle to leave no free nerve ending exposed. Following this, the interspace was irrigated with copious amounts of sterile saline and interspace explored for any other portions of nerve which may been missed on the previous dissection. It was noted that no other portions of the nerve were detectable and the proximal free nerve ending was embedded and found to be ________ the lumbrical muscle belly. Following this, the interspace was packed using iodoform gauze packing and was closed in layers with the packing extruding from the wound. Attention was then directed to the third interspace where in a manner as mentioned before. A dorsal linear incision which measured 5 cm was made over the third interspace extending from the proximal portion of the metatarsal distally to the metatarsal head. Like before, using a combination of blunt and dull dissection, with sharp dissection the incision was deepened down with care taken to cauterize all retracting vascular structures which were encountered.,The incision was deepened down to the level of the subcutaneous tissue and then down deeper to the interspace of the third and fourth metatarsal. The dissection was deepened distally down to the level of the transverse intermetatarsal ligament, where upon this was reflected and the nerve fibers to the third and fourth digit plantarly were identified. These were once again dissected distally out and transected at their most distal portions. Care was then taken to dissect the nerve proximally into the proximal metatarsal region. No other branches of the nerve were identified and the nerve in its entirety along with fibrous tissue encountered in the area was removed. The proximal portion of the nerve which remained was not large enough to suture into lumbrical muscle as was done in the previous interspace. Half of the nerve was transected proximally as was feasible and no exposed ending was noted. Incision was then flushed and irrigated using sterile saline. Following this, the incision wound was packed with iodoform gauze packed and closed in layers using as before #4-0 Vicryl and #4-0 nylon suture.,Following this, attention was directed to the fifth metatarsal head where a lateral 4 cm incision was placed along the lateral distal shaft and head of the fifth metatarsal using a fresh #10 blade. The incision was then deepened using #15 blade down to the level of the subcutaneous tissue. Care was taken to reflect any neurovascular structures which were encountered. Following this the incision was deepened down to the level of the periosteum and periosteum was reflected, using the sharp dissection, to expose the head of the metatarsal along with the neck region. After adequate exposure of the fifth metatarsal head was achieved, an oblique incision directed from distal lateral to proximal medial in a sagittal plane was performed and the head of the fifth metatarsal was shifted medially. Following this, an OrthoSorb pin was retrograded through the fifth metatarsal head into the neck of the fifth metatarsal and was cut off first with the lateral surfaces of bone. OrthoSorb pin was noted to be intact and the fifth metatarsal head was in good alignment and position. Following this, the sagittal saw and the #138 blade were used to provide rasping and smoothing of the sharp acute edges of bone laterally. Following this, the periosteum was closed using #4-0 Vicryl and the skin was closed in layers using #4-0 Vicryl and closed with running subcuticular #4-0 Monocryl suture. Upon completion of this, the foot was noted to be in good position with good visual alignment of the fifth metatarsal head and digit. The incisions in foot were then ________ draped in the normal manner using Owen silk, 4 x 4s, Kling, and Kerlix and covered with Coban bandage. The tourniquet was then deflated with the total tourniquet time of 103 minutes at 230 mmHg and immediate hyperemia was noted to end digits one through five of the left foot.,The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact. The patient tolerated the procedure well without any complications. The patient was then given prescriptions for Vicoprofen #30 and Augmentin #14 to be taken twice daily. The patient was instructed to followup with Dr. X after the weekend on Tuesday in his office. The patient also given postoperative instructions and was placed in a postoperative shoe and instructed to limit weightbearing to the heel only, ice and elevate her foot 20 minutes every hour as tolerated. The patient also instructed to take her medications and prescriptions as directed. She was given the emergency contact numbers. Postoperative x-rays were taken and the patient was discharged home in stable condition upon conclusion of this. orthopedic, tailor's bunion, neuroma, nerve lesion, interspace, metatarsal, osteotomy, metatarsal osteotomy, metatarsal head, foot, distally, head, incision, nerve, intermetatarsal, portions, Orthopedic Back injury with RLE radicular symptoms. The patient is a 52-year-old male who is here for independent medical evaluation. Back Injury IME 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., orthopedic, rle, radicular symptoms, independent medical evaluation, injury, lle, deep tendon reflex, emg, mri, lumbar radicular symptomatology, Orthopedic Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy. Chronic pain syndrome. Back & Leg Pain - Discharge Summary 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 orthopedic, chronic pain syndrome, spinal instability, pars defects, radiculopathy, spondylolysis, leg Orthopedic Ruptured distal biceps tendon, right elbow. Repair of distal biceps tendon, right elbow. Biceps Tendon Repair 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. orthopedic, ruptured distal biceps tendon, gentamicin solution, antecubital fossa, distal biceps, biceps tendon, tendon, tuberosity, biceps, elbow, Orthopedic Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup. Displace subcapital fracture, left hip. Austin-Moore Bipolar Hemiarthroplasty PREOPERATIVE DIAGNOSIS:, Displace subcapital fracture, left hip.,POSTOPERATIVE DIAGNOSIS: , Displace subcapital fracture, left hip.,PROCEDURE PERFORMED: , Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup.,PROCEDURE: , The patient was taken to OR #2, administered a subarachnoid block anesthetic and was then positioned in the right lateral decubitus position on the beanbag on the operative table. The right lower extremity was protectively padded. The left leg was propped with multiple blankets. The hip was then prepped and draped in the usual manner. A posterior incision was made on the posterolateral aspect of the left hip down to the skin and subcutaneous tissues. Hemostasis was achieved utilizing electrocautery. Gluteus fascia was incised in line with a skin incision and the muscle was split posteriorly. The external rotators were identified after removal of the trochanteric bursa. Hemostat was utilized to separate the external rotators from the underlying capsule, they were then transected off from their attachment at the posterior intertrochanteric line. They were then reflected distally. The capsule was then opened in a T-fashion utilizing the cutting cautery. Fraction hematoma exuded from the hip joint. The cork screw was then impacted into the femoral head and it was removed from the acetabulum. Bone fragments were removed from the neck and acetabulum. The acetabulum was then inspected and noted to be free from debris. The proximal femur was then delivered into the wound with the hip internally rotated.,A mortise chisel was then utilized to take the cancellous bone from the proximal femur. The T-handle broach was then passed down the canal. The canal was then sequentially broached up to a medium broach. The calcar was then plained with the hand plainer. The trial components were positioned into place. The medium component fit fairly well with the medium 28 mm femoral head. Once the trial reduction was performed, the hip was taken through range of motion. There was physiologic crystalling with longitudinal traction. There was no tendency towards dislocation with flexion of the hip past 90 degrees. The trial implants were then removed. The acetabulum was then copiously irrigated with gentamicin solution and suctioned dry. The medium fenestrated femoral stem was prepared by placing a large segment of bone from the femoral head into the fenestration making it a little larger than the width of the implant to provide a press fit. The implant was then impacted into place. The 28 mm femoral head was impacted on the mortise stapler of the femoral stem followed by placement of the 50 mm bipolar cup. The acetabulum was once again inspected, was free of debris. The hip was reduced. It was taken through full range of motion. There was no tendency for dislocation. The wound was copiously irrigated with gentamicin solution. The capsule was then repaired with interrupted #1 Ethibond suture. External rotators were then reapproximated to the posterior intertrochanteric line utilizing #1 Ethibond in a modified Kessler type stitch. The wound was once again copiously irrigated with gentamicin solution and suctioned dry. Gluteus fascia was approximated with interrupted #1 Ethibond. Subcutaneous layers were approximated with interrupted #2-0 Vicryl and skin approximated with staples. A bulky dressing was applied to the wound. The patient was then transferred to the hospital bed, an abductor pillow was positioned into place. Circulatory status was intact to the extremity at completion of the case. orthopedic, austin moore, bipolar hemiarthroplasty, femoral head, femoral, hip, hemiarthroplasty, ethibond, acetabulum, Orthopedic Diagnostic arthroscopy exam under anesthesia, left shoulder. Debridement of chondral injury, left shoulder. Debridement, superior glenoid, left shoulder. Arthrotomy. Bankart lesion repair. Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures). Arthroscopy, Arthrotomy, Bankart lesion repair TITLE OF OPERATION:,1. Diagnostic arthroscopy exam under anesthesia, left shoulder.,2. Debridement of chondral injury, left shoulder.,3. Debridement, superior glenoid, left shoulder.,4. Arthrotomy.,5. Bankart lesion repair.,6. Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures).,INDICATION FOR SURGERY: , The patient was seen multiple times preoperatively and found to have chronic instability of her shoulder. Risks and benefits of the procedure had been discussed in length including but not exclusive of infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, continued instability, recurrent instability, medical complications, surgical complications, and anesthesia complications. The patient understood and wishes to proceed.,PREOP DIAGNOSIS: , Anterior instability, left shoulder.,POSTOP DIAGNOSES:,1. Anterior instability, left shoulder.,2. Grade 4 chondromalacia, 10% humeral head, chondral defect 1 cm squared, left shoulder.,3. Type 1 superior labrum anterior and posterior lesion, left shoulder.,4. Anteroinferior glenoid erosions 10% bony surface, left shoulder.,5. Bankart lesion, left shoulder.,PROCEDURE: , The patient was placed in a supine position and both shoulders examined systematically. She had full range of motion with no joint adhesions. She had equal range of motion bilaterally. She had Hawkins 2 anteriorly and posteriorly in both shoulders with a grade 1 sulcus sign in both shoulders. This was the same when the arm was in neutral or in external rotation. The patient was then turned to right lateral decubitus position, axillary roll was placed, and beanbag was inflated. Peroneal nerve was well protected. All bony prominences were well protected.,The left upper extremity was then prepped and draped in the usual sterile fashion. The patient was given antibiotics well before the start of the procedure to decrease the risk of infection. The arm was placed in a arm holder with 10 pounds of traction. A posterior portal was created in the usual manner by isolating gently with the spinal needle, it was insufflated with 30 cubic centimeters of saline. A small incision was made after infiltrating the skin with Marcaine and epinephrine. The scope was introduced into the shoulder with no difficulty. It was then examined systematically. The patient did have diffuse synovitis throughout her shoulder. Her posterior humeral head showed an enlarged bold spot with some other areas of chondromalacia on the posterior head. She also had an area 1 cm in diameter, which was on more central portion of the head and more inferiorly which appeared to be more of an impaction-type injury. This had some portions of fibrillated and loose cartilage, hanging from the edges. These were later debrided, but the dissection was proximally 10 to 15% of the humeral surface.,The biceps tendon appeared to be normal. The supraspinatus, infraspinatus tendons were normal. The inferior pouch was normal with no capsular tearing and no HAGL lesions. The posteroinferior labrum was normal as well as the posterosuperior labrum. There was some fraying in the posterosuperior labrum, which was later debrided. It was found essentially to be a type 1 lesion anteriorly and superiorly. The anterosuperior labrum appeared to be detached, which appeared to be more consistent with a sublabral hole. The middle glenohumeral ligament was present as an entire sheath, but attach to the labrum. The labrum did appeared to be detached from the anterior glenoid from the 11 o'clock position all the way down to the 6 o'clock position. The biceps anchor itself was later probed and found to be stable and normal. The subscapularis tendon was normal. The anterior band of the glenohumeral ligament was present, but it was clearly avulsed off the glenoid. There was some suggestion of anteroinferior bony erosions, which was later substantiated when the shoulder was opened. The patient was missing about 10 to 15% of her anteroinferior glenoid rim. The patient had a positive drive-through sign.,The arm was then moved to lateral and placed through range of motion. There was contact of the rotator cuff to the superior glenoid in flexion at 115 degrees, maximum flexion was 150 degrees. The arm abducted and externally rotated. There was contact to the rotator cuff with posterosuperior labrum. This occurred with the arm position of 90 degrees with abduction at 55 degrees of external rotation. It should be noted that the maximum abduction is 150 degrees and with the arm abducted 90 degrees, maximum external rotation was 95 degrees. The patient did have a positive relocation maneuver. The posterior labrum did appear to tilt-off, but did not appear to peel off.,The arm was then placed back in the arm holder. Anterior portal was created with Wissinger rod. A blue cannula was inserted into the shoulder without difficulty. Shaver was introduced in the labrum. Also the area of chondromalacia as mentioned above was debrided. The labrum was found to be stable with only a type 1 SLAP lesion, and there was no evidence as there was really a type 2 SLAP lesion. The instruments were then removed along with excess fluid. The posterior portals were closed with single 4-0 nylon suture. The anterior portal was left open. The patient was then placed in a supine position, and the extremity was reprepped and draped in anticipation of performing open capsular shift.,The patient's anterior incision made just lateral to the coracoid in the skin line. Mediolateral skin flaps were developed, and cephalic vein was identified and protected throughout the case. The interval was developed down the clavipectoral fascia. The conjoined tendon was retracted medially and the deltoid laterally. The patient's subscapularis was intact, and the subscapularis split was then made between the upper one half and lower one half in line with muscle fibers. The capsule could easily be detached from the muscle, and the interval developed very easily. A retractor was placed inferiorly to protect the axillary nerve. Then Gelpi retractor was used to hold the subscapularis split open.,Next, an arthrotomy was made down at the 9 o'clock position. The labrum was identified and found to be attached all the way down to 6 o'clock position. The inferior flap was then created in a usual manner and tied with a 0 Vicryl suture. The patient's glenoid rim did have some erosion as mentioned above with some bone loss and flattening. This was debrided with the soft tissue. Three Mitek suture anchors were then placed into the glenoid rim right at the margin of articular cartilage to the scapular neck. These were absorbable anchors with nonabsorbable sutures. They had excellent fixation once they had been placed.,Next, the capsular shift and Bankart repair were performed in the usual manner with the number 2 Ti-Cron sutures as an outside in and then inside out technique. This brought the capsule right up to the edge of the glenoid rim. With the arm in internal rotation and posterior pressure on the head, the capsule was then secured to the rim with no difficulty under direct visualization. The capsule did come right up into the joint as expected with this type of repair. The superior flap was then closed, the inferior flap over the superior anchor. The interval between two flaps was closed with multiple number 2 Ti-Cron sutures. Once this has been completed, there was no tension on the repair with the arm to side until 10 degrees of external rotation was reached. The arm abducted 90 degrees. There was tension on the repair until 20 degrees of external rotation reached.,The wound was thoroughly irrigated throughout with antibiotic-impregnated irrigation. The subscapularis split was closed with interrupted 0 Vicryl sutures. The deep subcutaneous tissues were closed with interrupted 0 Vicryl sutures. The superficial subcutaneous tissues were closed with number 2-0 Vicryl sutures. The skin was closed with 4-0 subcuticular Prolene, reinforced with Steri-Strips. A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer. The patient was sent to the recovery room in stable and satisfactory condition. orthopedic, diagnostic arthroscopy, chondral injury, debridement, superior glenoid, arthrotomy, bankart lesion, capsular shift, mitek suture, absorbable anchors, anterior instability, chondromalacia, superior labrum, glenoid erosion, glenoid rim, external rotation, glenoid, labrum, shoulder, arthroscopy, Orthopedic Austin bunionectomy with internal screw fixation, first metatarsal, left foot. Austin Bunionectomy 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. orthopedic, internal screw fixation, first metatarsal, bunion deformity, osteomed, screw fixation system, subcutaneous tissues, metatarsal head, austin bunionectomy, screw fixation, ankle tourniquet, metatarsophalangeal joint, austin, tourniquet, metatarsophalangeal, bunionectomy, foot, metatarsal, Orthopedic Hemarthrosis, left knee, status post total knee replacement, rule out infection. Arthrotomy, irrigation and debridement, and polyethylene exchange, left knee. No complications were encountered throughout the procedure. Arthrotomy & I&D PREOPERATIVE DIAGNOSIS: , Hemarthrosis, left knee, status post total knee replacement, rule out infection.,POSTOPERATIVE DIAGNOSIS: , Hemarthrosis, left knee, status post total knee replacement, rule out infection.,OPERATIONS:,1. Arthrotomy, left total knee.,2. Irrigation and debridement, left knee.,3. Polyethylene exchange, left knee.,COMPLICATION: , None.,TOURNIQUET TIME: ,58 minutes.,ESTIMATED BLOOD LOSS: , Minimal.,ANESTHESIA: ,General.,INDICATIONS: ,This patient underwent an uncomplicated left total knee replacement. Postoperatively, unfortunately did not follow up with PT/INR blood test and he was taking Coumadin. His INR was seemed to elevated and developed hemarthrosis. Initially, it did look very benign, although over the last 24 hours it did become irritable and inflamed, and he therefore was indicated with the above-noted procedure.,This procedure as well as alternatives was discussed in length with the patient and he 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 with range of motion, risk of continued discomfort, risk of need for further reconstructive procedures, risk of need for total knee revision, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed. He understood them well. All questions were answered and he signed consent for the procedure as described.,DESCRIPTION OF PROCEDURE: , The patient was placed on operating table and general anesthesia was achieved. The left lower extremity was then prepped and draped in the usual sterile manner. The leg was elevated and the tourniquet was inflated to 325 mmHg. A longitudinal incision was then made and carried down through subcutaneous tissues. This was made through the prior incision site. There were some fatty necrotic tissues through the incision region and all necrotic tissue was debrided sharply on both sides of the incision site. Medial and lateral flaps were then made. The prior suture was identified, the suture removed and then a medial parapatellar arthrotomy was then performed. Effusion within the knee was noted. All hematoma was evacuated. I then did flex the knee and removed the polyethylene. Once the polyethylene was removed I did irrigate the knee with total of 9 liters of antibiotic solution. Further debridement was performed of all inflamed tissue and thickened synovial tissue. A 6 x 16-mm Stryker polyethylene was then snapped back in position. The knee has excellent stability in all planes and I did perform a light manipulation to improve the flexion of the knee. Further irrigation was performed on the all soft tissue in the knee with additional 3 liters of normal saline. The knee was placed in a flexed position and the extensor mechanism was reapproximated using #2 Ethibond suture in a figure-of-eight manner. The subcutaneous tissue was reapproximated in layers using #1 and 2-0 Vicryl sutures, and the skin was reapproximated using staples. Prior to closure a Hemovac drain was inserted through a superolateral approach into the knee joint.,No complications were encountered throughout the procedure, and the patient tolerated the procedure well. The patient was taken to recovery room in stable condition. orthopedic, Orthopedic Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee. Soft tissue mass and osteophyte lateral femoral condyle, right knee. Arthrotomy & Ostectomy & Capsular Mass Excision PREOPERATIVE DIAGNOSIS:, Soft tissue mass, right knee.,POSTOPERATIVE DIAGNOSES:,1. Soft tissue mass, right knee.,2. Osteophyte lateral femoral condyle, right knee.,PROCEDURES PERFORMED:, Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee.,SPECIFICATION: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital. This was done under a local and IV sedation via the Anesthesia Department.,HISTORY AND GROSS FINDINGS:, This is a 37-year-old African-American male with a mass present at the posterolateral aspect of his right knee. On aspiration, it was originally attempted to no avail. There was a long-standing history of this including two different MRIs, one about a year ago and one very recently both of which did not delineate the mass present. During aspiration previously, the patient had experienced neuritic type symptoms down his calf, which have mostly resolved by the time that this had occurred. The patient continued to complain of pain and dysfunction to his calf. This was discussed with him at length. He wished this to be explored and the mass excised even though knowing the possibility that they would not change his pain pattern with the potential of reoccurrence as well as the potential of scar stiffness, swelling, and peroneal nerve palsy. With this, he decided to proceed.,Upon observation preoperatively, the patient was noted to have a hard mass present to the posterolateral aspect of the right knee. It was noted to be tender. It was marked preoperatively prior to an anesthetic. Upon dissection, the patient was noted to have significant thickening of the posterior capsule. The posterolateral aspect of the knee above the posterolateral complex at the gastroc attachment to the lateral femoral condyle. There was also noted to be prominence of the lateral femoral condyle ridge. The bifurcation at the tibial and peroneal nerves were identified and no neuroma was present.,OPERATIVE PROCEDURE: ,The patient was laid supine upon the operating table. After receiving IV sedation, he was placed prone. Thigh tourniquet was placed. He was prepped and draped in the usual sterile manner. A transverse incision was carried down across the crease with a mass had been palpated through skin and subcutaneous tissue after exsanguination of the limb and tourniquet utilized. The nerve was identified and carefully retracted throughout the case. Both nerves were identified and carefully retracted throughout the case. There was noted to be no neuroma present. This was taken down until the gastroc was split. There was gross thickening of the joint capsule and after arthrotomy, a section of the capsule was excised. The lateral femoral condyle was then osteophied. We then smoothed off with a rongeur. After this, we could not palpate any mass whatsoever placing pressure upon the area of the nerve. Tourniquet was deflated. It was checked again. There was no excessive swelling. Swanson drain was placed to the depth of the wound and interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and #4-0 nylon was utilized for skin closure. Adaptic, 4x4s, ABDs, and Webril were placed for compression dressing. Digits were warm _______ pulses distally at the end of the case. The tourniquet as stated has been deflated prior to closure and hemostasis was controlled. Expected surgical prognosis on this patient is guarded. orthopedic, soft tissue mass, osteophyte, lateral femoral condyle, excision, capsular mass, arthrotomy, ostectomy, knee, soft tissue, femoral condyle, mass, subcutaneous, capsular, tourniquet, femoral, condyle, Orthopedic Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint. Weil osteotomy with internal screw fixation, first right metatarsal. Arthroplasty, second right PIP joint. Austin-Akin Bunionectomy 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. orthopedic, austin-akin bunionectomy, weil osteotomy, internal screw fixation, first right metatarsal, metatarsophalangeal joint, hammertoe deformity, extensor digitorum longus, austin akin bunionectomy, threaded cannulated screw, semi elliptical incisions, ankle tourniquet, surgical neck, cannulated screws, pip joint, proximal phalanx, fixation, metatarsophalangeal, proximal, screw, metatarsal, osteotomy, austin, joint, tourniquet, osteomed, phalanx, incision, Orthopedic Erythema of the right knee and leg, possible septic knee. Aspiration through the anterolateral portal of knee joint. Aspiration - Knee Joint PREOPERATIVE DIAGNOSES: , Erythema of the right knee and leg, possible septic knee.,POSTOPERATIVE DIAGNOSES:, Erythema of the right knee superficial and leg, right septic knee ruled out.,INDICATIONS: , Mr. ABC is a 52-year-old male who has had approximately eight days of erythema over his knee. He has been to multiple institutions as an outpatient for this complaint. He has had what appears to be prepatellar bursa aspirated with little to no success. He has been treated with Kefzol and 1 g of Rocephin one point. He also reports, in the emergency department today, an attempt was made to aspirate his actual knee joint which was unsuccessful. Orthopedic Surgery was consulted at this time. Considering the patient's physical exam, there is a portal that would prove to be outside of the erythema that would be useful for aspiration of the knee. After discussion of risks and benefits, the patient elected to proceed with aspiration through the anterolateral portal of his knee joint.,PROCEDURE: ,The patient's right anterolateral knee area was prepped with Betadine times two and a 20-gauge spinal needle was used to approach the knee joint approximately 3 cm anterior and 2 cm lateral to the superolateral pole of the patella. The 20-gauge spinal needle was inserted and entered the knee joint. Approximately, 4 cc of clear yellow fluid was aspirated. The patient tolerated the procedure well.,DISPOSITION: , Based upon the appearance of this synovial fluid, we have a very low clinical suspicion of a septic joint. We will send this fluid to the lab for cell count, crystal exam, as well as culture and Gram stain. We will follow these results. After discussion with the emergency department staff, it appears that they tend to try to treat his erythema which appears to be cellulitis with IV antibiotics. orthopedic, knee and leg, anterolateral portal, emergency department, spinal needle, septic knee, knee joint, knee, emergency, department, gauge, spinal, needle, aspiration, anterolateral, portal, aspirated, fluid, septic, erythema, joint, aspiraion, Orthopedic Arthroscopy of the left knee, left arthroscopic medial meniscoplasty of medial femoral condyle, and chondroplasty of the left knee as well. Chondromalacia of medial femoral condyle. Medial meniscal tear, left knee. Arthroscopy, Meniscoplasty, & Chondroplasty 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. orthopedic, medial meniscoplasty, arthroscopic, chondroplasty, arthroscopy, medial femoral condyle, medial meniscus, knee, meniscal, cartilage, meniscoplasty, meniscus, chondromalacia, condyle, femoral Orthopedic Arthrotomy, removal humeral head implant, right shoulder. Repair of torn subscapularis tendon (rotator cuff tendon) acute tear. Debridement glenohumeral joint. Biopsy and culturing the right shoulder. Arthrotomy & Subscapularis Tendon Repair TITLE OF OPERATION: ,1. Arthrotomy, removal humeral head implant, right shoulder.,2. Repair of torn subscapularis tendon (rotator cuff tendon) acute tear.,3. Debridement glenohumeral joint.,4. Biopsy and culturing the right shoulder.,INDICATION FOR SURGERY: , The patient had done well after a previous total shoulder arthroplasty performed by Dr. X. However, the patient was lifted with subsequent significant pain and apparent tearing of his subscapularis. Risks and benefits of the procedure had been discussed with the patient at length including, but not exclusive of infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, continued instability, retearing of the tendon, need for revision of his arthroplasty, permanent nerve or artery damage, etc. The patient understood and wished to proceed.,PREOP DIAGNOSIS: ,1. Torn subscapularis tendon, right shoulder.,2. Right total shoulder arthroplasty (Biomet system).,POSTOP DIAGNOSIS: ,1. Torn subscapularis tendon, right shoulder.,2. Right total shoulder arthroplasty (Biomet system).,3. Diffuse synovitis, right shoulder.,PROCEDURE: , The patient was anesthetized in the supine position. A Foley catheter was placed in his bladder. He was then placed in a beach chair position. He was brought to the side of the table and the torso secured with towels and tape. His head was then placed in the neutral position with no lateral bending or extension. It was secured with paper tape over his forehead. Care was taken to stay off his auricular cartilages and his orbits. Right upper extremity was then prepped and draped in the usual sterile fashion. The patient was given antibiotics well before the beginning of the procedure to decrease any risk of infection. Once he had been prepped and draped with the standard prep, he was prepped a second time with a chlorhexidine-type skin prep. This was allowed to dry and the skin was then covered with Ioban bandages also to decrease his risk of infection.,Also, preoperatively, the patient had his pacemaker defibrillator function turned off as a result during this case. Bipolar type cautery had to be used as opposed to monopolar cautery.,The patient's deltopectoral incision was then opened and extended proximally and distally. The patient had significant amount of scar already in this interval. Once we got down to the deltoid and pectoralis muscle, there was no apparent cephalic vein present, as a result the rotator cuff interval had to be developed through an area of scar. This created a significant amount of bleeding. As a result a very slow and meticulous dissection was performed to isolate his coracoid and then his proximal humerus. Care was taken to stay above the pectoralis minor and the conjoint tendon. The deltoid had already started to scar down the proximal humerus as a result a very significant amount of dissection had to be performed to release the deltoid from proximal humerus. Similarly, the deltoid insertion had to be released approximately 50% of its width to allow us enough mobility of the proximal humerus to be able to visualize the joint or the component. It was clear that the patient had an avulsion of the subscapularis tendon as the tissue on the anterior aspect of the shoulder was very thin. The muscle component of the subscapularis could be located approximately 1 cm off the glenoid rim and approximately 3 cm off the lesser tuberosity. The soft tissue in this area was significantly scarred down to the conjoint tendon, which had to be very meticulously released. The brachial plexus was identified as was the axillary nerve. Once this was completed, an arthrotomy was then made leaving some tissue attached to the lesser tuberosity in case it was needed for closure later. This revealed sanguineous fluid inside the joint. We did not feel it was infected based upon the fluid that came from the joint. The sutures for the subscapularis repair were still located in the proximal humerus with no tearing through the bone, which was fortunate because in that we could use the bone later for securing the sutures. The remaining sutures were seen to be retracted medially to an area of the subscapularis as mentioned previously. Some more capsule had to be released off the inferior neck in order for us to gain exposure during the scarring. This was done also very meticulously. The upper one half of the latissimus dorsi tendon was also released. Once this was completed, the humerus could be subluxed enough laterally that we could remove the head. This was done with no difficulty. Fortunately, the humeral component stayed intact. There were some exudates beneath the humeral head, which were somewhat mucinous. However, these do not really appear to be infected, however, we sent them to pathology for a frozen section. This frozen section later returned as possible purulent material. I discussed this personally with the pathologist at that point. We told him that the procedure is only 3 weeks old, but he was concerned that there might be more white blood cells in the tissue than he would expect. As a result, all the mucinous exudates were carefully removed. We also performed a fairly extensive synovectomy of the joint primarily to gain vision of the components, but also we irrigated the joint throughout the case with antibiotic impregnated irrigation. At that point, we also had sent portions of this mucinous material to pathology for a stat Gram stain. This came back as no organisms seen. We also sent portions for culture and sensitivity both aerobic and anaerobic.,Once this was completed, attention was then directed to the glenoid. The patient had significant amount of scar already. The subscapularis itself was significantly scarred down to the anterior rim. As a result, the adhesions along the anterior edge were released using a knife. Also adhesions in the subcoracoid space area were released very carefully and meticulously to prevent any injury to the brachial plexus. Two long retractors were placed medially to protect the brachial plexus during all portions of suturing of the subscapularis. The subscapularis was then tagged with multiple number 2 Tycron sutures. Adhesions were released circumferentially and it was found that with the arm in internal rotation about neutral degrees, the subscapularis could reach the calcar region without tension. As a result, seven number 2 Tycron sutures were placed from the bicipital groove all the way down to the inferior calcar region of the humerus. These all had excellent security in bone. Once the joint had been debrided and irrigated, the real humeral head was then placed back on the proximal humerus. Care was taken to remove fluid off the Morse taper. The head was then impacted. It should be noted that we tried multiple head sizes to see if a smaller or larger head size might be more appropriate for this patient. Unfortunately, any of the larger head sizes would overstep the joint and any smaller sizes would not give good coverage to the proximal humerus. As a result, it was felt to place the offset head back on the humerus, we did insert a new component as opposed to using the old component. The old component was given to the family postoperatively.,With the arm in internal rotation, the Tycron sutures were then placed through the subscapularis tendon in the usual horizontal mattress fashion. Also, it should be noted that the rotator cuff interval had to be released as part of the exposure. We started the repair by closing the rotator cuff interval. Anterior and posterior translation was then performed and was found to be very stable. The remaining sutures were then secured through the subscapularis tendon taking care to make sure that very substantial bites were obtained. This was then reinforced with the more flimsy tissue laterally being sewn into the tissue around the bicipital tuberosity essentially provided us with a two-layer repair of the subscapularis tendon. After the tendon had been repaired, there was no tension on repair until 0 degrees external rotation was reached with the arm to the side. Similarly with the arm abducted 90 degrees, tension was on repair at 0 degrees of external rotation. It should be noted that the wound was thoroughly irrigated throughout with antibiotic impregnated irrigation. The rotator cuff interval was closed with multiple number 2 Tycron sutures. It was reinforced with 0 Vicryl sutures. Two Hemovac drains were then placed inferiorly at the deltoid. The deltopectoral interval was then closed with 0 Vicryl sutures. A third drain was placed in the subcutaneous tissues to prevent any infections or any fluid collections. This was sewn into place with the drain pulled out superiorly. Once all the sutures have been secured and the drain visualized throughout this part of the closure, the drain was pulled distally until it was completely covered. There were no signs that it had been tagged or hung up by any sutures.,The superficial subcutaneous tissues were closed with interrupted with 2-0 Vicryl sutures. Skin was closed with staples. A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer. The patient was sent to the intensive care unit in stable and satisfactory condition.,Due to the significant amount of scar and bleeding in this patient, a 22 modifier is being requested for this case. This was a very difficult revision case and was significantly increased in technical challenges and challenges in the dissection and exposure of this implant compared to a standard shoulder replacement. Similarly, the repair of the subscapularis tendon presented significantly more challenges than that of a standard rotator cuff repair because of the implant. This was being dictated for insurance purposes only and reflects no inherent difficulties with this case. The complexity and the time involved in this case was approximately 30% greater than that of a standard shoulder replacement or of a rotator cuff repair. This is being dictated to indicate this was a revision case with significant amount of scar and bleeding due to the patient's situation with his pacemaker. This patient also had multiple medical concerns, which increased the complexity of this case including the necessity to place him in intensive care unit postoperatively for observation. orthopedic, arthrotomy, repair of torn subscapularis tendon, glenohumeral joint, biomet system, arthroplasty, diffuse synovitis, proximal humerus, torn subscapularis tendon, subscapularis tendon, rotator cuff, humerus, sutures, tendon, head, shoulder, subscapularis, torn, Orthopedic Partial rotator cuff tear, left shoulder. Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder. Arthroscopy - Shoulder PREOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,POSTOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,PROCEDURE PERFORMED:, Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.,ANESTHESIA: ,Scalene block with general anesthesia.,ESTIMATED BLOOD LOSS: , 30 cc.,COMPLICATIONS: , None.,DISPOSITION: ,The patient went to the PACU stable.,GROSS OPERATIVE FINDINGS: , There was no overt pathology of the biceps tendon. There was some softening and loss of the articular cartilage over the glenoid. The labrum was ________ attached permanently to the glenoid. The biceps tendon was nonsubluxable. Upon ranging of the shoulder in internal and external rotation showed no evidence of rotator cuff tear on the articular side. Subacromial space did show excessive soft tissue causing some overstuffing of the subacromial space. There was reconstitution of the bursa noted as well.,HISTORY OF PRESENT ILLNESS:, This is a 51-year-old female had left shoulder pain of chronic nature who has had undergone prior rotator cuff debridement in May with partial pain relief and has had continued pain in the left shoulder. MRI shows partial rotator cuff tear.,PROCEDURE: , The patient was taken to the operating room and placed in a beachchair position. After all bony prominences were adequately padded, the head was placed in the headholder with no excessive extension in the neck on flexion. The left extremity was prepped and draped in usual fashion. The #18 gauge needles were inserted into the left shoulder to locate the AC joint, the lateral aspect of the acromion as well as the pass of the first trocar to enter the shoulder joint from the posterior aspect. We took an #11 blade scalpel and made a small 1-cm skin incision posteriorly approximately 4-cm inferior and medial to the lateral port of the acromion. A blunt trocar was used to bluntly cannulate the joint and we put the camera into the shoulder at that point of the joint and instilled sterile saline to distend the capsule and begin our arthroscopic assessment of the shoulder. A second port was established superior to the biceps tendon anteriorly under direct arthroscopic visualization using #11 blade on the skin and inserted bluntly the trocar and the cannula. The operative findings found intra-articularly were as described previously gross operative findings. We did not see any evidence of acute pathology. We then removed all the arthroscopic instruments as well as the trocars and tunneled subcutaneously into the subacromial space and reestablished the portal and camera and inflow with saline. The subacromial space was examined and found to have excessive soft tissue and bursa that was in the subacromial space that we debrided using arthroscopic shaver after establishing a lateral portal. All this was done and hemostasis was achieved. The rotator cuff was examined from the bursal side and showed no evidence of tears. There was some fraying out laterally near its attachment over the greater tuberosity, which was debrided with the arthroscopic shaver. We removed all of our instruments and suctioned the subacromial space dry. A #4-0 nylon was used on the three arthroscopic portal and on the skin we placed sterile dressing and the arm was placed in an arm sling. She was placed back on the gurney, extubated and taken to the PACU in stable condition. orthopedic, subacromial space, arthroscopic, biceps tendon, labrum, glenoid, cartilage, partial rotator cuff tear, rotator cuff tear, shoulder arthroscopy, rotator cuff, arthroscopy, shoulder, tissue, subacromial, rotator, cuff, Orthopedic Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection, carpal tunnel release, left knee arthroscopy, and partial medial and lateral meniscectomy. Arthroscopy Shoulder/Knee 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. Orthopedic Arthroscopy of the arthroscopic glenoid labrum, rotator cuff debridement shaving glenoid and humeral head, and biceps tenotomy, right shoulder. Massive rotator cuff tear, right shoulder, near complete biceps tendon tear of right shoulder, chondromalacia of glenohumeral joint or right shoulder, and glenoid labrum tear of right shoulder. Arthroscopy - Glenoid Labrum PREOPERATIVE DIAGNOSIS:, Rotator cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSES:,1. Massive rotator cuff tear, right shoulder.,2. Near complete biceps tendon tear, right shoulder.,3. Chondromalacia of glenohumeral joint, right shoulder.,4. Glenoid labrum tear, right shoulder.,PROCEDURE PERFORMED: ,1. Arthroscopy of the arthroscopic glenoid labrum.,2. Rotator cuff debridement shaving glenoid and humeral head.,3. Biceps tenotomy, right shoulder.,SPECIFICATION: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital. This was done under interscalene block anesthetic in the modified beachchair position.,HISTORY AND GROSS FINDINGS: , This is a 61-year-old white male who is dominantly right-handed. He had increasing right shoulder pain and dysfunction for a number of years prior to surgical intervention. This was gradually done over a period of time. No specific accident or injury could be seen or pointed. He was refractory to conservative outpatient therapy. After discussing alternatives of the care as well as the advantages, disadvantages, risks, complications, and expectations, he elected to undergo the above-stated procedure on this date.,Preoperatively, the patient did not have limitation of motion. He had gross weakness to his supraspinatus, mildly to the infraspinatus and subscapularis upon strength testing prior to his anesthetic.,Intraarticularly, the patient had an 80% biceps tendon tear that was dislocated. His rotator interval was resolved as well as his subscapularis with tearing. The supraspinatus was completely torn, retracted back beyond the level of the labrum and approximately one-third or so of the infraspinatus was involved with the remaining portion being greatly thinned as far as we could observe. Glenoid labrum had degenerative tear in the inferior surface. Gross chondromalacia was present to approximately 50% of the humeral head and approximately the upper 40% of the glenoid surface.,OPERATIVE PROCEDURE: , The patient was laid supine upon the operative table. After receiving interscalene block anesthetic by the Anesthesia Department, he was safely placed in a modified beachchair position. He was prepped and draped in the usual sterile manner. The portals were created outside the end posteriorly and then anteriorly. A full and complete diagnostic arthroscopy was carried out with the above-noted findings. The shaver was placed anteriorly. Debridement was carried out to the glenoid labrum tear and the last 20% of the biceps tendon tear was completed. Debridement was carried out to the end or attachment of the bicep itself.,Debridement was carried out to what could be seen of the remaining rotator cuff there, but then the scope was redirected in a subacromial direction and gross bursectomy carried out. Debridement was then carried out to the rotator cuff remaining tendon near the tuberosity. No osteophytes were present. Because of the massive nature of the tear, the CA ligament was maintained and there were no substantial changes to the subacromial region to necessitate burring. There was concern because of instability that could be present at the end of this.,Another portal was created laterally to do all of this. We did what we could to mobilize all sections of the rotator cuff, superiorly, posteriorly, and anteriorly. We took this back to the level of coracoid base. We released the coracohumeral ligament basically all but there was no excursion basically all to the portion of the rotator cuff torn. Because of this, further debridement was carried out. Debridement had been previously carried out to the humeral head as well as glenoid surface to debride the chondromalacia and take this down to the smooth edge. Care was taken to not to debride deeper than that. This was done prior to the above.,All instrumentation was removed. A Pain-Buster catheter was placed into a separate anterolateral portal cut to length. Interrupted #4-0 nylon was utilized for portal closures. Adaptic, 4x4s, ABDs, Elastoplast tape were placed for a compression dressing.,The patient's arm was placed in an arm sling. He was transferred to his cart and to the PACU in apparent satisfactory condition. Expected surgical prognosis on this patient is quite guarded because of the above-noted pathology. orthopedic, modified beachchair position, rotator cuff tear, glenoid labrum tear, glenohumeral joint, interscalene block, glenoid labrum, rotator cuff, rotator, debridement, glenoid, shoulder, tear, arthroscopy, arthroscopic, tenotomy, glenohumeral, supraspinatus, infraspinatus, subscapularis, chondromalacia, biceps, labrum, cuff, Orthopedic Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression. Arthroscopic Rotator Cuff Repair 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. Orthopedic Diagnostic arthroscopy with partial chondroplasty of patella, lateral retinacular release, and open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws. Grade-IV chondromalacia patella and patellofemoral malalignment syndrome. Arthroscopy & Chondroplasty PREOPERATIVE DIAGNOSES:,1. Chondromalacia patella.,2. Patellofemoral malalignment syndrome.,POSTOPERATIVE DIAGNOSES:,1. Grade-IV chondromalacia patella.,2. Patellofemoral malalignment syndrome.,PROCEDURE PERFORMED:,1. Diagnostic arthroscopy with partial chondroplasty of patella.,2. Lateral retinacular release.,3. Open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws.,ANESTHESIA:, General.,COMPLICATIONS: , None.,TOURNIQUET TIME: , Approximately 70 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , Grade-IV chondromalacia noted to the central and lateral facet of the patella. There was a grade II to III chondral changes to the patellar groove. The patella was noted to be displaced laterally riding on the edge of the lateral femoral condyle. The medial lateral meniscus showed small amounts of degeneration, but no frank tears were seen. The articular surfaces and the remainder of the knee appeared intact. Cruciate ligaments also appeared intact to direct stress testing.,HISTORY: ,This is a 36-year-old Caucasian female with a long-standing history of right knee pain. She has been diagnosed in the past with chondromalacia patella. She has failed conservative therapy. It was discussed with her the possibility of a arthroscopy lateral release and a tubercle transfer (anterior medialization of the tibial tubercle) to release stress from her femoral patellofemoral joint. She elected to proceed with the surgical intervention. All risks and benefits of the surgery were discussed with her. She was in agreement with the treatment plan.,PROCEDURE: , On 09/04/03, she was taken to Operating Room at ABCD General Hospital. She was placed supine on the operating table with the general anesthesia administered by the Anesthesia Department. Her leg was placed in a Johnson knee holder and sterilely prepped and draped in the usual fashion. A stab incision was made in inferolateral and parapatellar regions. Through this the cannula was placed and the knee was inflated with saline solution. Intraoperative pictures were obtained. The above findings were noted. Second portal site was initiated in the inferomedial parapatellar region. Through this, a arthroscopic shaver was placed and the chondroplasty in the patella was performed and removed the loose articular debris. Next, the camera was placed through the inferomedial portal. An arthroscopic Bovie was placed through the inferolateral portal. A release of lateral retinaculum was then performed using the Bovie. Hemostasis was controlled with electrocautery. Next, the knee was suctioned dry. An Esmarch was used to exsanguinate the lower extremity. Tourniquet was inflated to 325 mmHg. An oblique incision was made along the medial parapatellar region of the knee. The subcuticular tissues were carefully dissected and the hemostasis was again controlled with electrocautery. The retinaculum was then incised in line with the incision. The patellar tendon was identified. The lateral and medial border of the tibial tubercle were cleared of all soft tissue debris. Next, an osteotome was then used to cut the tibial tubercle to 45 degree angle leaving the base of the bone incision intact. The tubercle was then pushed anteriorly and medially decreasing her Q-angle and anteriorizing the tibial tubercle. It was then held in place with a Steinmann pin. Following this, a two 4.5 mm cannulated screws, partially threaded, were drilled in place using standard technique to help fixate the tibial tubercle. There was excellent fixation noted. The Q-angle was noted to be decreased to approximately 15 degrees. She was transferred approximately 1 cm in length. The wound was copiously irrigated and suctioned dry. The medial retinaculum was then plicated causing further medialization of the patella. The retinaculum was reapproximated using #0 Vicryl. Subcuticular tissue were reapproximated with #2-0 Vicryl. Skin was closed with #4-0 Vicryl running PDS suture. Sterile dressing was applied to the lower extremities. She was placed in a Donjoy knee immobilizer locked in extension. It was noted that the lower extremity was warm and pink with good capillary refill following deflation of the tourniquet. She was transferred to recovery room in apparent stable and satisfactory condition.,Prognosis of this patient is poor secondary to the advanced degenerative changes to the patellofemoral joint. She will remain in the immobilizer approximately six weeks allowing the tubercle to reapproximate itself to the proximal tibia. orthopedic, diagnostic arthroscopy, patellofemoral malalignment syndrome, cannulated, partial chondroplasty, retinacular, chondromalacia patella, tibial tubercle, patella, tubercle, arthroscopy, tourniquet, chondroplasty, chondromalacia, patellofemoral, Orthopedic Torn lateral meniscus and chondromalacia of the patella, right knee. Arthroscopic lateral meniscoplasty and patellar shaving of the right knee. Arthroscopic Meniscoplasty PREOPERATIVE DIAGNOSES:,1. Torn lateral meniscus, right knee.,2. Chondromalacia of the patella, right knee.,POSTOPERATIVE DIAGNOSES:,1. Torn lateral meniscus, right knee.,2. Chondromalacia of the patella, right knee.,PROCEDURE PERFORMED:,1. Arthroscopic lateral meniscoplasty.,2. Patellar shaving of the right knee.,ANESTHESIA: ,General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOTAL TOURNIQUET TIME:, Zero.,GROSS FINDINGS: , A complex tear involving the lateral and posterior horns of the lateral meniscus and grade-II chondromalacia of the patella.,HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old Caucasian male presented to the office complaining of right knee pain. He complained of pain on the medial aspect of his right knee after an injury at work, which he twisted his right knee.,PROCEDURE: ,After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained. The operative extremity was then confirmed with the operative surgeon, the patient, the Department of Anesthesia and the nursing staff.,The patient was then transferred to preoperative area to Operative Suite #2, placed on the operating table in supine position. Department of Anesthesia administered general anesthetic to the patient. All bony prominences were well padded at this time. The right lower extremity was then properly positioned in a Johnson knee holder. At this time, 1% lidocaine with epinephrine 20 cc was administered to the right knee intra-articularly under sterile conditions. The right lower extremity was then sterilely prepped and draped in usual sterile fashion. Next, after all bony soft tissue landmarks were identified, an inferolateral working portal was established by making a 1-cm transverse incision at the level of the joint line lateral to the patellar tendon. The cannula and trocar were then inserted through this, putting the patellofemoral joint. An arthroscopic camera was then inserted and the knee was sequentially examined including the patellofemoral joint, the medial and lateral gutters, medial lateral joints, and the femoral notch. Upon viewing of the patellofemoral joint, there was noted to be grade-II chondromalacia changes of the patella. There were no loose bodies noted in the either gutter. Upon viewing of the medial compartment, there was no chondromalacia or meniscal tear was noted. While in this area, attention was directed to establish the inferomedial instrument portal. This was first done using a spinal needle for localization followed by 1-cm transverse incision at the joint line. A probe was then inserted through this portal and the meniscus was further probed. Again, there was noted to be no meniscal tear. The knee was taken through range of motion and there was no chondromalacia. Upon viewing of the femoral notch, there was noted to be intact ACL with negative drawer sign. PCL was also noted to be intact. Upon viewing of the lateral compartment, there was noted to be a large bucket-handle tear involving the lateral and posterior horns. It was reduced from the place, however, involved the white and red white area was elected to excise the bucket-handle. An arthroscopic scissor was then inserted and the two remaining attachments the posterior and lateral attachments were then clipped and a Schlesinger grasper was then used to remove the resected meniscus. It was noted that the meniscus was followed out to the whole and the entire piece was taken out of the knee. Pictures were taken both pre-meniscal resection and post-meniscal resection. The arthroscopic shaver was then inserted into the medial portal and the remaining meniscus was contoured. The lateral gutter was then examined and was noted to be no loose bodies and ______ was intact. Next, attention was directed to the inner surface of the patella. This was debrided using the 2.5 arthroscopic shaver. It was noted to be quite smooth and postprocedure the patient was taken ________ well. The knee was then copiously irrigated and suctioned dry and all instrumentation was removed. 20 cc of 0.25% Marcaine was then administered to each portal as well as intra-articularly.,Sterile dressing was then applied consisting of Adaptic, 4x4s, ABDs, and sterile Webril and a stockinette to the right lower extremity. At this time, Department of Anesthesia reversed the anesthetic. The patient was transferred back to the hospital gurney to the Postanesthesia Care Unit. The patient tolerated the procedure and there were no complications. orthopedic, patella, chondromalacia, lateral meniscus, complex tear, torn lateral meniscus, femoral notch, meniscal tear, bucket handle, meniscal resection, arthroscopic shaver, patellofemoral joint, arthroscopic, knee, torn, meniscoplasty, meniscal, joint, meniscus, Orthopedic Rotated cuff tear, right shoulder. Glenoid labrum tear. Arthroscopy with arthroscopic glenoid labrum debridement, subacromial decompression, and rotator cuff repair, right shoulder. Arthroscopic Rotator Cuff Repair - 1 PREOPERATIVE DIAGNOSIS: , Rotated cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSES:,1. Rotated cuff tear, right shoulder.,2. Glenoid labrum tear.,PROCEDURE PERFORMED:,1. Arthroscopy with arthroscopic glenoid labrum debridement.,2. Subacromial decompression.,3. Rotator cuff repair, right shoulder.,SPECIFICATIONS:, Intraoperative procedure was done at Inpatient Operative Suite, room #1 at ABCD Hospital. This was done under interscalene and subsequent general anesthetic in the modified beach chair position.,HISTORY AND GROSS FINDINGS: , The patient is a 48-year-old with male who has been suffering increasing right shoulder pain for a number of months prior to surgical intervention. He was completely refractory to conservative outpatient therapy. After discussing the alternative care as well as the advantages, disadvantages, risks, complications, and expectations, he elected to undergo the above stated procedure on this date.,Intraarticularly, the joint was observed. There was noted to be a degenerative glenoid labrum tear. The biceps complex was otherwise intact. There were minimal degenerative changes at the glenohumeral joint. Rotator cuff tear was appreciated on the inner surface. Subacromially, the same was true. This was an elliptical to V-type tear. The patient has a grossly positive type III acromion.,OPERATIVE PROCEDURE: , The patient was laid supine on the operating table after receiving interscalene and then general anesthetic by the Anesthesia Department. He was safely placed in modified beach chair position. He was prepped and draped in the usual sterile manner. Portals were created outside to end, posterior to anterior, and ultimately laterally in the typical fashion. Upon complete diagnostic arthroscopy was carried out in the intraarticular aspect of the joint, a 4.2 meniscus shaver was placed anteriorly with the scope posteriorly. Debridement was carried out to the glenoid labrum. The biceps was probed and noted to be intact. Undersurface of the rotator cuff was debrided with the shaver along with debridement of the subchondral region of the greater tuberosity attachment.,After this, instrumentation was removed. The scope was placed subacromially and a lateral portal created. Gross bursectomy was carried out in a stepwise fashion to the top part of the cuff as well as in the gutters. An anterolateral portal was created. Sutures were placed via express silk as well as other sutures with a #2 fiber wire. With passing of the suture, they were tied with a slip-tight knot and then two half stitches. There was excellent reduction of the tear. Superolateral portal was then created. A #1 Mitek suture anchor was then placed in the posterior cuff to bring this over to bleeding bone. _______ suture was placed. The implant was put into place. The loop was grabbed and it was impacted in the previously drilled holes. There was excellent reduction of the tear.,Trial range of motion was carried out and seemed to be satisfactory.,Prior to this, a subacromial decompression was accomplished after release of CA ligament with the vapor Bovie. A 4.8 motorized barrel burr was utilized to sequentially take this down from the type III acromion to a flat type I acromion.,After all was done, copious irrigation was carried out throughout the joint. Gross bursectomy lightly was carried out to remove all bony elements. A pain buster catheter was placed through a separate portal and cut to length. 0.5% Marcaine was instilled after portals were closed with #4-0 nylon. Adaptic, 4 x 4s, ABDs, and Elastoplast tape placed for dressing. The patient was ultimately transferred to his cart and PACU in apparent satisfactory condition. Expected surgical prognosis of this patient is fair. orthopedic, subacromial decompression, rotator cuff repair, arthroscopic glenoid labrum debridement, arthroscopy, glenoid labrum tear, glenoid labrum, cuff, tear, arthroscopic, subacromial, decompression, debridement, rotator, glenoid, labrum, shoulder, Orthopedic Arthroscopic rotator cuff repair, arthroscopic subacromial decompression, and arthroscopic extensive debridement, superior labrum anterior and posterior tear. Arthroscopic Rotator Cuff Repair - 2 PROCEDURES,1. Arthroscopic rotator cuff repair.,2. Arthroscopic subacromial decompression.,3. Arthroscopic extensive debridement, superior labrum anterior and posterior tear.,PROCEDURE IN DETAIL: , After written consent was obtained from the patient, the patient was brought back into the operating room and identified. The patient was placed on the operating room table in supine position and given general anesthetic. Once the patient was under general anesthetic, a careful examination of the shoulder was performed. It revealed no patholigamentous laxity. The patient was then carefully positioned into a beach-chair position. We maintained the natural alignment of the head, neck, and thorax at all times. The shoulder and upper extremity was then prepped and draped in the usual sterile fashion.,Once we fully prepped and draped, we then began the surgery. We injected the glenohumeral joint with sterile saline with a spinal needle. This consisted of 60 cc of fluid. We then made a posterior incision for our portal, 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion. Through this incision, a blunt trocar and cannula were placed in the glenohumeral joint. Through the cannula, a camera was placed; and the shoulder was insufflated with sterile saline through a preoperative feed. We then carefully examined the glenohumeral joint.,We found the articular surface to be in good condition. There was a superior labral tear (SLAP). This was extensively debrided using a shaver through an anterior portal. We also found a full thickness rotator cuff tear. We then drained the glenohumeral joint. We redirected our camera into the subacromial space. An anterolateral portal was made, both superior and inferior.,We then proceeded to perform a subacromial decompression using high-speed shaver. The bursa was extensively debrided. We then abraded the bone over the footprint of where the rotator cuff is usually attached. The corkscrew anchors were used to perform a rotator cuff repair. Pictures were taken.,Through a separate incision, an indwelling pain catheter was then placed. It was carefully positioned. Pictures were taken. We then drained the joint. All instruments were removed. The patient did receive IV antibiotic preoperatively. All portals were closed using 4-0 nylon sutures.,Xeroform, 4 x 4s, and OpSite were applied over the pain pump. ABD, tape, and a sling were also applied. A Cryo/Cuff was also placed over the shoulder. The patient was taken out of the beach-chair position maintaining the neutral alignment of the head, neck, and thorax. The patient was extubated and brought to the recovery room in stable condition. I then went out and spoke with the family, going over the case, postoperative instructions, and followup care. orthopedic, debridement, superior labrum, patholigamentous, laxity, arthroscopic rotator cuff repair, subacromial decompression, glenohumeral joint, rotator cuff, arthroscopic, decompression, repair, glenohumeral, subacromial, rotator, cuff, Orthopedic Rotator cuff tear, right shoulder. Superior labrum anterior and posterior lesion (peel-back), right shoulder. Arthroscopy with arthroscopic SLAP lesion. Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder. Arthroscopic SLAP lesion PREOPERATIVE DIAGNOSIS: , Rotator cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSIS: , Superior labrum anterior and posterior lesion (peel-back), right shoulder.,PROCEDURE PERFORMED:,1. Arthroscopy with arthroscopic SLAP lesion.,2. Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.,SPECIFICATIONS: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital. This was done under a interscalene block anesthetic and subsequent general anesthetic in the modified beachchair position.,HISTORY AND GROSS FINDINGS: ,This is a 54-year-old white female suffering an increasing right shoulder pain for a few months prior to surgical intervention. She had an injury to her right shoulder when she fell off a bike. She was diagnosed preoperatively with a rotated cuff tear.,Intra-articularly besides we noted a large SLAP lesion, superior and posterior to the attachment of the glenoid labrum from approximately 12:30 back to 10:30. This acted as a peel-back type of mechanism and was displaced into the joint beyond the superior rim of the glenoid. This was an obvious avulsion into subchondral bone with bone exposed. The anterior aspect had degenerative changes, but did not have evidence of avulsion. The subscapular was noted to be intact. On the joint side of the supraspinatus, there was noted to be a laminated type of tearing to the rotated cuff to the anterior and mid-aspect of the supraspinatus attachment.,This was confirmed subacromially. The patient had a type-I plus acromion in outlet view and thus it was elected to not perform a subacromial decompression, but soft tissue release of the CA ligament in a releasing resection type fashion.,OPERATIVE PROCEDURE: , The patient was placed supine upon the operative table after she was given interscalene and then general anesthesia by the Anesthesia Department. She was safely placed in a modified beachchair position. She was prepped and draped in the usual sterile manner. The portals were created from outside the ends, posterior to the scope and anteriorly for an intraoperative portal and then laterally. She had at least two other portals appropriate for both repair mechanisms described above.,Attention was then turned to the SLAP lesion. The edges were debrided both on the bony side as well as soft tissue side. We used the anterior portal to lift up the mechanism and created a superolateral portal through the rotator cuff and into the edge of the labrum. Further debridement was carried out here. A drill hole was made just on the articular surface superiorly for a knotless anchor. A pull-through suture of #2 fiber wire was utilized with the ________. This was pulled through. It was tied to the leader suture of the knotless anchor. This was pulled through and one limb of the anchor loop was grabbed and the anchor impacted with a mallet. There was excellent fixation of the superior labrum. It was noted to be solid and intact. The anchor was placed safely in the bone. There was no room for further knotless or other anchors. After probing was carried out, hard copy Polaroid was obtained.,Attention was then turned to the articular side for the rotator cuff. It was debrided. Subchondral debridement was carried out to the tuberosity also. Care was taken to go to the subchondral region but not beyond. The bone was satisfactory.,Scope was then placed in the subacromial region. Gross bursectomy was carried out with in the lateral portal. This was done throughout as well as in the gutters anterolaterally and posteriorly. Debridement was carried out further to the rotator cuff. Two types of fixation were carried out, one with a superolateral portal a drill hole was made and anchor of the _knotless suture placed after PDS leader suture placed with a Caspari punch. There was an excellent reduction of the tear posteriorly and then anteriorly. Tendon to tendon repair was accomplished by placing a fiber wire across the tendon and tying sutured down through the anterolateral portal. This was done with a sliding stitch and then two half stitches. There was excellent reduction of the tear.,Attention was then turned to the CA ligament. It was released along with periosteum and the undersurface of the anterior acromion. The CA ligament was not only released but resected. There was noted to be no evidence of significant spurring with only a mostly type-I acromion. Thus, it was not elected to perform subacromial decompression for bone with soft tissue only. A pain buster catheter was placed separately. It was cut to length. An interrupted #4-0 nylon was utilized for portal closure. A 0.5% Marcaine was instilled subacromially. Adaptic, 4x4s, ABDs, and Elastoplast tape placed for dressing. The patient's arm was placed in a arm sling. She was transferred to PACU in apparent satisfactory condition. Expected surgical prognosis on this patient is fair. orthopedic, rotator cuff tear, shoulder, labrum, lesion, decompression, subacromial, arthroscopic slap lesion, slap lesion, rotator cuff, anterior, arthroscopy, arthroscopic, slap, cuff Orthopedic Femoroacetabular impingement. Left hip arthroscopic debridement, femoral neck osteoplasty, and labral repair. Arthroscopic Debridement & Labral Repair - Hip 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. orthopedic, labral repair, femoral neck osteoplasty, arthroscopic debridement, femoroacetabular impingement, arthroscopic, femoroacetabular, impingement, debridement, osteoplasty, acetabulum Orthopedic Arthroplasty of the right second digit. Hammertoe deformity of the right second digit. Arthroplasty - Hammertoe 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. orthopedic, hammertoe deformity, arthroplasty, digit, proximal interphalangeal joint, periosteal tissue, interrupted sutures, interphalangeal joint, proximal phalanx, proximal, painful, tourniquet, hammertoe, phalanx, head, incisional, tendon Orthopedic Recurrent anterior dislocating left shoulder. Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder. Arthroscopic Debridement - Shoulder PREOPERATIVE DIAGNOSIS: , Recurrent anterior dislocating left shoulder.,POSTOPERATIVE DIAGNOSIS:, Recurrent anterior dislocating left shoulder.,PROCEDURE PERFORMED:, Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.,PROCEDURE: ,The patient was taken to OR #2, administered general anesthetic after ineffective interscalene block had been administered in the preop area. The patient was positioned in the modified beachchair position utilizing the Mayfield headrest. The left shoulder was propped posteriorly with a rolled towel. His head was secured to the Mayfield headrest. The left shoulder and upper extremity were then prepped and draped in the usual manner. A posterior lateral port was made for _____ the arthroscopic cannula. The scope was introduced into the glenohumeral joint. There was noted to be a complete tear of the anterior glenoid labrum off from superiorly at about 11:30 extending down inferiorly to about 6 o'clock. The labrum was adherent to the underlying capsule. The margin of the glenoid was frayed in this area. The biceps tendon was noted to be intact. The articular surface of the glenoid was fairly well preserved. The articular surface on the humeral head was intact; however, there was a large Hill-Sachs lesion on the posterolateral aspect of the humeral head. The rotator cuff was visualized and noted to be intact. The axillary pouch was visualized and it was free of injury. There were some cartilaginous fragments within the axillary pouch. Attention was first directed after making an anterior portal to fixation of the anterior glenoid labrum. Utilizing the Chirotech system through the anterior cannula, the labrum was secured with the pin and drill component and was then tacked back to the superior glenoid rim at about the 11 o'clock position. A second tack was then placed at about the 8 o'clock position. The labrum was then probed and was noted to be stable. With some general ranging of the shoulder, the tissue was pulled out from the tacks. An attempt was made at placement of two other tacks; however, the tissue was not of good quality to be held in position. Therefore, all tacks were either buried down to a flat surface or were removed from the anterior glenoid area. At this point, it was deemed that an open Bankart arthroplasty was necessary. The arthroscopic instruments were removed. An anterior incision was made extending from just lateral of the coracoid down toward the axillary fold. The skin incision was taken down through the skin. Subcutaneous tissues were then separated with the coag Bovie to provide hemostasis. The deltopectoral fascia was identified. It was split at the deltopectoral interval and the deltoid was reflected laterally. The subdeltoid bursa was then removed with rongeurs. The conjoint tendon was identified. The deltoid and conjoint tendons were then retracted with a self-retaining retractor. The subscapularis tendon was identified. It was separated about a centimeter from its insertion, leaving the tissue to do sew later. The subscapularis was reflected off superiorly and inferiorly and the muscle retracted medially. This allowed for visualization of the capsule. The capsule was split near the humeral head insertion leaving a tag for repair. It was then split longitudinally towards the glenoid at approximately 9 o'clock position. This provided visualization of the glenohumeral joint. The friable labral and capsular tissue was identified. The glenoid neck was already prepared for suturing, therefore, three Mitek suture anchors were then positioned to place at approximately 7 o'clock, 9 o'clock, and 10 o'clock. The sutures were passed through the labral capsular tissue and tied securely. At this point, the anterior glenoid rim had been recreated. The joint was then copiously irrigated with gentamicin solution and suctioned dry. The capsule was then repaired with interrupted #1 Vicryl suture and repaired back to its insertion site with #1 Vicryl suture. This later was then copiously irrigated with gentamicin solution and suctioned dry. Subscapularis was reapproximated on to the lesser tuberosity of the humerus utilizing interrupted #1 Vicryl suture. This later was then copiously irrigated as well and suctioned dry. The deltoid fascia was approximated with running #2-0 Vicryl suture. Subcutaneous tissues were approximated with interrupted #2-0 Vicryl and the skin was approximated with a running #4-0 subcuticular Vicryl followed by placement of Steri-Strips. 0.25% Marcaine was placed in the subcutaneous area for postoperative analgesia. The patient was then placed in a shoulder immobilizer after a bulky dressing had been applied. The patient was then transferred to the recovery room in apparent satisfactory condition. orthopedic, dislocating, bankart, arthroplasty, bankart repair, arthroscopic debridement, anterior, arthroscopic, debridement, deltoid, glenoid, humeral, interrupted, shoulder, subscapularis Orthopedic Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate. Severe low back pain. Anterior Lumbar Fusion PREOPERATIVE DIAGNOSIS: , Severe low back pain.,POSTOPERATIVE DIAGNOSIS: , Severe low back pain.,OPERATIONS PERFORMED: , Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 50 mL.,DRAINS:, None.,COMPLICATIONS: , None.,PATHOLOGICAL FINDINGS:, Dr. X made the approach and once we were at the L5-S1 disk space, we removed the disk and we placed a 13-mm PEEK vertebral spacer filled with a core of bone taken from the L5 vertebral body. This was filled with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug. At L4-L5, we used a 13-mm PEEK vertebral spacer with structural autograft and BMP, and then we placed a two-level 87-mm Integra sacral plate with 28 x 6-mm screws, two each at L4 and L5 and 36 x 6-mm screws at S1.,OPERATION IN DETAIL:, The patient was placed under general endotracheal anesthesia. The abdomen was prepped and draped in the usual fashion. Dr. X made the approach, and once the L5-S1 disk space was identified, we incised this with a knife and then removed a large core of bone taking rotating cutters. I was able to remove additional disk space and score the vertebral bodies. The rest of the disk removal was done with the curette, scraping the endplates. I tried various sized spacers, and at this point, we exposed the L5 body and took a dowel from the body and filled the hole with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug. Half of this was used to fill the spacer at L5-S1, BMP was placed in the spacer as well and then it was tapped into place. We then moved the vessels over the opposite way approaching the L4-L5 disk space laterally, and the disk was removed in a similar fashion and we also used a 13-mm PEEK vertebral spacer, but this is the variety that we could put in from one side. This was filled with bone and BMP as well. Once this was done, we were able to place an 87-mm Integra sacral plate down over the three vertebral bodies and place these screws. Following this, bleeding points were controlled and Dr. X proceeded with the closure of the abdomen.,SUMMARY: , This is a 51-year-old man who reports 15-year history of low back pain and intermittent bilateral leg pain and achiness. He has tried multiple conservative treatments including physical therapy, epidural steroid injections, etc. MRI scan shows a very degenerated disk at L5-S1, less so at L3-L4 and L4-L5. A discogram was positive with the lower 3 levels, but he has pain, which starts below the iliac crest and I feel that the L3-L4 disk is probably that symptomatic. An anterior lumbar interbody fusion was suggested. Procedure, risks, and complications were explained. orthopedic, peek vertebral spacer, autograft, anterior lumbar fusion, lumbar fusion, vertebral body, vertebral spacer, vertebral, spacer, anterior, lumbar, fusion, Orthopedic Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size. Arthroplasty PREOPERATIVE DIAGNOSES:,1. Hammertoe deformity, left fifth digit.,2. Ulceration of the left fifth digit plantolaterally.,POSTOPERATIVE DIAGNOSIS:,1. Hammertoe deformity, left fifth toe.,2. Ulceration of the left fifth digit plantolaterally.,PROCEDURE PERFORMED:,1. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally.,2. Excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.,OPERATIVE PROCEDURE IN DETAIL: , The patient is a 38-year-old female with longstanding complaint of painful hammertoe deformity of her left fifth toe. The patient had developed ulceration plantarly after being scheduled for removal of a plantar mass in the same area. The patient elects for surgical removal of this ulceration and correction of her hammertoe deformity at this time.,After an IV was instituted by the Department of Anesthesia, the patient was escorted to the OR where the patient was placed on the Operating Room table in the supine position. After adequate amount of IV sedation was administered by Anesthesia Department, the patient was given a digital block to the left fifth toe using 0.5% Marcaine plain with 1% lidocaine plain in 1:1 mixture totaling 6 cc. Following this, the patient was draped and prepped in a normal sterile orthopedic manner. An ankle tourniquet was placed on the left ankle and the left foot was elevated and Esmarch bandage applied to exsanguinate the foot. The ankle tourniquet was then inflated to 230 mmHg and then was brought back down to the level of the table. The stockinette was then cut and reflected and held in place using towel clamp.,The skin was then cleansed using the wet and dry Ray-Tec sponge and then the plantar lesion was outlined. The lesion measured 1 cm in diameter at the level of the skin and a 3 cm elliptical incision line was drawn on the surface of the skin in the plantolateral aspect of the left fifth digit. Then using a fresh #15 blade, skin incision was made. Following this, the incision was then deepened using a fresh #15 blade down to the level of the subcutaneous tissue. Using a combination of sharp and blunt dissection, the skin was reflected distally and proximally to the lesion. The lesion appeared well encapsulated with fibrous tissue and through careful dissection using combination of sharp and drill instrumentation the ulceration was removed in its entirety. The next further exploration was performed to ensure that no residual elements of the fibrous capsular tissue remained within. The lesion extended from the level of the skin down to the periosteal tissue of the middle and distal phalanx, however, did not show any evidence of extending beyond the level of a periosteum. Remaining tissues were inspected and appeared healthy. The lesion was placed in the specimen container and sent to pathology for microanalysis as well as growth. Attention was then directed to the proximal interphalangeal joint of the left fifth digit and using further dissection with a #15 blade, the periosteum was reflected off the lateral aspect of the proximal ________ median phalanx. The capsule was also reflected to expose the prominent lateral osseous portion of this joint. Using a sagittal saw and #139 blade, the lateral osseous prominence was resected. This was removed in entirety. Then using power-oscillating rasp, the sharp edges were smoothed and recontoured to the desirable anatomic condition. Then the incision and wound was flushed using copious amounts of sterile saline with gentamycin. Following this, the bone was inspected and appeared to be healthy with no evidence of involvement from the removed aforementioned lesion.,Following this, using #4-0 nylon in a combination of horizontal mattress and simple interrupted sutures, the lesion wound was closed and skin was approximated well without tension to the surface skin. Following this, the incision site was dressed using Owen silk, 4x4s, Kling, and Coban in a normal fashion. The tourniquet was then deflated and hyperemia was noted to return to digits one through five of the left foot. The patient was then escorted from the operative table into the Postanesthesia Care Unit. The patient tolerated the procedure and anesthesia well and was brought to the Postanesthesia Care Unit with vital signs stable and vascular status intact. In the recovery, the patient was given a surgical shoe as well as given instructions for postoperative care to include rest ice and elevation as well as the patient was given prescription for Naprosyn 250 mg to be taken three times daily as well as Vicodin ES to be taken q.6h. as needed.,The patient will follow-up on Friday with Dr. X in office for further evaluation. The patient was also given instructions as to signs of infection and to monitor her operative site. The patient was instructed to keep daily dressings intact, clean, dry, and to not remove them. orthopedic, hammertoe deformity, plantolaterall, ulceration, arthroplasty, plantar ulceration, interphalangeal, painful hammertoe, proximal interphalangeal joint, interphalangeal joint, digit, toe, blade, deformity, incision, hammertoe, lesion Orthopedic Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three. Anterior Cervical Discectomy & Interbody Fusion - 1 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. orthopedic, herniated nucleus pulposus, radiculopathy, cervical stenosis, anterior instrumentation, stabilization, slim-loc, neural decompression, anterior cervical discectomy, cord compression, interbody fusion, bengal cages, interbody, compression, anterior, fusion, decompression, discectomy, cervical Orthopedic Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast. Arthrodesis PREOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,POSTOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,PROCEDURE: , Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.,ANESTHESIA: , Surgery performed under general anesthesia. The patient received 6 mL of 0.25% Marcaine local anesthetic on each side.,TOURNIQUET TIME: ,Tourniquet time was 53 minutes on the left and 45 minutes on the right.,COMPLICATIONS: , There were no intraoperative complications.,DRAINS:, None.,SPECIMENS: , None.,HARDWARE USED: , Staple 7/8 inch x1 on each side.,HISTORY AND PHYSICAL: ,The patient is a 5-year-4-month-old male who presents for evaluation of feet. He has been having significant feet pain with significant planovalgus deformity. The patient was noted to have flexible vertical talus. It was decided that the patient would benefit by subtalar arthrodesis, possible autograft, and Achilles lengthening. This was explained to the mother in detail. This is going to be a stabilizing measure and the patient will probably need additional surgery at a later day when his foot is more mature. Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for other surgical procedures, need to be nonweightbearing for some time. All questions were answered and the mother agreed to the above plan.,PROCEDURE NOTE: , The patient was taken to the operating room, placed supine on the operating room, general anesthesia was administered. The patient received Ancef preoperatively. Bilateral nonsterile tourniquets were placed on each thigh. A bump was placed underneath the left buttock. Both the extremities were then prepped and draped in standard surgical fashion. Attention was first turned towards the left side. Intended incision was marked on the skin. The ankle was taken through a range of motion with noted improvement in the reduction of the talocalcaneal alignment with the foot in plantar flexion on the lateral view. The foot was wrapped in Esmarch prior to inflation of tourniquet to 200 mmHg. Incision was then made over the left lateral aspect of the hind foot to expose the talocalcaneal joint. The sinus tarsi was then identified using a U-shaped flap to tack muscles, and periosteum was retracted distally. Once the foot was reduced a Steinman pin was used to hold it in position. This position was first checked on the fluoroscopy. The 7/8th inch staple was then placed across the sinus tarsi to maintain the reduction. This was also checked with fluoroscopy. The incision was then extended posteriorly to allow for visualization of the Achilles, which was Z-lengthened with the release of the lateral distal half. This was sutured using 2-0 Ethibond and that was also oversewn. The wound was irrigated with normal saline. The periosteal flap was sutured over the staple using 2-0 Vicryl. Skin was closed using 2-0 Vicryl interrupted and then with 4-0 Monocryl. The area was injected with 6 mL of 0.25% Marcaine local anesthetic. The wound was cleaned and dried, dressed with Steri-Strips, Xeroform, and 4 x 4s and Webril. Tourniquet was released after 53 minutes. The exact same procedure was repeated on the right side with no changes or complications. Tourniquet time on the right side was 45 minutes. The patient tolerated the procedure well. Bilateral long-leg casts were then placed with the foot in neutral with some moulding of his medial plantar arch. The patient was subsequently was taken to Recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized overnight for pain as per parents' request. The patient is to be strict nonweightbearing for at least 6 weeks. He is to follow up in the next 10 days for a check. We will plan of changing to short-leg casts in about 4 weeks postop. orthopedic, myotonic muscular dystrophy, muscular dystrophy, planovalgus feet, achilles z-lengthening, subtalar arthrodesis, bilateral crawford subtalar arthrodesis, bilateral long leg cast, sinus tarsi, leg casts, tourniquet time, arthrodesis, intraoperative, fluoroscopy, tourniquet, surgery, subtalar, achilles, anesthesia, planovalgus, foot, bilateral, Orthopedic Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture and placement of antibiotic-impregnated beads. Open calcaneus fracture on the right. Antibiotic-Impregnated Beads Placement 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. orthopedic, open calcaneus fracture, irrigation and debridement, antibiotic impregnated beads, irrigation, subcutaneous, placement, debridement, calcaneus, fracture, wound, beads, antibiotic Orthopedic Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction. Removal of loose bodies. Medial femoral chondroplasty and meniscoplasty. Anterior Cruciate Ligament Reconstruction 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., orthopedic, femoral chondroplasty, intraarticular loose bodies, anterior cruciate ligament reconstruction, anterior, arthroscopy, meniscoplasty, fixation, reconstruction, chondroplasty, ligament, femoral, intraarticular, medial Orthopedic Anterior cervical discectomy for neural decompression and anterior interbody fusion C5-C6 utilizing Bengal cage. Anterior Cervical Discectomy & Interbody Fusion - 3 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:, orthopedic, spondylosis, neck pain, headaches, decompression, uniplate, anterior cervical discectomy, neural decompression, cervical stenosis, prevertebral space, antibiotic solution, cervical discectomy, interbody fusion, bengal cage, interbody, anterior, cervical, discectomy, Orthopedic Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage. Anterior Cervical Discectomy & Interbody Fusion - 2 PREOPERATIVE DIAGNOSES: ,1. Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2. Cervical spondylosis.,3. Cervical stenosis, C5-C6 secondary to above (723.0).,POSTOPERATIVE DIAGNOSES: ,1. Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2. Cervical spondylosis.,3. Cervical stenosis, C5-C6 secondary to above (723.0), with surgical findings confirmed.,PROCEDURES: , ,1. Anterior cervical discectomy at C5-C6 with spinal cord and spinal canal decompression (63075).,2. Anterior interbody fusion at C5-C6, (22554) utilizing Bengal cage (22851).,3. Anterior instrumentation for stabilization by Uniplate construction, C5-C6, (22845); with intraoperative x-ray times two.,ANESTHESIA: , General.,SERVICE: , Neurosurgery.,OPERATION: ,The patient was brought into the operating room, placed in a supine position where general anesthesia was administered. Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion. A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected only in a subplatysmal manner bluntly, and with only blunt dissection at the prevertebral space where a localizing intraoperative x-ray was obtained, once self-retaining retractors were placed along the mesial edge of a cauterized longus colli muscle, to protect surrounding tissues throughout the remainder of the case. A prominent anterior osteophyte at C5-C6 was then localized, compared to preoperative studies in the usual fashion intraoperatively, and the osteophyte was excised with a rongeur and bony fragments saved. This allowed for an annulotomy, which was carried out with a #11 blade and discectomy, removed with straight disc forceps portions of the disc, which were sent to Pathology for a permanent section. Residual osteophytes and disc fragments were removed with 1 and 2-mm micro Kerrison rongeurs as necessary as drilling extended into normal cortical and cancellous elements widely laterally as well. A hypertrophied ligament and prominent posterior spurs were excised as well until the dura bulged into the interspace, a sign of a decompressed status. At no time during the case was evidence of CSF leakage, and hemostasis was readily achieved with pledgets of Gelfoam subsequently removed with copious amounts of antibiotic irrigation. Once the decompression was inspected with a double ball dissector and all found to be completely decompressed, and the dura bulged at the interspace, and pulsated, then a Bengal cage was filled with the patient's own bone elements and fusion putty and countersunk into position, and was quite tightly applied. Further stability was added nonetheless with an appropriate size Uniplate, which was placed of appropriate size with appropriate size screws and these were locked into place in the usual manner. The wound was inspected, and irrigated again with antibiotic solution and after further inspection was finally closed in a routine closure in a multiple layer event by first approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was Steri-Stripped for reinforcement, and a sterile dressing was applied, incorporating a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in the usual manner. Once the sterile dressing was applied, the patient was taken from the operating room to the recovery area having left in stable condition.,At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type. orthopedic, herniated nucleus pulposus, myelopathy, cervical spondylosis, cervical stenosis, anterior instrumentation, uniplate, decompression, anterior cervical discectomy, spinal cord, spinal canal, sterile dressing, interbody fusion, bengal cage, interbody, cervical, anterior, discectomy, Orthopedic C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating. Anterior Cervical Discectomy & Fusion - 8 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. orthopedic, allograft fusion, anterior cervical discectomy, neck pain, cervical spine, discectomy, fusion, sternocleidomastoid muscle, assured hemostasis, anterior cervical, cervical discectomy, disc space, cervical, anterior, allograft Orthopedic C4-C5, C5-C6 anterior cervical discectomy and fusion. The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms. Her MRI showed stenosis at portion of C4 to C6. Anterior Cervical Discectomy & Fusion - 7 PREOPERATIVE DIAGNOSIS:, C4-C5, C5-C6 stenosis.,PREOPERATIVE DIAGNOSIS: , C4-C5, C5-C6 stenosis.,PROCEDURE: , C4-C5, C5-C6 anterior cervical discectomy and fusion.,COMPLICATIONS: , None.,ANESTHESIA: , General.,INDICATIONS OF PROCEDURE: , The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms. Her MRI showed stenosis at portion of C4 to C6. I discussed the procedure as well as risks and complications. She wishes to proceed with surgery. Risks will include but are not limited to infection, hemorrhage, spinal fluid leak, worsened neurologic deficit, recurrent stenosis, requiring further surgery, difficulty with fusion requiring further surgery, long-term hoarseness of voice, difficulty swallowing, medical anesthesia risk.,PROCEDURE: ,The patient was taken to the operating room on 10/02/2007. She was intubated for anesthesia. TEDS and boots as well as Foley catheter were placed. She was placed in a supine position with her neck in neutral position. Appropriate pads were also used. The area was prepped and draped in usual sterile fashion. Preoperative localization was taken. _____ not changed. Incision was made on the right side in transverse fashion over C5 vertebral body level. This was made with a #10 blade knife and further taken down with pickups and scissors. The plane between the esophagus and carotid artery was carefully dissected both bluntly and sharply down to the anterior aspect of the cervical spine. Intraoperative x-ray was taken. Longus colli muscles were retracted laterally. Caspar retractors were used. Intraoperative x-ray was taken. I first turned by attention at C5-C6 interspace. This was opened with #15 blade knife. Disc material was taken out using pituitary as well as Kerrison rongeur. Anterior aspects were taken down. End plates were arthrodesed using curettes. This was done under distraction. Posterior longitudinal ligament was opened with a nerve hook and Kerrison rongeur. Bilateral foraminotomies were done. At this point, I felt that there was a good decompression. The foramen appeared to be opened. Medtronic cage was then encountered and sent few millimeters. This was packed with demineralized bone matrix. The distraction was then taken down. The cage appeared to be strong. This procedure was then repeated at C4-C5. A 42-mm AcuFix plate was then placed between C4 and C6. This was carefully screwed and locked. The instrumentation appeared to be strong. Intraoperative x-ray was taken. Irrigation was used. Hemostasis was achieved. The platysmas was closed with 3-0 Vicryl stitches. The subcutaneous was closed with 4-0 Vicryl stitches. The skin was closed with Steri-strips. The area was clean and dry and dressed with Telfa and Tegaderm. Soft cervical collar was placed for the patient. She was extubated per anesthesia and brought to the recovery in stable condition. orthopedic, anterior cervical discectomy, fusion, infection, hemorrhage, spinal fluid leak, anesthesia, foley catheter, teds, anterior cervical, cervical discectomy, anterior, cervical, discectomy, stenosis, Orthopedic Anterior cervical discectomy with decompression, C5-C6, arthrodesis with anterior interbody fusion, C5-C6, spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium), implant using PEEK 7 mm, and Allograft using Vitoss. Anterior Cervical Discectomy & Interbody Fusion PREOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy, left more than the right.,2. Cervical spondylosis with herniated nucleus pulposus, C5-C6.,POSTOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy, left more than the right.,2. Cervical spondylosis with herniated nucleus pulposus, C5-C6.,OPERATIVE PROCEDURES,1. Anterior cervical discectomy with decompression, C5-C6.,2. Arthrodesis with anterior interbody fusion, C5-C6.,3. Spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium).,4. Implant using PEEK 7 mm.,5. Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS: ,1200 cc of crystalloids.,URINE OUTPUT: , No Foley catheter.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,INDICATIONS FOR THE OPERATION:, This is a case of a very pleasant 38-year-old Caucasian female who has been complaining over the last eight years of neck pain and shoulder pain radiating down across the top of her left shoulder and also across her shoulder blades to the right side, but predominantly down the left upper extremity into the wrist. The patient has been diagnosed with fibromyalgia and subsequently, has been treated with pain medications, anti-inflammatories and muscle relaxants. The patient's symptoms continued to persist and subsequently, an MRI of the C-spine was done, which showed disc desiccation, spondylosis and herniated disk at C5-C6, an EMG and CV revealed a presence of mild-to-moderate carpal tunnel syndrome. The patient is now being recommended to undergo decompression and spinal instrumentation and fusion at C5-C6. The patient understood the risks and benefits of the surgery. Risks include but not exclusive of bleeding and infection. Bleeding can be in the form of soft tissue bleeding, which may compromise airway for which she can be brought emergently back to the operating room for emergent evacuation of the hematoma as this may cause weakness of all four extremities, numbness of all four extremities, as well as impairment of bowel and bladder function. This could also result in dural tear with its attendant symptoms of headache, nausea, vomiting, photophobia, and posterior neck pain as well as the development of pseudomeningocele. Should the symptoms be severe or the pseudomeningocele be large, she can be brought back to the operating room for repair of the CSF leak and evacuation of the pseudomeningocele. There is also the risk of pseudoarthrosis and nonfusion, for which she may require redo surgery at this level. There is also the possibility of nonimprovement of her symptoms in about 10% of cases. The patient understands this risk on top of the potential injury to the esophagus and trachea as well as the carotid artery. There is also the risk of stroke, should an undiagnosed plaque be propelled into the right cerebral circulation. The patient also understands that there could be hoarseness of the voice secondary to injury to the recurrent laryngeal nerve. She understood these risks on top of the risks of anesthesia and gave her consent for the procedure.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room, awake, alert and not in any form of distress. After smooth induction and intubation, the patient was positioned supine on the operating table with the neck placed on hyperextension and the head supported on a foam doughnut. A marker was placed. This verified the level to be at the C5-C6 level and incision was then marked in a transverse fashion starting from the midline extending about 5 mm beyond the anterior border of the sternocleidomastoid muscle. The area was then prepped with DuraPrep after the head was turned 45 degrees to the left.,After sterile drapes were laid out, an incision was made using a scalpel blade #10. Wound edge bleeders were carefully controlled with bipolar coagulation and the platysma was cut using a hot knife in a transverse fashion. Dissection was then carried underneath the platysma superiorly inferiorly. The anterior border of the sternocleidomastoid was identified and dissection was carried out lateral to the esophagus to trachea as well as medial to the carotid sheath in the sternocleidomastoid muscle. The prevertebral fascia was noted to be taken her case with a lot of fat deposition. Bipolar coagulation of bleeders was done; however, branch of the superior thyroid artery was ligated with Hemoclips x4. After this was completed, a localizing x-ray verified the marker to be at the C6-C7 level. We proceeded to strip the longus colli muscles off the vertebral body of the C5 and C6. Self-retaining retractor was then laid down. An anterior osteophyte was carefully drilled using a Midas 5-mm bur and the disk together with the inferior endplate of C5 and the superior endplate of C6 was also drilled down with the Midas 5-mm bur. This was later followed with a 3-mm bur and the disk together with posterior longitudinal ligament was removed using Kerrison's ranging from 1 to 4 mm. The herniation was noted on the right. However, there was significant neuroforaminal stenosis on the left. Decompression on both sides was done and after this was completed, a Valsalva maneuver showed no evidence of any CSF leakage. The area was then irrigated with saline with bacitracin solution. A 7 mm implant with its inferior packed with Vitoss was then laid down and secured in place with four 14 x 4.0 mm screws and plate 18 mm, all of which were titanium. X-ray after this placement showed excellent position of all these implants and screws and _____ and the patient's area was also irrigated with saline with bacitracin solution. A round French 10 JP drain was then laid down and exteriorized through a separate stab incision on the patient's right inferiorly. The catheter was then anchored to the skin with a nylon 3-0 stitch and connected to a sterile draining system. The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl subcuticular 4-0 Stitch for the dermis, and the wound was reinforced with Dermabond. Dressing was placed only at the exit site of the catheter. C-collar was placed. The patient was extubated and transferred to recovery. Orthopedic Herniated nucleus pulposus C5-C6. Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap. Operating microscope was used for both illumination and magnification. Anterior Cervical Discectomy & Fusion - 9 PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,PROCEDURE:, Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap. Operating microscope was used for both illumination and magnification.,FIRST ASSISTANT: , Nurse practitioner.,PROCEDURE IN DETAIL: , The patient was placed in supine position. The neck was prepped and draped in the usual fashion for anterior discectomy and fusion. An incision was made midline to the anterior body of the sternocleidomastoid at C5-C6 level. The skin, subcutaneous tissue, and platysma muscle was divided exposing the carotid sheath, which was retracted laterally. Trachea and esophagus were retracted medially. After placing the self-retaining retractors with the longus colli muscles having been dissected away from the vertebral bodies at C5 and C6 and confirming our position with intraoperative x-rays, we then proceeded with the discectomy.,We then cleaned out the disc at C5-C6 after incising the annulus fibrosis. We cleaned out the disc with a combination of angled and straight pituitary rongeurs and curettes, and the next step was to clean out the disc space totally. With this having been done, we then turned our attention with the operating microscope to the osteophytes. We drilled off the vertebral osteophytes at C5-C6, as well as the uncovertebral osteophytes. This was removed along with the posterior longitudinal ligament. After we had done this, the dural sac was opposed very nicely and both C6 nerve roots were thoroughly decompressed. The next step after the decompression of the thecal sac and both C6 nerve roots was the fusion. We observed that there was a ____________ in the posterior longitudinal ligament. There was a free fragment disc, which had broken through the posterior longitudinal ligament just to the right of midline.,The next step was to obtain the bone from the back bone, using cortical cancellous graft 10 mm in size after we had estimated the size. That was secured into place with distraction being applied on the vertebral bodies using vertebral body distractor.,After we had tapped in the bone plug, we then removed the distraction and the bone plug was fitting nicely.,We then use the Aesculap cervical titanium instrumentation with the 16-mm screws. After securing the C5-C6 disc with four screws and titanium plate, x-rays showed good alignment of the spine, good placement of the bone graft, and after x-rays showed excellent position of the bone graft and instrumentation, we then placed in a Jackson-Pratt drain in the prevertebral space brought out through a separate incision. The wound was closed with 2-0 Vicryl for subcutaneous tissues and skin was closed with Steri-Strips. Blood loss during the operation was less than 10 mL. No complications of the surgery. Needle count, sponge count, and cottonoid count were correct., orthopedic, aesculap, titanium dynamic plating system, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, operating microscope, longitudinal ligament, discectomy, anterior, instrumentation, cervical, titanium Orthopedic Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6. Anterior Cervical Discectomy & Fusion - Discharge Summary "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." orthopedic, slimlock, herniated nucleuses pulposus, anterior cervical discectomy, bengal cages, anterior, herniated, cervical, radiculopathy, discectomy, Orthopedic Anterior cervical discectomy and osteophytectomy. Application of prosthetic interbody fusion device. Anterior cervical interbody arthrodesis. Anterior cervical instrumentation Anterior Cervical Discectomy & Osteophytectomy PREOPERATIVE DIAGNOSES,1. Cervical radiculopathy, C5-C6 and C6-C7.,2. Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3. Symptomatic cervical stenosis, C5-C6 and C6-C7.,4. Symptomatic cervical disc herniations, C5-C6 and C6-C7.,POSTOPERATIVE DIAGNOSES,1. Cervical radiculopathy, C5-C6 and C6-C7.,2. Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3. Symptomatic cervical stenosis, C5-C6 and C6-C7.,4. Symptomatic cervical disc herniations, C5-C6 and C6-C7.,OPERATIVE PROCEDURE,1. CPT code 63075: Anterior cervical discectomy and osteophytectomy, C5-C6.,2. CPT code 63076: Anterior cervical discectomy and osteophytectomy, C6-C7, additional level.,3. CPT code 22851: Application of prosthetic interbody fusion device, C5-C6.,4. CPT code 22851-59: Application of prosthetic interbody fusion device, C6-C7, additional level.,5. CPT code 22554-51: Anterior cervical interbody arthrodesis, C5-C6.,6. CPT code 22585: Anterior cervical interbody arthrodesis, C6-C7, additional level.,7. CPT code 22845: Anterior cervical instrumentation, C5-C7.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS: ,Negligible.,DRAINS: , Small suction drain in the cervical wound.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL:, The patient was given intravenous antibiotic prophylaxis and thigh-high TED hoses were placed on the lower extremities while in the preanesthesia holding area. The patient was transported to the operative suite and on to the operative table in the supine position. General endotracheal anesthesia was induced. The head was placed on a well-padded head holder. The eyes and face were protected from pressure. A well-padded roll was placed beneath the neck and shoulders to help preserve the cervical lordosis. The arms were tucked and draped to the sides. All bony prominences were well padded. An x-ray was taken to confirm the correct level of the skin incision. The anterior neck was then prepped and draped in the usual sterile fashion.,A straight transverse skin incision over the left side of the anterior neck was made and carried down sharply through the skin and subcutaneous tissues to the level of the platysma muscle, which was divided transversely using the electrocautery. The superficial and deep layers of the deep cervical fascia were divided. The midline structures were reflected to the right side. Care was taken during the dissection to avoid injury to the recurrent laryngeal nerve and the usual anatomical location of that nerve was protected. The carotid sheath was palpated and protected laterally. An x-ray was taken to confirm the level of C5-C6 and C6-C7.,The longus colli muscle was dissected free bilaterally from C5 to C7 using blunt dissection. Hemostasis was obtained using the electrocautery. The blades of the cervical retractor were placed deep to the longus colli muscles bilaterally. At C5-C6, the anterior longitudinal ligament was divided transversely. Straight pituitary rongeurs and a curette were used to remove the contents of the disc space. All cartilages were scraped off the inferior endplate of C5 and from the superior endplate of C6. The disc resection was carried posteriorly to the posterior longitudinal ligament and laterally to the uncovertebral joints. The posterior longitudinal ligament was resected using a 1 mm Kerrison rongeur. Beginning in the midline and extending into both neural foramen, posterior osteophytes were removed using a 1 m and a 2 mm Kerrison rongeurs. The patient was noted to have significant bony spondylosis causing canal and foraminal stenosis as well as a degenerative and protruding disc in agreement with preoperative diagnostic imaging studies. Following completion of the discectomy and osteophytectomy, a blunt nerve hook was passed into the canal superiorly and inferiorly as well as in the both neural foramen to make sure that there were no extruded disc fragments and to make sure the bony decompression was complete. A portion of the uncovertebral joint was resected bilaterally for additional nerve root decompression. Both nerve roots were visualized and noted to be free of encroachment. The same procedure was then carried out at C6-C7 with similar findings. The only difference in the findings was that at C6-C7 on the left side, the patient was found to have an extruded disc fragment in the canal and extending into the left side neural foramen causing significant cord and nerve root encroachment.,In preparation for the arthrodesis, the endplates of C5, C6, and C7 were burred in a parallel fashion down to the level of bleeding bone using a high-speed cutting bur with irrigant solution for cooling. The disc spaces were then measured to the nearest millimeter. Attention was then turned toward preparation of the structural allograft, which consisted of two pieces of pre-machined corticocancellous bone. The grafts were further shaped to fit the disc spaces exactly in a press-fit manner with approximately 1.5 mm of distraction at each disc space. The grafts were shaped to be slightly lordotic to help preserve the cervical lordosis. The grafts were impacted into the disc spaces. There was complete bony apposition between the ends of the bone grafts and the vertebral bodies of C5, C6, and C7. A blunt nerve hook was passed posterior to each bone graft to make sure that the bone grafts were in good position. Anterior osteophytes were removed using a high-speed cutting bur with irrigant solution for cooling. An appropriate length Synthes cervical plate was selected and bent slightly to conform to the patient's cervical lordosis. The plate was held in the midline with provided instrumentation while a temporary fixation screw was applied at C6. Screw holes were then drilled using the provided drill and drill guide taking care to avoid injury to neurovascular structures. The plate was then rigidly fixed to the anterior spine using 14-mm cancellous screws followed by locking setscrews added to the head of each screw to prevent postoperative loosening of the plate and/or screws.,An x-ray was taken, which confirmed satisfactory postioning of the plate, screws, and bone grafts.,Blood loss was minimal. The wound was irrigated with irrigant solution containing antibiotics. The wound was inspected and judged to be dry. The wound was closed over a suction drain placed in the deepest portion of the wound by reapproximating the platysma muscle with #4-0 Vicryl running suture, the subdermal and subcuticular layers with #4-0 Monocryl interrupted sutures, and the skin with Steri-Strips. The sponge and needle count were correct. A sterile dressing was applied to the wound. The neck was placed in a cervical orthosis. The patient tolerated the procedure and was transferred to the recovery room in stable condition. Orthopedic Anterior cervical discectomy with decompression of spinal cord. Anterior cervical fusion. Anterior cervical instrumentation. Insertion of intervertebral device. Use of operating microscope. Anterior Cervical Discectomy & Fusion - 6 PREOPERATIVE DIAGNOSIS: ,Symptomatic disk herniation, C7-T1.,FINAL DIAGNOSIS: ,Symptomatic disk herniation, C7-T1.,PROCEDURES PERFORMED,1. Anterior cervical discectomy with decompression of spinal cord C7-T1.,2. Anterior cervical fusion, C7-T1.,3. Anterior cervical instrumentation, anterior C7-T1.,4. Insertion of intervertebral device, C7-T1.,5. Use of operating microscope.,ANESTHESIOLOGY: , General endotracheal.,ESTIMATED BLOOD LOSS: ,A 30 mL.,PROCEDURE IN DETAIL: ,The patient was taken to the operating room where he was orally intubated by The Anesthesiology Service. He was placed in the supine position on an OR table. His arms were carefully taped down. He was sterilely prepped and draped in the usual fashion.,A 4-cm incision was made obliquely over the left side of his neck. Subcutaneous tissue was dissected down to the level of the platysma. The platysma was incised using electrocautery. Blunt dissection was done to create a plane between the strap muscles and the sternoclavicular mastoid muscle. This allowed us to get right down on to the anterior cervical spine. Blunt dissection was done to sweep off the longus colli. We isolated the C7-T1 interspace. An x-ray was taken to verify; we were indeed at the C7-T1 interspace.,Shadow-Line retractor was placed as well as Caspar pins. This provided very, very good access to the C7-T1 disk.,At this point, the operating microscope was brought into the decompression.,A thorough and aggressive C7-T1 discectomy was done using a succession of curettes, pituitary rongeur, 4-mm cutting bur and a #2 Kerrison rongeur. At the end of the discectomy, the cartilaginous endplates were carefully removed using 4-mm cutting burr. The posterior longitudinal ligament was carefully resected using #2 Kerrison rongeur. Left-sided C8 foraminotomy was accomplished using nerve hook and a 2-mm Kerrison rongeur. At the end of the decompression, there was no further compression on the left C8 nerve root.,A Synthes cortical cancellous ____________ bone was placed in the interspace. Sofamor Danek Atlantis plate was then placed over the interspace and four screws were placed, two in the body of C7 and two in the body of T1. An x-ray was taken. It showed good placement of the plate and screws.,A deep drain was placed. The platysma layer was closed in running fashion using #1 Vicryl. Subcutaneous tissue was closed in an interrupted fashion using 2-0 Vicryl. Skin was closed in a running fashion using 4-0 Monocryl. Steri-Strips and dressings were applied. All counts were correct. There were no complications. orthopedic, disk herniation, cervical discectomy, decompression, spinal cord, anterior cervical fusion, anterior cervical discectomy, kerrison rongeur, anterior cervical, instrumentation, cervical, anterior, platysma, kerrison, fashion, interspace, rongeur, discectomy, herniation, Orthopedic Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression and anterior interbody fusion at C5-C6 and C6-C7 utilizing Bengal cages x2. Anterior instrumentation by Uniplate construction C5, C6, and C7 with intraoperative x-ray x2. Anterior Cervical Discectomy & Fusion - 5 PREOPERATIVE DIAGNOSES: ,1. Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2. Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4).,POSTOPERATIVE DIAGNOSES: ,1. Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2. Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4), surgical findings confirmed.,PROCEDURES: ,1. Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression (63075, 63076).,2. Anterior interbody fusion at C5-C6 and C6-C7 (22554, 22585) utilizing Bengal cages x2 (22851).,3. Anterior instrumentation by Uniplate construction C5, C6, and C7 (22845); with intraoperative x-ray x2.,ANESTHESIA: ,General.,OPERATIONS: , The patient was brought to the operating room and placed in the supine position where general anesthesia was administered. Then the anterior aspect of the neck was prepped and draped in the 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 with only blunt dissection, the prevertebral space was encountered and localizing intraoperative x-ray was obtained once cauterized the longus colli muscle bilaterally allowed for the placement along its mesial portion of self-retaining retractors for exposure of tissues. Prominent anterior osteophytes once identified and compared to preoperative studies were removed at C5-C6 and then at C6-C7 with rongeur, allowing for an annulotomy with an #11 blade through collapsed disc space at C5-6, and even more collapsed at C6-C7. Gross instability appeared and though minimally at both interspaces and residual disc were removed then with the straight disc forceps providing a discectomy at both levels, sending to Pathology in a routine fashion as disc specimen. This was sent separately and allowed for residual disc removal of power drill where drilling extended in normal cortical and cancellous elements of the C5 and C6 interspaces and at C6-C7 removing large osteophytes and process, residual osteophytes from which were removed finally with 1 and 2 mm micro Kerrison rongeurs allowing for excision of other hypertrophied ligament posteriorly as well. This allowed for the bulging into the interspace of the dura, sign of decompressed status, and this was done widely bilaterally to decompress the nerve roots themselves and this was assured by inspection with a double ball dissector as needed. At no time during the case was there evidence of CSF leakage and hemostasis was well achieved with pledgets of Gelfoam and subsequently removed with copious amounts of antibiotic irrigation as well as Surgifoam. Once hemostasis well achieved, Bengal cage was filled with the patient's own bone elements of appropriate size, and this was countersunk into position and quite tightly applied it at first C5-C6, then secondly at C6-C7. These were checked and found to be well applied and further stability was then added by placement nonetheless of a Uniplate of appropriate size. The appropriate size screws and post-placement x-ray showed well-aligned elements and removal of osteophytes, etc. The wound was again irrigated with antibiotic solution, inspected, and finally closed in a multiple layered closure by approximation of platysma with interrupted #3-0 Vicryl and the skin with subcuticular stitch of #4-0 Vicryl incorporating a Penrose drain from vertebral space externally through the skin wound and safety pin, and later incorporated itself into sterile bandage.,Once the bandage was placed, the patient was taken, extubated from the operating room to the Recovery area, having in stable, but guarded condition. At the conclusion of the case, all instrument, needle, and sponge counts were accurate and correct. There were no intraoperative complications of any type. orthopedic, cervical spondylosis, anterior cervical discectomy, anterior instrumentation, annulotomy, kerrison rongeurs, surgifoam, vertebral space, uniplate construction, bengal cages, neural decompression, anterior cervical, cervical discectomy, interbody, anterior, cervical, discectomy Orthopedic Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion. Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium). Anterior Cervical Discectomy & Fusion - 4 PREOPERATIVE DIAGNOSIS: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,POSTOPERATIVE DIAGNOSES: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,OPERATIVE PROCEDURES,1. Anterior cervical discectomy with decompression, C3-4.,2. Arthrodesis with anterior interbody fusion, C3-4.,3. Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,4. Implant using PEEK 7 mm.,5. Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS: , 1800 mL of crystalloids.,URINE OUTPUT: ,1000 mL.,SPECIMENS: , None.,COMPLICATIONS: ,None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: ,Less than 100 mL.,CONDITION: ,To postanesthesia care unit extubated with stable vital signs.,INDICATIONS FOR THE OPERATION: ,This is a case of a very pleasant 32-year-old Caucasian male who had been experiencing posterior neck discomfort and was shooting basketball last week, during which time he felt a pop. Since then, the patient started complaining of acute right arm and right leg weakness, which had been progressively worsening. About two days ago, he started noticing weakness on the left arm. The patient also noted shuffling gait. The patient presented to a family physician and was referred to Dr. X for further evaluation. Dr. X could not attempt to this, so he called me at the office and the patient was sent to the emergency room, where an MRI of the brain was essentially unremarkable as well as MRI of the thoracic spine. MRI of the cervical spine, however, revealed an acute disk herniation at C3-C4 with evidence of stenosis and cord changes. Based on these findings, I recommended decompression. The patient was started on Decadron at 10 mg IV q.6h. Operation, expected outcome, risks, and benefits were discussed with him. Risks to include but not exclusive of bleeding and infection. Bleeding can be superficial, but can compromise airway, for which he has been told that he may be brought emergently back to the operating room for evacuation of said hematoma. The hematoma could also be an epidural hematoma, which may compress the spinal cord and result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function. Should this happen, he needs to be brought emergently back to the operating room for evacuation of said hematoma. There is also the risk by removing the hematoma that he can deteriorate as far as neurological condition, but this hopefully with the steroid prep will be prevented or if present will only be transient. There is also the possibility of infection, which can be superficial and treated with IV and p.o. antibiotics. However, should the infection be extensive or be deep, he may require return to the operating room for debridement and irrigation. This may pose a medical problem since in the presence of infection, the graft as well as spinal instrumentation may have to be removed. There is also the possibility of dural tear with its attendant complaints of headache, nausea, vomiting, photophobia, as well as the development of pseudomeningocele. This too can compromise airway and may require return to the operating room for repair of the dural tear. There is also potential risk of injury to the esophagus, the trachea, as well as the carotid. The patient can also have a stroke on the right cerebral circulation should the plaque be propelled into the right circulation. The patient understood all these risks together with the risk associated with anesthesia and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room, awake, alert and not in any form of distress. After smooth induction and intubation, a Foley catheter was inserted. No monitoring leads were placed. The patient was then positioned supine on the operating table with the head supported on a foam doughnut and the neck placed on hyperextension with a shoulder roll under both shoulders. Localizing x-ray verified the marker to be right at the C3-4 interspace. Proceeded to mark an incision along the anterior border of the sternocleidomastoid with the central point at the area of the marker measuring about 3 cm in length. The area was then prepped with DuraPrep.,After sterile drapes were laid out, an incision was made using a scalpel blade #10. Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to cut the platysma in a similar fashion. The anterior border of the sternocleidomastoid was identified and dissection was carried superior to and lateral to the esophagus and trachea, but medial to the carotid sheath. The prevertebral fascia was identified. Localizing x-ray verified another marker to be at the C3-4 interspace. Proceeded to strip the longus colli muscles off the vertebral body of C3 and C4 and a self-retaining retractor was then laid out. There was some degree of anterior osteophyte and this was carefully drilled down with a Midas 5-mm bur. The disk was then cut through the annulus and removal of the disk was done with the use of the Midas 5-mm bur and later a 3-mm bur. The inferior endplate of C3 and the superior endplate of C4 were likewise drilled out together with posterior inferior osteophyte at the C3 and the posterior superior osteophyte at C4. There was note of a central disk herniation centrally, but more marked displacement of the cord on the left side. By careful dissection of this disk, posterior longitudinal ligament was removed and pressure on the cord was removed. Hemostasis of the epidural bleeders was done with a combination of bipolar coagulation, but we needed to put a small piece of Gelfoam on the patient's left because of profuse venous bleeder. With this completed, the Valsalva maneuver showed no evidence of any CSF leakage. A 7-mm implant with its interior packed with Vitoss was then tapped into place. An 18-mm plate was then screwed down with four 14 x 4.0 mm screws. The area was irrigated with saline, with bacitracin solution. Postoperative x-ray showed excellent placement of the graft and spinal instrumentation. A round French 10 JP drain was laid over the construct and exteriorized though a separate stab incision on the patient's right inferiorly. The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl 4-0 subcuticular stitch for the dermis and Dermabond. The catheter was anchored to the skin with a nylon 3-0 stitch. Dressing was placed only on the exit site of the drain. C-collar was placed, and the patient was transferred to the recovery awake and moving all four extremities. Orthopedic Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal. Anterior cervical fusion. Utilization of allograft for purposes of spinal fusion. Application of anterior cervical locking plate. Anterior Cervical Discectomy & Fusion - 3 PREOPERATIVE DIAGNOSES,1. Cervical spinal stenosis, C3-c4 and C4-C5.,2. Cervical spondylotic myelopathy.,POSTOPERATIVE DIAGNOSES,1. Cervical spinal stenosis, C3-C4 and C4-C5.,2. Cervical spondylotic myelopathy.,OPERATIVE PROCEDURES,1. Radical anterior discectomy, C3-C4 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63075).,2. Radical anterior discectomy C4-C5 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63076).,3. Anterior cervical fusion, C3-C4 (CPT 22554),4. Anterior cervical fusion, C4-C5 (CPT 22585).,5. Utilization of allograft for purposes of spinal fusion (CPT 20931).,6. Application of anterior cervical locking plate C3-C5 (CPT 22845).,ANESTHESIA:, General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,250 cc.,OPERATIVE INDICATIONS: ,The patient is a 50-year-old gentleman who presented to the hospital after a fall, presenting with neck and arm pain as well as weakness. His MRI confirmed significant neurologic compression in the cervical spine, combined with a clinical exam consistent with radiculopathy, myelopathy, and weakness. We discussed the diagnosis and the treatment options. Due to the severity of his neurologic symptoms as well as the amount of neurologic compression seen radiographically, I recommended that he proceed with surgical intervention as opposed to standard nonsurgical treatment such as physical therapy, medications, and steroid injections. I explained the surgery itself which will be to remove pressure from the spinal cord via anterior cervical discectomy and fusion at C3-C4 and C4-C5. We reviewed the surgery itself as well as risks including infection and blood vessels or nerves, leakage of spinal fluid, weakness or paralysis, failure of the pain to improve, possible worsening of the pain, failure of the neurologic symptoms to improve, possible worsening of the neurologic symptoms, and possible need for further surgery including re-revision and/or removal. Furthermore I explained that the fusion may not become solid or that the hardware could break. We discussed various techniques available for obtaining fusion and I recommended allograft and plate fixation. I explained the rationale for this as well as the options of using his own bone. Furthermore, I explained that removing motion at the fusion sites will transfer stress to other disc levels possibly accelerating there degeneration and causing additional symptoms and/or necessitating additional surgery in the future.,OPERATIVE TECHNIQUE: , After obtaining the appropriate signed and informed consent, the patient was taken to the operating room, where he underwent general endotracheal anesthesia without complications. He was then positioned supine on the operating table, and all bony prominences were padded. Pulse oximetry was maintained on both feet throughout the case. The arms were carefully padded and tucked at his sides. A roll was placed between the shoulder blades. The areas of the both ears were sterilely prepped and cranial tongs were applied in routine fashion. Ten pounds of traction was applied. A needle was taped to the anterior neck and an x-ray was done to determine the appropriate level for the skin incision. The entire neck was then sterilely prepped and draped in the usual fashion.,A transverse skin incision was made and carried down to the platysma muscle. This was then split in line with its fibers. Blunt dissection was carried down medial to the carotid sheath and lateral to the trachea and esophagus until the anterior cervical spine was visualized. A needle was placed into a disc and an x-ray was done to determine its location. The longus colli muscles were then elevated bilaterally with the electrocautery unit. Self-retaining retractors were placed deep to the longus colli muscle in an effort to avoid injury to the sympathetic chains.,Radical anterior discectomies were performed at C3-C4 and C4-C5. This included complete removal of the anterior annulus, nucleus, and posterior annulus. The posterior longitudinal ligament was removed as were the posterior osteophytes. Foraminotomies were then accomplished bilaterally. Once all of this was accomplished, the blunt-tip probe was used to check for any residual compression. The central canal was wide open at each level as were the foramen.,A high-speed bur was used to remove the cartilaginous endplates above and below each interspace. Bleeding cancellous bone was exposed. The disc spaces were measured and appropriate size allografts were placed sterilely onto the field. After further shaping of the grafts with the high-speed bur, they were carefully impacted in to position. There was good juxtaposition against the bleeding decorticated surfaces and good distraction of each interspace. All weight was then removed from the crania tongs.,The appropriate size anterior cervical locking plate was chosen and bent into gentle lordosis. Two screws were then placed into each of the vertebral bodies at C3, C4, and C5. There was excellent purchase. A final x-ray was done confirming good position of the hardware and grafts. The locking screws were then applied, also with excellent purchase.,Following a final copious irrigation, there was good hemostasis and no dural leaks. The carotid pulse was strong. A drain was placed deep to the level of the platysma muscle and left at the level of the hardware. The wounds were then closed in layers using 4-0 Vicryl suture for the platysma muscle, 4-0 Vicryl suture for the subcutaneous tissue, and 4-0 Vicryl suture in a subcuticular skin closure. Steri-Strips were placed followed by application of a sterile dressing. The drain was hooked to bulb suction. A Philadelphia collar was applied.,The cranial tongs were carefully removed. The soft tissue overlying the puncture site was massaged to free it up from the underlying bone. There was good hemostasis.,The patient was then carefully returned to the supine position on his hospital bed where he was reversed and extubated and taken to the recovery room having tolerated the procedure well. Orthopedic Herniated nucleus pulposus, C5-C6, with spinal stenosis. Anterior cervical discectomy with fusion C5-C6. Anterior Cervical Discectomy & Fusion - 2 PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,PROCEDURE: , Anterior cervical discectomy with fusion C5-C6.,PROCEDURE IN DETAIL: , The patient was placed in supine position. The neck was prepped and draped in the usual fashion. An incision was made from midline to the anterior border of the sternocleidomastoid in the right side. Skin and subcutaneous tissue were divided sharply. Trachea and esophagus were retracted medially. Carotid sheath was retracted laterally. Longus colli muscles were dissected away from the vertebral bodies of C5-C6. We confirmed our position by taking intraoperative x-rays. We then used the operating microscope and cleaned out the disk completely. We then sized the interspace and then tapped in a #7 mm cortical cancellous graft. We then used the DePuy Dynamic plate with 14-mm screws. Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision. The wound was closed in layers using 2-0 Vicryl for muscle and fascia. The blood loss was less than 10-20 mL. No complication. Needle count, sponge count, and cottonoid count was correct. orthopedic, carotid sheath, jackson-pratt drain, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, herniated nucleus, nucleus pulposus, spinal stenosis, discectomy, fusion, herniated, nucleus, pulposus, spinal, stenosis, anterior Orthopedic Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws. Cervical spondylosis and herniated nucleus pulposus of C4-C5. Anterior Cervical Discectomy & Arthrodesis - 2 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. orthopedic, synthes vector plate, lordotic, acf spacer, corticocancellous, arthrodesis, anterior cervical discectomy, herniated nucleus pulposus, anterior, cervical, spacer, screws, discectomy, Orthopedic Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure. Cervical spondylotic myelopathy with cord compression and cervical spondylosis. Anterior Cervical Discectomy & Fusion PREOPERATIVE DIAGNOSES:, Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,POSTOPERATIVE DIAGNOSES:, Cervical spondylotic myelopathy with cord compression and cervical spondylosis. In addition to this, he had a large herniated disk at C3-C4 in the midline.,PROCEDURE: , Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.,PROCEDURE IN DETAIL: , The patient placed in the supine position, the neck was prepped and draped in the usual fashion. Incision was made in the midline the anterior border of the sternocleidomastoid at the level of C4. Skin, subcutaneous tissue, and vertebral muscles divided longitudinally in the direction of the fibers and the trachea and esophagus was retracted medially. The carotid sheath was retracted laterally after dissecting the longus colli muscle away from the vertebral osteophytes we could see very large osteophytes at C4-C5. It appeared that the C5-C6 disk area had fused spontaneously. We then confirmed that position by taking intraoperative x-rays and then proceeded to do discectomy and fusion at C3-C4, C4-C5.,After placing distraction screws and self-retaining retractors with the teeth beneath the bellies of the longus colli muscles, we then meticulously removed the disk at C3-C4, C4-C5 using the combination of angled strip, pituitary rongeurs, and curettes after we had incised the anulus fibrosus with #15 blade.,Next step was to totally decompress the spinal cord using the operating microscope and high-speed cutting followed by the diamond drill with constant irrigation. We then drilled off the uncovertebral osteophytes and midline osteophytes as well as thinning out the posterior longitudinal ligaments. This was then removed with 2-mm Kerrison rongeur. After we removed the posterior longitudinal ligament, we could see the dura pulsating nicely. We did foraminotomies at C3-C4 as well as C4-C5 as well. After having totally decompressed both the cord as well as the nerve roots of C3-C4, C4-C5, we proceeded to the next step, which was a fusion.,We sized two 8-mm cortical cancellous grafts and after distracting the bone at C3-C4, C4-C5, we gently tapped the grafts into place. The distraction was removed and the grafts were now within. We went to the next step for the procedure, which was the instrumentation and stabilization of the fused area.,We then placed a titanium ABC plate from C3-C5, secured it with 16-mm titanium screws. X-rays showed good position of the screws end plate.,The next step was to place Jackson-Pratt drain to the vertebral fascia. Meticulous hemostasis was obtained. The wound was closed in layers using 2-0 Vicryl for the subcutaneous tissue. Steri-Strips were used for skin closure. Blood loss less than about 200 mL. No complications of the surgery. Needle counts, sponge count, and cottonoid count was correct. orthopedic, titanium plates fixation, bone black bone procedure, anterior cervical discectomy, titanium plates, cervical discectomy, spondylotic myelopathy, cord compression, cervical spondylosis, foraminotomies, cervical, anterior Orthopedic C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy. Anterior Cervical Discectomy - 4 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. orthopedic, cervical radiculopathy, anterior cervical discectomy, bank allograft, cervical discectomy, anterior, cervical, foramen, discectomy, allograft, radiculopathy, Orthopedic Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6. Anterior Cervical Discectomy & Decompression - 1 PREOPERATIVE DIAGNOSES,1. Herniated disc, C5-C6.,2. Cervical spondylosis, C5-C6.,POSTOPERATIVE DIAGNOSES,1. Herniated disc, C5-C6.,2. Cervical spondylosis, C5-C6.,PROCEDURES,1. Anterior cervical discectomy with decompression, C5-C6.,2. Anterior cervical fusion, C5-C6.,3. Anterior cervical instrumentation, C5-C6.,4. Allograft C5-C6.,ANESTHESIA: ,General endotracheal.,COMPLICATIONS:, None.,PATIENT STATUS: , Taken to recovery room in stable condition.,INDICATIONS: , The patient is a 36-year-old female who has had severe, recalcitrant right upper extremity pain, numbness, tingling, shoulder pain, axial neck pain, and headaches for many months. Nonoperative measures failed to relieve her symptoms and surgical intervention was requested. We discussed reasonable risks, benefits, and alternatives of various treatment options. Continuation of nonoperative care versus the risks associated with surgery were discussed. She understood the risks including bleeding, nerve vessel damage, infection, hoarseness, dysphagia, adjacent segment degeneration, continued worsening pain, failed fusion, and potential need for further surgery. Despite these risks, she felt that current symptoms will be best managed operatively.,SUMMARY OF SURGERY IN DETAIL: , Following informed consent and preoperative administration of antibiotics, the patient was brought to the operating suite. General anesthetic was administered. The patient was placed in the supine position. All prominences and neurovascular structures were well accommodated. The patient was noted to have pulse in this position. Preoperative x-rays revealed appropriate levels for skin incision. Ten pound inline traction was placed via Gardner-Wells tongs and shoulder roll was placed. The patient was then prepped and draped in sterile fashion. Standard oblique incision was made over the C6 vertebral body in the proximal nuchal skin crease. Subcutaneous tissue was dissected down to the level of the omohyoid which was transected. Blunt dissection was carried out with the trachea and the esophagus in the midline and the carotid sheath in its vital structures laterally. This was taken down to the prevertebral fascia which was bluntly split. Intraoperative x-ray was taken to ensure proper levels. Longus colli was identified and reflected proximally 3 to 4 mm off the midline bilaterally so that the anterior cervical Trimline retractor could be placed underneath the longus colli, thus placing no new traction on the surrounding vital structures. Inferior spondylosis was removed with high-speed bur. A scalpel and curette was used to remove the disc. Decompression was carried posterior to the posterior longitudinal ligament down to the uncovertebral joints bilaterally. Disc herniation was removed from the right posterolateral aspect of the interspace. High-speed bur was used to prepare the endplate down to good bleeding bone and preparation for fusion. Curette and ball tip dissector was then passed out the foramen and along the ventral aspect of the dura. No further evidence of compression was identified. Hemostasis was achieved with thrombin-soaked Gelfoam. Interspace was then distracted with Caspar pin distractions set gently. Interspace was then gently retracted with the Caspar pin distraction set. An 8-mm allograft was deemed in appropriate fit. This was press fit with demineralized bone matrix and tamped firmly into position achieving excellent interference fit. The graft was stable to pull-out forces. Distraction and traction was then removed and anterior cervical instrumentation was completed using a DePuy Trimline anterior cervical plate with 14-mm self-drilling screws. Plate and screws were then locked to the plate. Final x-rays revealed proper positioning of the plate, excellent distraction in the disc space, and apposition of the endplates and allograft. Wounds were copiously irrigated with normal saline. Omohyoid was approximated with 3-0 Vicryl. Running 3-0 Vicryl was used to close the platysma. Subcuticular Monocryl and Steri-Strips were used to close the skin. A deep drain was placed prior to wound closure. The patient was then allowed to awake from general anesthetic and was taken to the recovery room in stable condition. There were no intraoperative complications. All needle and sponge counts were correct. Intraoperative neurologic monitoring was used throughout the entirety of the case and was normal. orthopedic, cervical spondylosis, cervical fusion, decompression, instrumentation, anterior cervical discectomy, anterior cervical, herniated disc, cervical discectomy, anterior, cervical, fusion, allograft, discectomy Orthopedic Anterior cervical discectomy and fusion, C2-C3, C3-C4. Removal of old instrumentation, C4-C5. Fusion C3-C4 and C2-C3 with instrumentation using ABC plates. Anterior Cervical Discectomy & Fusion - 1 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. orthopedic, abc plates, osteophyte, cervical, discectomy, cervical fusion, herniated nucleus pulposus, anterior cervical discectomy, nucleus pulposus, vertebral bodies, osteophyte formation, spinal stenosis, cervical discectomy, anterior, instrumentation, vertebral, stenosis, fusion Orthopedic Arthrodesis - anterior interbody technique, anterior cervical discectomy, anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws, implantation of machine bone implant. Disc herniation with right arm radiculopathy. Anterior Cervical Discectomy & Arthrodesis - 1 PREOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,POSTOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,PROCEDURE:,1. C5-C6 arthrodesis, anterior interbody technique.,2. C5-C6 anterior cervical discectomy.,3. C5-C6 anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws.,4. Implantation of machine bone implant.,5. Microsurgical technique.,ANESTHESIA: ,General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,BACKGROUND INFORMATION AND SURGICAL INDICATIONS: ,The patient is a 45-year-old right-handed gentleman who presented with neck and right arm radicular pain. The pain has become more and more severe. It runs to the thumb and index finger of the right hand and it is accompanied by numbness. If he tilts his neck backwards, the pain shoots down the arm. If he is working with the computer, it is very difficult to use his mouse. He tried conservative measures and failed to respond, so he sought out surgery. Surgery was discussed with him in detail. A C5-C6 anterior cervical discectomy and fusion was recommended. He understood and wished to proceed with surgery. Thus, he was brought in same day for surgery on 07/03/2007.,DESCRIPTION OF PROCEDURE: , He was given Ancef 1 g intravenously for infection prophylaxis and then transported to the OR. There general endotracheal anesthesia was induced. He was positioned on the OR table with an IV bag between the scapulae. The neck was slightly extended and taped into position. A metal arch was placed across the neck and intraoperative x-ray was obtain to verify a good position for skin incision and the neck was prepped with Betadine and draped in the usual sterile fashion.,A linear incision was created in the neck beginning just to the right of the midline extending out across the anterior border of the sternocleidomastoid muscle. The incision was extended through skin, subcutaneous fat, and platysma. Hemostasis was assured with Bovie cautery. The anterior aspect of the sternocleidomastoid muscle was identified and dissection was carried medial to this down to the carotid sheath. The trachea and the esophagus were swept out of the way and dissection proceeded medial to the carotid sheath down between the two bellies of the longus colli muscle on to the anterior aspect of the spine. A Bovie cautery was used to mobilize the longus colli muscle around initially what turned out to be C6-C7 disk based on x-rays and then around the C5-C6 disk space. An intraoperative x-ray confirmed C5-C6 disk space had been localized and then the self-retained distraction system was inserted to maintain exposure. A 15-blade knife was used to incise the C5-C6 disk and remove disk material. and distraction pins were inserted into C5-C6 and distraction placed across the disk space. The operating microscope was then brought into the field and used throughout the case except for the closure. Various pituitaries, #15 blade knife, and curette were used to evacuate the disk as best as possible. Then, the Midas Rex drill was taken under the microscope and used to drill where the cartilaginous endplate driven back all the way into the posterior aspect of the vertebral body. A nerve hook was swept underneath the posterior longitudinal ligament and a fragment of disk was produced and was pulled up through the ligament. A Kerrison rongeur was used to open up the ligament in this opening and then to march out in the both neural foramina. A small amount of disk material was found at the right neural foramen. After a good decompression of both neural foramina was obtained and the thecal sac was exposed throughout the width of the exposure, the wound was thoroughly irrigated. A spacing mechanism was intact into the disk space and it was determined that a #7 spacer was appropriate. So, a #7 machine bone implant was taken and tapped into disk space and slightly counter sunk. The wound was thoroughly irrigated and inspected for hemostasis. A Mystique plate 23 mm in length was then inserted and anchored to the anterior aspect of C5-C6 to hold the bone into position and the wound was once again irrigated. The patient was valsalved. There was no further bleeding seen and intraoperative x-ray confirmed a good position near the bone, plate, and screws and the wound was enclosed in layers. The 3-0 Vicryl was used to approximate platysma and 3-0 Vicryl was used in inverted interrupted fashion to perform a subcuticular closure of the skin. The wound was cleaned.,Mastisol was placed on the skin, and Steri-strips were used to approximate skin margins. Sterile dressing was placed on the patient's neck. He was extubated in the OR and transported to the recovery room in stable condition. There were no complications. orthopedic, herniation, radiculopathy, interbody, mystique, bone implant, anterior cervical discectomy, neural foramina, mystique plate, disc herniation, arm radiculopathy, cervical discectomy, disk space, disk, cervical, anterior, wound, discectomy, Orthopedic " Anterior cervical discectomy, arthrodesis, partial corpectomy, Machine bone allograft, placement of anterior cervical plate with a Zephyr. 7. Microscopic dissection." Anterior Cervical Discectomy & Arthrodesis PREOPERATIVE DIAGNOSIS:, Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,POSTOPERATIVE DIAGNOSIS: , Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,PROCEDURE PERFORMED:,1. Anterior cervical discectomy, C4-C5 and C5-C6.,2. Arthrodesis, C4-C5 and C5-C6.,3. Partial corpectomy, C5.,4. Machine bone allograft, C4-C5 and C5-C6.,5. Placement of anterior cervical plate with a Zephyr C4 to C6.,6. Fluoroscopic guidance.,7. Microscopic dissection.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: , 60 mL.,COMPLICATIONS: , None.,INDICATIONS:, This is a patient who presents with progressive weakness in the left upper extremity as well as imbalance. He has also noted to have cord signal at the C4-C5 level secondary to a very large disc herniation that came behind the body at C5 as well and as well as a large disc herniation at C5-C6. Risks and benefits of the surgery including bleeding, infection, neurologic deficit, nonunion, progressive spondylosis, and lack of improvement were all discussed. He understood and wished to proceed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in the supine position. Preoperative antibiotics were given. The patient was placed in the supine position with all pressure points noted and well padded. The patient was prepped and draped in standard fashion. An incision was made approximately above the level of the cricoid. Blunt dissection was used to expose the anterior portion of the spine with carotid moved laterally and trachea and esophagus moved medially. We then placed needle into the disc spaces and was found to be at C5-C6. Distracting pins were placed in the body of C4 and in to the body of C6. The disc was then completely removed at C4-C5. There was very significant compression of the cord. This was carefully removed to avoid any type of pressure on the cord. This was very severe and multiple free fragments were noted. This was taken down to the level of ligamentum. Both foramen were then also opened. Other free fragments were also found behind the body of C5, part of the body of C5 was taken down to assure that all of these were removed. The exact same procedure was done at C5-C6; however, if there were again free fragments noted, there was less not as severe compression at the C4-C5 area. Again part of the body at C5 was removed to make sure that there was no additional constriction. Both nerve roots were then widely decompressed. Machine bone allograft was placed into the C4-C5 as well as C5-C6 and then a Zephyr plate was placed in the body of C4 and to the body of C6 with a metal pin placed into the body at C5. Excellent purchase was obtained. Fluoroscopy showed good placement and meticulous hemostasis was obtained. Fascia was closed with 3-0 Vicryl, subcuticular 3-0 Dermabond for skin. The patient tolerated the procedure well and went to recovery in good condition. orthopedic, fluoroscopic guidance, microscopic dissectio, cervical plate, zephyr, corpectomy, arthrodesis, anterior cervical discectomy, machine bone allograft, cervical discectomy, bone allograft, disc herniations, anterior, cervical, discectomy, Orthopedic Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss. Anterior Cervical Discectomy & Decompression 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. Orthopedic Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used. Anterior Cervical Discectomy - 3 PREOPERATIVE DIAGNOSES: , Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,POSTOPERATIVE DIAGNOSES:, Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,PROCEDURES:, C5-C6 and C6-C7 anterior cervical discectomy (two levels) C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:, None.,INDICATION FOR THE PROCEDURE: , This lady presented with history of cervical pain associated with cervical radiculopathy with cervical and left arm pain, numbness, weakness, with MRI showing significant disk protrusions with the associate complexes at C5-C6 and C6-C7 with associated cervical radiculopathy. After failure of conservative treatment, this patient elected to undergo surgery.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the OR and after adequate general endotracheal anesthesia, she was placed supine on the OR table with the head of the bed about 10 degrees. A shoulder roll was placed and the head supported on a donut support. The cervical region was prepped and draped in the standard fashion. A transverse cervical incision was made from the midline, which was lateral to the medial edge of the sternocleidomastoid two fingerbreadths above the right clavicle. In a transverse fashion, the incision was taken down through the skin and subcutaneous tissue and through the platysmata and a subplatysmal dissection done. Then, the dissection continued medial to the sternocleidomastoid muscle and then medial to the carotid artery to the prevertebral fascia, which was gently dissected and released superiorly and inferiorly. Spinal needles were placed into the displaced C5-C6 and C6-C7 to confirm these disk levels using lateral fluoroscopy. Following this, monopolar coagulation was used to dissect the medial edge of the longus colli muscles off the adjacent vertebrae between C5-C7 and then the Trimline retractors were placed to retract the longus colli muscles laterally and blunt retractors were placed superiorly and inferiorly. A #15 scalpel was used to do a discectomy at C5-C6 from endplate-to-endplate and uncovertebral joint. On the uncovertebral joint, a pituitary rongeur was used to empty out any disk material ____________ to further remove the disk material down to the posterior aspect. This was done under the microscope. A high-speed drill under the microscope was used to drill down the endplates to the posterior aspect of the annulus. A blunt trocar was passed underneath the posterior longitudinal ligament and it was gently released using the #15 scalpel and then Kerrison punches 1-mm and then 2-mm were used to decompress further disk calcified material at the C5-C6 level. This was done bilaterally to allow good decompression of the thecal sac and adjacent neuroforamen. Then, at the C6-C7 level, in a similar fashion, #15 blade was used to do a discectomy from uncovertebral joint to uncovertebral joint and from endplate-to-endplate using a #15 scalpel to enter the disk space and then the curette was then used to remove the disk calcified material in the endplate, and then high-speed drill under the microscope was used to drill down the disk space down to the posterior aspect of the annulus where a blunt trocar was passed underneath the posterior longitudinal ligament which was gently released. Then using the Kerrison punches, we used 1-mm and 2-mm, to remove disk calcified material, which was extending more posteriorly to the left and the right. This was gently removed and decompressed to allow good decompression of the thecal sac and adjacent nerve roots. With this done, the wound was irrigated. Hemostasis was ensured with bipolar coagulation. Vertebral body distraction pins were then placed to the vertebral body of C5 and C7 for vertebral distraction and then a 6-mm allograft performed grafts were taken and packed in either aspect with demineralized bone matrix and this was tapped in flush with the vertebral bodies above and below C5-C6 and C6-C7 discectomy sites. Then, the vertebral body distraction pins were gently removed to allow for graft seating and compression and then the anterior cervical plate (Danek windows titanium plates) was then taken and sized and placed. A temporary pin was initially used to align the plate and then keeping the position and then two screw holes were drilled in the vertebral body of C5, two in the vertebral body of C6, and two in the vertebral body of C7. The holes were then drilled and after this self-tapping screws were placed into the vertebral body of C5, C6, and C7 across the plate to allow the plate to fit and stay flush with the vertebral body between C5, C6, and C7. With this done, operative fluoroscopy was used to check good alignment of the graft, screw, and plate, and then the wound was irrigated. Hemostasis was ensured with bipolar coagulation and then the locking screws were tightened down. A #10 round Jackson-Pratt drain was placed into the prevertebral space and brought out from a separate stab wound skin incision site. Then, the platysma was approximated using 2-0 Vicryl inverted interrupted stitches and the skin closed with 4-0 Vicryl running subcuticular stitch. Steri-Strips and sterile dressings were applied. The patient remained hemodynamically stable throughout the procedure. Throughout the procedure, the microscope had been used for the disk decompression and high-speed drilling. In addition, intraoperative SSEP, EMG monitoring, and motor-evoked potentials remained stable throughout the procedure. The patient remained stable throughout the procedure. orthopedic, cervical disk protrusions, cervical radiculopathy, cervical pain, cervical plate fixation, sofamor danek titanium window plate, anterior cervical discectomy, vertebral body, vertebral, disk, intraoperative, anterior, decompression, fluoroscopy, radiculopathy, discectomy, cervical, Orthopedic Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. Right C5-C6 herniated nucleus pulposus. Anterior Cervical Discectomy - 2 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. orthopedic, herniated nucleus pulposus, anterior cervical discectomy, artificial disk replacement, cervical, discectomy, nucleusNOTE Orthopedic Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression. Harvesting of autologous bone from the vertebral bodies. Grafting of allograft bone for creation of arthrodesis. Anterior Cervical Discectomy 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. Orthopedic History and Physical for right ankle sprain Ankle Sprain - H&P 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. Orthopedic Achilles tendon rupture, left lower extremity. Primary repair left Achilles tendon. The patient 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. Achilles Tendon Repair 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. orthopedic, repair, achilles tendon rupture, longitudinal incision, tendon rupture, achilles tendon, tendon, achilles, rupture, extremity Orthopedic Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique. Anterior Cervical Discectomy - 1 PREOPERATIVE DIAGNOSIS: , Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:, Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,OPERATION PERFORMED,1. Anterior cervical discectomy of C3-C4.,2. Removal of herniated disc and osteophytes.,3. Bilateral C4 nerve root decompression.,4. Harvesting of bone for autologous vertebral bodies for creation of arthrodesis.,5. Grafting of fibular allograft bone for creation of arthrodesis.,6. Creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies.,7. Placement of anterior spinal instrumentation using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has progressive and intractable right C4 radiculopathy with neck and shoulder pain. Conservative therapy has failed to improve the problem. Imaging studies showed severe spondylosis of C3-C4 with neuroforaminal narrowing and spinal cord compression.,A detailed discussion ensued with the patient as to the nature of the procedure including all risks and alternatives. He clearly understood it and had no further questions and requested that I proceed.,PROCEDURE IN DETAIL: , The patient was placed on the operating room table and was intubated using a fiberoptic technique. The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion doses. The neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made on a skin crease on the left side of the neck. Dissection was carried down through the platysmal musculature and the anterior spine was exposed. The medial borders of the longus colli muscles were dissected free from their attachments to the spine. A needle was placed and it was believed to be at the C3-C4 interspace and an x-ray properly localized this space. Castoff self-retaining pins were placed into the body of the C3 and C4. Self-retaining retractors were placed in the wound keeping the blades of the retractors underneath the longus colli muscles.,The annulus was incised and a discectomy was performed. Quite a bit of overhanging osteophytes were identified and removed. As I worked back to the posterior lips of the vertebral body, the operating microscope was utilized.,There was severe overgrowth of spondylitic spurs. A high-speed diamond bur was used to slowly drill these spurs away. I reached the posterior longitudinal ligament and opened it and exposed the underlying dura.,Slowly and carefully I worked out towards the C3-C4 foramen. The dura was extremely thin and I could see through it in several areas. I removed the bony compression in the foramen and identified soft tissue and veins overlying the root. All of these were not stripped away for fear of tearing this very tissue-paper-thin dura. However, radical decompression was achieved removing all the bony compression in the foramen, out to the pedicle, and into the foramen. An 8-mm of the root was exposed although I left the veins over the root intact.,The microscope was angled to the left side where a similar procedure was performed.,Once the decompression was achieved, a high-speed cortisone bur was used to decorticate the body from the greater posterior shelf to prevent backward graft migration. Bone thus from the drilling was preserved for use for the arthrodesis.,Attention was turned to creation of the arthrodesis. As I had drilled quite a bit into the bodies, I selected a large 12-mm graft and distracted the space maximally. Under distraction the graft was placed and fit well. An x-ray showed good graft placement.,Attention was turned to spinal instrumentation. A Synthes Short Stature plate was used with four 3-mm screws. Holes were drilled with all four screws were placed with pretty good purchase. Next, the locking screws were then applied. An x-ray was obtained which showed good placement of graft, plate, and screws. The upper screws were near the upper endplate of C3. The C3 vertebral body that remained was narrow after drilling off the spurs. Rather than replace these screws and risk that the next holes would be too near the present holes I decided to leave these screws intact because their position is still satisfactory as they are below the disc endplate.,Attention was turned to closure. A Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab wound incision in the skin. The wound was then carefully closed in layers. Sterile dressings were applied along with a rigid Philadelphia collar. The operation was then 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 and there were no intraoperative complications.,Specimens were sent to Pathology consisted of bone and soft tissue as well as C3-C4 disc material. orthopedic, herniated, osteophytes, nerve root decompression, harvesting, autologous, vertebral, arthrodesis, anterior technique, anterior cervical discectomy, spinal cord compression, fibular allograft bone, creation of arthrodesis, cervical discectomy, spinal instrumentation, cord compression, vertebral body, vertebral bodies, spinal cord, bone, instrumentation, cervical, anterior, grafting, spinal, discectomy, allograft, Orthopedic The patient was running and twisted her right ankle - right ankle sprain. Ankle Pain - Consult 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. Orthopedic Herniated nucleus pulposus. Anterior cervical decompression, anterior spine instrumentation, anterior cervical spine fusion, and application of machined allograft. Anterior Cervical Decompression PREOPERATIVE DIAGNOSES,1. Herniated nucleus pulposus, C5-C6.,2. Herniated nucleus pulposus, C6-C7.,POSTOPERATIVE DIAGNOSES,1. Herniated nucleus pulposus, C5-C6.,2. Herniated nucleus pulposus, C6-C7.,PROCEDURE PERFORMED,1. Anterior cervical decompression, C5-C6.,2. Anterior cervical decompression, C6-C7.,3. Anterior spine instrumentation.,4. Anterior cervical spine fusion, C5-C6.,5. Anterior cervical spine fusion, C6-C7.,6. Application of machined allograft at C5-C6.,7. Application of machined allograft at C6-C7.,8. Allograft, structural at C5-C6.,9. Allograft, structural at C6-C7.,ANESTHESIA: , General.,PREOPERATIVE NOTE: ,This patient is a 47-year-old male with chief complaint of severe neck pain and left upper extremity numbness and weakness. Preoperative MRI scan showed evidence of herniated nucleus pulposus at C5-C6 and C6-C7 on the left. The patient has failed epidural steroid injections. Risks and benefits of the above procedure were discussed with the patient including bleeding, infection, muscle loss, nerve damage, paralysis, and death.,OPERATIVE REPORT: , The patient was taken to the OR and placed in the supine position. After general endotracheal anesthesia was obtained, the patient's neck was sterilely prepped and draped in the usual fashion. A horizontal incision was made on the left side of the neck at the level of the C6 vertebral body. It was taken down through the subcutaneous tissues exposing the platysmus muscle. The platysmus muscle was incised along the skin incision and the deep cervical fascia was bluntly dissected down to the anterior cervical spine. An #18 gauge needle was placed in the C5-C6 interspace and the intraoperative x-ray confirmed that this was the appropriate level. Next, the longus colli muscles were resected laterally on both the right and left side, and then a complete anterior cervical discectomy was performed. The disk was very degenerated and brown in color. There was an acute disk herniation through posterior longitudinal ligament. The posterior longitudinal ligament was removed and a bilateral foraminotomy was performed. Approximately, 5 mm of the nerve root on both the right and left side was visualized. A ball-ended probe could be passed up the foramen. Bleeding was controlled with bipolar electrocautery and Surgiflo. The end plates of C5 and C6 were prepared using a high-speed burr and a 6-mm lordotic machined allograft was malleted into place. There was good bony apposition both proximally and distally. Next, attention was placed at the C6-C7 level. Again, the longus colli muscles were resected laterally and a complete anterior cervical discectomy at C6-C7 was performed. The disk was degenerated and there was acute disk herniation in the posterior longitudinal ligament on the left. The posterior longitudinal ligament was removed. A bilateral foraminotomy was performed. Approximately, 5 mm of the C7 nerve root was visualized on both sides. A micro nerve hook was able to be passed up the foramen easily. Bleeding was controlled with bipolar electrocautery and Surgiflo. The end plates at C6-C7 were then prepared using a high-speed burr and then a 7-mm machined lordotic allograft was malleted into place. There was good bony apposition, both proximally and distally. Next, a 44-mm Blackstone low-profile anterior cervical plate was applied to the anterior cervical spine with six 14 mm screws. Intraoperative x-ray confirmed appropriate positioning of the plate and the graft. The wound was then copiously irrigated with normal saline and bacitracin. There was no active bleeding upon closure of the wound. A small drain was placed deep. The platysmal muscle was closed with 3-0 Vicryl. The skin was closed with #4-0 Monocryl. Mastisol and Steri-Strips were applied. The patient was monitored throughout the procedure with free-running EMGs and SSEPs and there were no untoward events. The patient was awoken and taken to the recovery room in satisfactory condition. orthopedic, herniated nucleus pulposus, anterior cervical decompression, spine fusion, cervical spine, allograft, anterior cervical spine, anterior, cervical, Orthopedic Removal of the hardware and revision of right AC separation. Loose hardware with superior translation of the clavicle implants. Arthrex bioabsorbable tenodesis screws. AC Separation Revision & Hardware Removal PREOPERATIVE DIAGNOSIS:, Right AC separation.,POSTOPERATIVE DIAGNOSIS:, Right AC separation.,PROCEDURES:, Removal of the hardware and revision of right AC separation.,ANESTHESIA:, General.,BLOOD LOSS:, 100 cc.,COMPLICATIONS:, None.,FINDINGS: , Loose hardware with superior translation of the clavicle implants.,IMPLANTS: , Arthrex bioabsorbable tenodesis screws.,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, he was positioned in the beach chair and his right shoulder was sterilely prepped and draped in a normal fashion. The incision was reopened and the hardware was removed without difficulty. The AC joint was inspected and reduced. An allograft was used to recreate the coracoacromial ligaments and then secured to decorticate with a bioabsorbable tenodesis screw and then to the clavicle. And two separate areas that were split, one taken medially and one taken laterally, and then sewed together for further stability. This provided good stability with no further superior translation of the clavicle as viewed under fluoroscopy. The wound was copiously irrigated and the wound was closed in layers and a soft dressing was applied. He was awakened from anesthesia and taken to recovery room in a stable condition.,Final needle and instrument counts were correct. orthopedic, loose hardware, superior translation, clavicle implants, ac separation, removal of the hardware, arthrex bioabsorbable tenodesis screws, bioabsorbable tenodesis, tenodesis screws, translation, implants, bioabsorbable, tenodesis, clavicle, separation, hardware Orthopedic Right Achilles tendon rupture. Achilles Ruptured Tendon "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." orthopedic, achilles tendon rupture, alignment, crutches, joint space, nonweightbearing, plantarflexion, achilles ruptured tendon, achilles ruptured, ruptured tendon, achilles tendon, tendon rupture, achilles, Orthopedic Bilateral open Achilles lengthening with placement of short leg walking cast. Achilles Lengthening PREOPERATIVE DIAGNOSIS: , Idiopathic toe walker.,POSTOPERATIVE DIAGNOSIS: , Idiopathic toe walker.,PROCEDURE: , Bilateral open Achilles lengthening with placement of short leg walking cast.,ANESTHESIA: , Surgery performed under general anesthesia. A total of 10 mL of 0.5% Marcaine local anesthetic was used.,COMPLICATIONS: ,No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,TOURNIQUET TIME: ,On the left side was 30 minutes, on the right was 21 minutes.,HISTORY AND PHYSICAL:, The patient is a 10-year-old boy who has been a toe walker since he started ambulating at about a year. The patient had some mild hamstring tightness with his popliteal angle of approximately 20 degrees bilaterally. He does not walk with a crouched gait but does toe walk. Given his tightness, surgery versus observation was recommended to the family. Family however wanted to correct his toe walking. Surgery was then discussed. Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to resolve toe walking, possible stiffness, cast, and cast problems. All questions were answered and parents agreed to above surgical plan.,PROCEDURE IN DETAIL: , 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. The patient was then subsequently placed prone with all bony prominences padded. Two bilateral nonsterile tourniquets were placed on each thigh. Both extremities were then prepped and draped in a standard surgical fashion. We turned our attention first towards the left side. A planned incision of 1 cm medial to the Achilles tendon was marked on the skin. The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg. Incision was then made and carried down through subcutaneous fat down to the tendon sheath. Achilles tendon was identified and Z-lengthening was done with the medial distal half cut. Once Z-lengthening was completed proximally, the length of the Achilles tendon was then checked. This was trimmed to obtain an end-on-end repair with 0 Ethibond suture. This was also oversewn. Wound was then irrigated. Achilles tendon sheath was reapproximated using 2-0 Vicryl as well as the subcutaneous fat. The skin was closed using 4-0 Monocryl. Once the wound was cleaned and dried and dressed with Steri-Strips and Xeroform, the area was injected with 0.5% Marcaine. It was then dressed with 4 x 4 and Webril. Tourniquet was released at 30 minutes. The same procedure was repeated on the right side with tourniquet time of 21 minutes. While the patient was still prone, two short-leg walking casts were then placed. The patient tolerated the procedure well and was subsequently flipped supine on to hospital gurney and taken to PACU in stable condition.,POSTOPERATIVE PLAN: ,The patient will be discharged on the day of surgery. He may weightbear as tolerated in his cast, which he will have for about 4 to 6 weeks. He is to follow up in approximately 10 days for recheck as well as prescription for intended AFOs, which he will need up to 6 months. The patient may or may not need physical therapy while his Achilles lengthenings are healing. The patient is not to participate in any PE for at least 6 months. The patient is given Tylenol No. 3 for pain. orthopedic, toe walker, achilles lengthening, idiopathic toe walker, short leg walking, subcutaneous fat, tendon sheath, leg walking, achilles tendon, toe, tourniquet, tendon, intraoperative, Orthopedic EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region. Video EEG - 3 PROCEDURE: , EEG during wakefulness demonstrates background activity consisting of moderate-amplitude beta activity seen bilaterally. The EEG background is symmetric. Independent, small, positive, sharp wave activity is seen in the frontotemporal regions bilaterally with sharp-slow wave discharges seen more predominantly in the right frontotemporal head region. No clinical signs of involuntary movements are noted during synchronous video monitoring. Recording time is 22 minutes and 22 seconds. There is attenuation of the background, faster activity during drowsiness and some light sleep is recorded. No sustained epileptogenic activity is evident, but the independent bilateral sharp wave activity is seen intermittently. Photic stimulation induced a bilaterally symmetric photic driving response.,IMPRESSION:, EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region. The EEG findings are consistent with potentially epileptogenic process. Clinical correlation is warranted. neurology, epileptogenic, wakefulness, eeg, frontotemporal, activityNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., Neurology A pleasant gentleman with a history of Wilson's disease who has been treated with penicillamine. Wilson's Disease - Letter Doctor's Address,Dear Doctor:,This letter is an introduction to my patient, A, who you will be seeing in the near future. He is a pleasant gentleman with a history of Wilson's disease. It has been treated with penicillamine. He was diagnosed with this at age 14. He was on his way to South Carolina for a trip when he developed shortness of breath, palpitations, and chest discomfort. He went to the closest hospital that they were near in Randolph, North Carolina and he was found to be in atrial fibrillation with rapid rate. He was admitted there and observed. He converted to normal sinus rhythm spontaneously and so he required no further interventions. He was started on Lopressor, which he has tolerated well. An echocardiogram was performed, which revealed mild-to-moderate left atrial enlargement. Normal ejection fraction. No other significant valvular abnormality. He reported to physicians there that he had cirrhosis related to his Wilson's disease. Therefore hepatologist was consulted. There was a recommendation to avoid Coumadin secondary to his questionable significant liver disease, therefore he was placed on aspirin 325 mg once a day.,In discussion with Mr. A and review of his chart that I have available, it is unclear as to the status of his liver disease, however, he has never had a liver biopsy, so his diagnosis of cirrhosis that they were concerned about in North Carolina is in doubt. His LFTs have remained normal and his copper level has been undetectable on his current dose of penicillamine.,I would appreciate your input into the long term management of his anticoagulation and also any recommendations you would have about rhythm control. He is in normal sinus rhythm as of my evaluation of him on 06/12/2008. He is tolerating his metoprolol and aspirin without any difficulty. I guess the big question remains is what level of risk that is entailed by placing him on Coumadin therapy due to his potentially paroxysmal atrial fibrillation and evidence of left atrial enlargement that would place him in increased risk of recurrent episodes.,I appreciate your input regarding this friendly gentleman. His current medicines include penicillamine 250 mg p.o. four times a day, metoprolol 12.5 mg twice a day, and aspirin 325 mg a day.,If you have any questions regarding his care, please feel free to call me to discuss his case. Otherwise, I will look forward to hearing back from you regarding his evaluation. Thank you as always for your care of our patient. neurology, atrial enlargement, wilson's disease, penicillamine, Neurology This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology. Video EEG TIME SEEN: , 0734 hours and 1034 hours.,TOTAL RECORDING TIME: , 27 hours 4 minutes.,PATIENT HISTORY: , This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology.,VIDEO EEG DIAGNOSES,1. AWAKE: Normal.,2. SLEEP: No activation.,3. CLINICAL EVENTS: None.,DESCRIPTION: , Approximately 27 hours of continuous 21-channel digital video EEG monitoring was performed. The waking background is unchanged from that previously reported. Hyperventilation produced no changes in the resting record. Photic stimulation failed to elicit a well-developed photic driving response.,Approximately five-and-half hours of spontaneous intermittent sleep was obtained. Sleep spindles were present and symmetric.,The patient had no clinical events during the recording.,CLINICAL INTERPRETATION: ,This is normal video EEG monitoring for a patient of this age. No interictal epileptiform activity was identified. The patient had no clinical events during the recording. Clinical correlation is required. neurology, electroencephalography, eeg monitoring, video eeg, seizures, eeg, Neurology The patient has a history of epilepsy and has also had non-epileptic events in the past. Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events. Video EEG - 1 DATE OF EXAMINATION: , Start: 12/29/2008 at 1859 hours. End: 12/30/2008 at 0728 hours.,TOTAL RECORDING TIME:, 12 hours, 29 minutes.,PATIENT HISTORY:, This is a 46-year-old female with a history of events concerning for seizures. The patient has a history of epilepsy and has also had non-epileptic events in the past. Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,VIDEO EEG DIAGNOSES,1. Awake: Normal.,2. Sleep: Activation of a single left temporal spike seen maximally at T3.,3. Clinical events: None.,DESCRIPTION: ,Approximately 12 hours of continuous 21-channel digital video EEG monitoring was performed. During the waking state, there is a 9-Hz dominant posterior rhythm. The background of the record consists primarily of alpha frequency activity. At times, during the waking portion of the record, there appears to be excessive faster frequency activity. No activation procedures were performed.,Approximately four hours of intermittent sleep was obtained. A single left temporal, T3, spike is seen in sleep. Vertex waves and sleep spindles were present and symmetric.,The patient had no clinical events during the recording.,CLINICAL INTERPRETATION: ,This is abnormal video EEG monitoring for a patient of this age due to the presence of a single left temporal spike seen during sleep. The patient had no clinical events during the recording period. Clinical correlation is required. neurology, non-epileptic events, temporal spike, eeg monitoring, video eeg, epilepsy, frequency, eeg, epileptic, Neurology EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity. Video EEG - 2 IMPRESSION: ,EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity. neurology, ekg artifact, video monitoring, wakefulness, drowsiness, eegNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., Neurology Chronic venous hypertension with painful varicosities, lower extremities, bilaterally. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally. Vein Stripping PREOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,POSTOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,PROCEDURES,1. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, right leg.,2. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, left leg.,PROCEDURE DETAIL: , After obtaining the informed consent, the patient was taken to the operating room where she underwent a general endotracheal anesthesia. A time-out process was followed and antibiotics were given.,Then, both legs were prepped and draped in the usual fashion with the patient was in the supine position. An incision was made in the right groin and the greater saphenous vein at its junction with the femoral vein was dissected out and all branches were ligated and divided. Then, an incision was made just below the knee where the greater saphenous vein was also found and connection to varices from the calf were seen. A third incision was made in the distal third of the right thigh in the area where there was a communication with large branch varicosities. Then, a vein stripper was passed from the right calf up to the groin and the greater saphenous vein, which was divided, was stripped without any difficultly. Several minutes of compression was used for hemostasis. Then, the exposed branch varicosities both in the lower third of the thigh and in the calf were dissected out and then many stabs were performed to do stab phlebectomies at the level of the thigh and the level of the calf as much as the position would allow us to do.,Then in the left thigh, a groin incision was made and the greater saphenous vein was dissected out in the same way as was on the other side. Also, an incision was made in the level of the knee and the saphenous vein was isolated there. The saphenous vein was stripped and a several minutes of local compression was performed for hemostasis. Then, a number of stabs to perform phlebectomy were performed at the level of the calf to excise branch varicosities to the extent that the patient's position would allow us. Then, all incisions were closed in layers with Vicryl and staples.,Then, the patient was placed in the prone position and the stab phlebectomies of the right thigh and calf and left thigh and calf were performed using 10 to 20 stabs in each leg. The stab phlebectomies were performed with a hook and they were very satisfactory. Hemostasis achieved with compression and then staples were applied to the skin.,Then, the patient was rolled onto a stretcher where both legs were wrapped with the Kerlix, fluffs, and Ace bandages.,Estimated blood loss probably was about 150 mL. The patient tolerated the procedure well and was sent to recovery room in satisfactory condition. The patient is to be observed, so a decision will be made whether she needs to stay overnight or be able to go home. neurology, chronic venous hypertension, varicosities, stab phlebectomies, greater saphenous vein stripping, lower extremities, vein stripping, saphenous vein, vein, incisions, hemostasis, stripping, branches, phlebectomies, thigh, calf, saphenous, Neurology Patient experienced a single episode of his vision decreasing. During the episode, he felt nauseated and possibly lightheaded. His wife was present and noted that he looked extremely pale. TIA & Lumbar Stenosis "CHIEF COMPLAINT: , Transient visual loss lasting five minutes.,HISTORY OF PRESENT ILLNESS: , This is a very active and pleasant 82-year-old white male with a past medical history significant for first-degree AV block, status post pacemaker placement, hypothyroidism secondary to hyperthyroidism and irradiation, possible lumbar stenosis. He reports he experienced a single episode of his vision decreasing ""like it was compressed from the top down with a black sheet coming down"". The episode lasted approximately five minutes and occurred three weeks ago while he was driving a car. He was able to pull the car over to the side of the road safely. During the episode, he felt nauseated and possibly lightheaded. His wife was present and noted that he looked extremely pale and ashen during the episode. He went to see the Clinic at that time and received a CT scan, carotid Dopplers, echocardiogram, and neurological evaluation, all of which were unremarkable. It was suggested at that time that he get a CT angiogram since he cannot have an MRI due to his pacemaker. He has had no further similar events. He denies any lesions or other visual change, focal weakness or sensory change, headaches, gait change or other neurological problem.,He also reports that he has been diagnosed with lumbar stenosis based on some mild difficulty arising from a chair for which an outside physician ordered a CT of his L-spine that reportedly showed lumbar stenosis. The question has arisen as to whether he should have a CT myelogram to further evaluate this process. He has no back pain or pain of any type, he denies bowel or bladder incontinence or frank lower extremity weakness. He is extremely active and plays tennis at least three times a week. He denies recent episodes of unexpected falls.,REVIEW OF SYSTEMS: , He only endorses hypothyroidism, the episode of visual loss described above and joint pain. He also endorses having trouble getting out of a chair, but otherwise his review of systems is negative. A copy is in his clinic chart.,PAST MEDICAL HISTORY: ,As above. He has had bilateral knee replacement three years ago and experiences some pain in his knees with this.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:, He is retired from the social security administration x 20 years. He travels a lot and is extremely active. He does not smoke. He consumes alcohol socially only. He does not use illicit drugs. He is married.,MEDICATIONS: , The patient has recently been started on Plavix by his primary care doctor, was briefly on baby aspirin 81 mg per day since the TIA-like event three weeks ago. He also takes Proscar 5 mg q.d and Synthroid 0.2 mg q.d.,PHYSICAL EXAMINATION:,Vital Signs: BP 134/80, heart rate 60, respiratory rate 16, and weight 244 pounds. He denies any pain.,General: This is a pleasant white male in no acute distress.,HEENT: He is normocephalic and atraumatic. Conjunctivae and sclerae are clear. There is no sinus tenderness.,Neck: Supple.,Chest: Clear to auscultation.,Heart: There are no bruits present.,Extremities: Extremities are warm and dry. Distal pulses are full. There is no edema.,NEUROLOGIC EXAMINATION:,MENTAL STATUS: He is alert and oriented to person, place and time with good recent and long-term memory. His language is fluent. His attention and concentration are good.,CRANIAL NERVES: Cranial nerves II through XII are intact. VFFTC, PERRL, EOMI, facial sensation and expression are symmetric, hearing is decreased on the right (hearing aid), palate rises symmetrically, shoulder shrug is strong, tongue protrudes in the midline.,MOTOR: He has normal bulk and tone throughout. There is no cogwheeling. There is some minimal weakness at the iliopsoas bilaterally 4+/5 and possibly trace weakness at the quadriceps -5/5. Otherwise he is 5/5 throughout including hip adductors and abductors.,SENSORY: He has decreased sensation to vibration and proprioception to the middle of his feet only, otherwise sensory is intact to light touch, and temperature, pinprick, proprioception and vibration.,COORDINATION: There is no dysmetria or tremor noted. His Romberg is negative. Note that he cannot rise from the chair without using his arms.,GAIT: Upon arising, he has a normal step, stride, and toe, heel. He has difficulty with tandem and tends to fall to the left.,REFLEXES: 2 at biceps, triceps, patella and 1 at ankles.,The patient provided a CT scan without contrast from his previous hospitalization three weeks ago, which is normal to my inspection.,He has had full labs for cholesterol and stroke for risk factors although he does not have those available here.,IMPRESSION:,1. TIA. The character of his brief episode of visual loss is concerning for compromise of the posterior circulation. Differential diagnoses include hypoperfusion, stenosis, and dissection. He is to get a CT angiogram to evaluate the integrity of the cerebrovascular system. He has recently been started on Paxil by his primary care physician and this should be continued. Other risk factors need to be evaluated; however, we will wait for the results to be sent from the outside hospital so that we do not have to repeat his prior workup. The patient and his wife assure me that the workup was complete and that nothing was found at that time.,2. Lumbar stenosis. His symptoms are very mild and consist mainly of some mild proximal upper extremity weakness and very mild gait instability. In the absence of motor stabilizing symptoms, the patient is not interested in surgical intervention at this time. Therefore we would defer further evaluation with CT myelogram as he does not want surgery.,PLAN:,1. We will get a CT angiogram of the cerebral vessels.,2. Continue Plavix.,3. Obtain copies of the workup done at the outside hospital.,4. We will follow the lumbar stenosis for the time being. No further workup is planned." Neurology Placement of left ventriculostomy via twist drill. Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure. Ventriculostomy Placement 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. neurology, intraventricular hemorrhage, hydrocephalus, intracranial pressure, camino monitor, twist drill, ventriculostomy, hemorrhage, intracranial, pressure, intraventricular Neurology Subcutaneous ulnar nerve transposition. 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. Ulnar Nerve Transposition 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. neurology, neurolysis, ulnar, periosteal, flexor-pronator mass, ulnar nerve transposition, medial intermuscular septum, nerve transposition, intermuscular septum, flexor pronator, ulnar nerve, nerve Neurology Headaches, question of temporal arteritis. Bilateral temporal artery biopsies. Temporal Artery Biopsy - 1 PREOPERATIVE DIAGNOSIS:, Headaches, question of temporal arteritis.,POSTOPERATIVE DIAGNOSIS:, Headaches, question of temporal arteritis.,PROCEDURE:, Bilateral temporal artery biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was brought to the operating room where her right temporal area was prepped and draped in the usual fashion. Xylocaine 1% was utilized and then an incision was made in front of the right ear and deepened anteriorly. The temporal artery was found and exposed in an extension of about 2 cm. The artery was proximally and distally ligated with 6-0 Prolene and also a side branch and a sample was sent for pathology. Hemostasis achieved with a cautery and the incision was closed with a subcuticular suture of Monocryl.,Then, the patient was turned and her left temporal area was prepped and draped in the usual fashion. A similar procedure was performed with 1% Xylocaine and exposed her temporal artery, which was excised in an extent to about 2 cm. This was also proximally and distally ligated with 6-0 Prolene and also side branch. Hemostasis was achieved with a cautery and the skin was closed with a subcuticular suture of Monocryl.,Dressings were applied to both areas.,The patient tolerated the procedure well. Estimated blood loss was negligible, and the patient went back to Same Day Surgery for recovery. neurology, temporal arteritis, temporal artery, temporal, artery, biopsies, hemostasis, subcuticular, headaches, arteritis, Neurology Bilateral temporal artery biopsy. Rule out temporal arteritis. Temporal Artery Biopsy 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. neurology, headaches, bilateral temporal artery, temporal artery biopsy, temporal arteritis, temporal artery, temporal, biopsy, arteritis Neurology A 92-year-old female had a transient episode of slurred speech and numbness of her left cheek for a few hours. TIA - Cosult REASON FOR CONSULTATION: , This 92-year-old female states that last night she had a transient episode of slurred speech and numbness of her left cheek for a few hours. However, the chart indicates that she had recurrent TIAs x3 yesterday, each lasting about 5 minutes with facial drooping and some mental confusion. She had also complained of blurred vision for several days. She was brought to the emergency room last night, where she was noted to have a left carotid bruit and was felt to have recurrent TIAs.,CURRENT MEDICATIONS: , The patient is on Lanoxin, amoxicillin, Hydergine, Cardizem, Lasix, Micro-K and a salt-free diet. ,SOCIAL HISTORY: , She does not smoke or drink alcohol.,FINDINGS: ,Admission CT scan of the head showed a densely calcified mass lesion of the sphenoid bone, probably representing the benign osteochondroma seen on previous studies. CBC was normal, aside from a hemoglobin of 11.2. ECG showed atrial fibrillation. BUN was 22, creatinine normal, CPK normal, glucose normal, electrolytes normal.,PHYSICAL EXAMINATION: , On examination, the patient is noted to be alert and fully oriented. She has some impairment of recent memory. She is not dysphasic, or apraxic. Speech is normal and clear. The head is noted to be normocephalic. Neck is supple. Carotid pulses are full bilaterally, with left carotid bruit. Neurologic exam shows cranial nerve function II through XII to be intact, save for some slight flattening of the left nasolabial fold. Motor examination shows no drift of the outstretched arms. There is no tremor or past-pointing. Finger-to-nose and heel-to-shin performed well bilaterally. Motor showed intact neuromuscular tone, strength, and coordination in all limbs. Reflexes 1+ and symmetrical, with bilateral plantar flexion, absent jaw jerk, no snout. Sensory exam is intact to pinprick touch, vibration, position, temperature, and graphesthesia.,IMPRESSION: , Neurological examination is normal, aside from mild impairment of recent memory, slight flattening of the left nasolabial fold, and left carotid bruit. She also has atrial fibrillation, apparently chronic. In view of her age and the fact that she is in chronic atrial fibrillation, I would suspect that she most likely has had an embolic phenomenon as the cause of her TIAs.,RECOMMENDATIONS:, I would recommend conservative management with antiplatelet agents unless a near occlusion of the carotid arteries is demonstrated, in which case you might consider it best to do an angiography and consider endarterectomy. In view of her age, I would be reluctant to recommend Coumadin anticoagulation. I will be happy to follow the patient with you. neurology, atrial fibrillation, carotid bruit, slurred speech, numbness, calcified mass lesion, neurological examination, tias, carotid, benign, Neurology Evaluation of possible tethered cord. She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. Tethered Cord Evaluation 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. neurology, tethering, lipomyomeningocele repair, sensory loss, tethered cord, mri, cord, lipomyomeningocele, Neurology Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty. Suboccipital Craniectomy 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. neurology, suboccipital, craniectomy, microscope, cranioplasty, acoustic neuroma, cerebellar peduncle, nerve complex, brainstem, nurolon, cavitron, kerrison, leksell, lateral pontine vein, suboccipital craniectomy, nerve, tumor Neurology Severe back pain and sleepiness. The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes with a low blood pressure. Sleepiness - Consult 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. Neurology MRI demonstrated right contrast-enhancing temporal mass. SOAP - Temporal Mass SUBJECTIVE: , The patient is a 55-year-old African-American male that was last seen in clinic on 07/29/2008 with diagnosis of new onset seizures and an MRI scan, which demonstrated right contrast-enhancing temporal mass. Given the characteristics of this mass and his new onset seizures, it is significantly concerning for a high-grade glioma. ,OBJECTIVE: , The patient is alert and oriented times three, GCS of 15. Cranial nerves II to XII are grossly intact. Motor exam demonstrates 5/5 strength in all four extremities. Sensation is intact to light touch, pain, temperature, and proprioception. Cerebellar exam is intact. Gait is normal and tandem on heels and toes. Speech is appropriate. Judgment is intact. Pupils are equal and reactive to light.,ASSESSMENT AND PLAN: , The patient is a 55-year-old African-American male with a new diagnosis of rim-enhancing right temporal mass. Given the characteristics of the MRI scan, it is highly likely that he demonstrates high-grade glioma and concerning for glioblastoma multiforme. We have discussed in length the possible benefits of biopsy, surgical resection, medical management, as well as chemotherapy, radiation treatments, and doing nothing. Given the high probability that the mass represents a high-grade glioma, the patient, after weighing the risks and the benefits of surgery, has agreed to undergo a surgical biopsy and resection of the mass as well as concomitant chemotherapy and radiation as the diagnosis demonstrates a high-grade glioma. The patient has signed consent for his right temporal craniotomy for biopsy and likely resection of right temporal brain tumor. He agrees that he will be n.p.o. after mid night on Wednesday night. He is sent for preoperative assessment with the Anesthesiology tomorrow morning. He has undergone vocational rehab assessment. neurology, new onset seizures, temporal mass, cerebellar exam, glioma, temporal, massNOTE Neurology Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist. Carpal tunnel syndrome suspected. SOAP - Numbness & Tingling SUBJECTIVE: , This patient presents to the office today because of some problems with her right hand. It has been going tingling and getting numb periodically over several weeks. She just recently moved her keyboard down at work. She is hoping that will help. She is worried about carpal tunnel. She does a lot of repetitive type activities. It is worse at night. If she sleeps on it a certain way, she will wake up and it will be tingling then she can usually shake out the tingling, but nonetheless it is very bothersome for her. It involves mostly the middle finger, although, she says it also involves the first and second digits on the right hand. She has some pain in her thumb as well. She thinks that could be arthritis.,OBJECTIVE: , Weight 213.2 pounds, blood pressure 142/84, pulse 92, respirations 16. General: The patient is nontoxic and in no acute distress. Musculoskeletal: The right hand was examined. It appears to be within normal limits and the appearance is similar to the left hand. She has good and equal grip strength noted bilaterally. She has negative Tinel's bilaterally. She has a positive Phalen's test. The fingers on the right hand are neurovascularly intact with a normal capillary refill.,ASSESSMENT: ,Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist. I suspect carpal tunnel syndrome.,PLAN: ,The patient is going to use Anaprox double strength one pill every 12 hours with food as well as a cock-up wrist splint. We are going to try this for two weeks and if the condition is still present, then we are going to proceed with EMG test at that time. She is going to let me know. While she is here, I am going to also get her the blood test she needs for her diabetes. I am noting that her blood pressure is elevated, but improved from the last visit. I also noticed that she has lost a lot of weight. She is working on diet and exercise and she is doing a great job. Right now for the blood pressure we are going to continue to observe as she carries forward additional measures in her diet and exercise to lose more weight and I expect the blood pressure will continue to improve. neurology, tinel's, phalen's, positioning of the wrist, numbness and tingling, carpal tunnel syndrome, carpal tunnel, numbness, tingling Neurology Sleep study - patient with symptoms of obstructive sleep apnea with snoring. Sleep Study Interpretation PROCEDURE:, Sleep study.,CLINICAL INFORMATION:, This patient is a 56-year-old gentleman who had symptoms of obstructive sleep apnea with snoring, hypertension. The test was done 01/24/06. The patient weighed 191 pounds, five feet, seven inches tall.,SLEEP QUESTIONNAIRE:, According to the patient's own estimate, the patient took about 15 minutes to fall asleep, slept for six and a half hours, did have some dreams. Did not wake up and the sleep was less refreshing. He was sleepy in the morning.,STUDY PROTOCOL:, An all night polysomnogram was recorded with a Compumedics E Series digital polysomnograph. After the scalp was prepared, Ag/AgCl electrodes were applied to the scalp according to the International 10-20 System. EEG was monitored from C4-A1, C3-A2, O2-A1 and O2-A1. EOG and EMG were continuously monitored by electrodes placed at the outer canthi and chin respectively. Nasal and oral airflow were monitored using a triple port Thermistor. Respiratory effort was measured by piezoelectric technology employing an abdominal and thoracic belt. Blood oxygen saturation was continuously monitored by pulse oximetry. Heart rate and rhythm were monitored by surface electrocardiography. Anterior tibialis EMG was studied by using surface mounted electrodes placed 5 cm apart on both legs. Body position and snoring level were also monitored.,TECHNICAL QUALITY OF STUDY:, Good.,ELECTROPHYSIOLOGIC MEASUREMENTS:, Total recording time 406 minutes, total sleep time 365 minutes, sleep latency 25.5 minutes, REM latency 49 minutes, _____ 90%, sleep latency measured 86%. _____ period was obtained. The patient spent 10% of the time awake in bed.,Stage I: 3.8,Stage II: 50.5,Stage III: 14%,Stage REM: 21.7%,The patient had relatively good sleep architecture, except for excessive waking.,RESPIRATORY MEASUREMENTS:, Total apnea/hypopnea 75, age index 12.3 per hour. REM age index 15 per hour. Total arousal 101, arousal index 15.6 per hour. Oxygen desaturation was down to 88%. Longest event 35 second hypopnea with an FiO2 of 94%. Total limb movements 92, PRM index 15.1 per hour. PRM arousal index 8.9 per hour.,ELECTROCARDIOGRAPHIC OBSERVATIONS:, Heart rate while asleep 60 to 64 per minute, while awake 70 to 78 per minute.,CONCLUSIONS:, Obstructive sleep apnea syndrome with moderately loud snoring and significant apnea/hypopnea index.,RECOMMENDATIONS:,AXIS B: Overnight polysomnography.,AXIS C: Hypertension.,The patient should return for nasal CPAP titration. Sleep apnea if not treated, may lead to chronic hypertension, which may have cardiovascular consequences. Excessive daytime sleepiness, dysfunction and memory loss may also occur. neurology, sleep study, obstructive sleep apnea, snoring, hypertension, polysomnogram, compumedics, polysomnograph, ag/agcl electrodes, triple port thermistor, rem, latency, polysomnography, cpap titration, sleep latency, apnea, sleep, obstructive, index, Neurology HCT: SAH, Contusion, Skull fracture SAH, Contusion, Skull Fracture "CC: ,Headache.,HX:, This 51 y/o RHM was moving furniture several days prior to presentation when he struck his head (vertex) against a door panel. He then stepped back and struck his back on a trailer hitch. There was no associated LOC but he felt ""dazed."" He complained a HA since the accident. The following day he began experiencing episodic vertigo lasting several minutes with associated nausea and vomiting. He has been lying in bed most of the time since the accident. He also complained of transient left lower extremity weakness. The night before admission he went to his bedroom and his girlfriend heard a loud noise. She found him on the floor unable to speak or move his left side well. He was taken to a local ER. In the ER experienced a spell in which he stared to the right for approximately one minute. During this time he was unable to speak and did not seem to comprehend verbal questions. This resolved. ER staff noted decreased left sided movement and a left Babinski sign.,He was given valium 5 mg, and DPH 1.0g. A HCT was performed and he was transferred to UIHC.,PMH:, DM, Coronary Artery Disease, Left femoral neuropathy of unknown etiology. Multiple head trauma in past (?falls/fights).,MEDS:, unknown oral med for DM.,SHX:, 10+pack-year h/o Tobacco use; quit 2 years ago. 6-pack beer/week. No h/o illicit drug use.,FHX:, unknown.,EXAM: ,70BPM, BP144/83, 16RPM, 36.0C,MS: Alert and oriented to person, place, time. Fluent speech.,CN: left lower facial weakness with right gaze preference. Pupils 3/3 decreasing to 2/2 on exposure to light. Optic disks flat.,MOTOR: decreased spontaneous movement of left-sided extremities. 5/4 strength in both upper and lower extremities. Normal muscle tone and bulk.,SENSORY: withdrew equally to noxious stimulation in all four extremities. GAIT/STATION/COORDINATION: not tested.,The general physical exam was unremarkable.,During the exam the patient experienced a spell during which his head turned and eyes deviated to the leftward, and his right hand twitched. The entire spell lasted one minute.,During the episode he was verbally unresponsive. He appeared groggy and lethargic after the event.,HCT without contrast: 11/18/92: right frontal skull fracture with associated minimal epidural hematoma and small subdural hematoma, as well as some adjacent subarachnoid blood and brain contusion.,LABS:, CBC, GS, PT/PTT were all WNL.,COURSE:, The patient was diagnosed with a right frontal SAH/contusion and post traumatic seizures. DPH was continued and he was given a Librium taper for possible alcoholic withdrawal. A neurosurgical consult was obtained. He did not receive surgical intervention and was discharged 12/1/92. Neuropsychological testing on 11/25/92 revealed: poor orientation to time or place and poor attention. Anterograde verbal and visual memory was severely impaired. Speech became mildly dysarthric when fatigued. Defective word finding. Difficulty copying 2 of 3 three dimensional figures. Recent head injury as well as a history of ETOH abuse and multiple prior head injuries probably contribute to his deficits." neurology, sah, contusion, skull fracture, headache, post traumatic seizures, lower extremity weakness, loud noise, hct, weakness, skull, hematoma, fracture, Neurology A 6-year-old male who is a former 27-week premature infant, suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis. Status Epilepticus 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. Neurology Diagnosis of benign rolandic epilepsy. Rolandic Epilepsy 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. neurology, tonic-clonic seizures, benign rolandic epilepsy, rolandic epilepsy, epilepsy, seizures, electroencephalogram, Neurology Reflex sympathetic dystrophy of both lower extremities. Reflex Sympathetic Dystrophy - Letter Doctor's Address,Dear Doctor:,This letter serves as a reintroduction of my patient, A, who will be seeing you on Thursday, 06/12/2008. As you know, he is an unfortunate gentleman who has reflex sympathetic dystrophy of both lower extremities. His current symptoms are more severe on the right and he has had a persisting wound that has failed to heal on his right leg. He has been through Wound Clinic to try to help heal this, but was intolerant of compression dressings and was unable to get satisfactory healing of this. He has been seen by Dr. X for his pain management and was considered for the possibility of amputation being a therapeutic option to help reduce his pain. He was seen by Dr. Y at Orthopedic Associates for review of this. However, in my discussion with Dr. Z and his evaluation of Mr. A, it was felt that this may be an imprudent path to take given the lack of likelihood of reduction of his pain from his RST, his questionable healing of his wound given noninvasive studies that did reveal tenuous oxygenation of the right lower leg, and concerns of worsening of his RST symptoms on his left leg if he would have an amputation. Based on the results of his transcutaneous oxygen levels and his dramatic improvement with oxygen therapy at this test, Dr. Z felt that a course of hyperbaric oxygen may be of utility to help in improving his wounds. As you may or may not know we have certainly pursued aggressive significant measures to try to improve Mr. A's pain. He has been to Cleveland Clinic for implantable stimulator, which was unsuccessful at dramatically improving his pain. He currently is taking methadone up to eight tablets four times a day, morphine up to 100 mg three times a day, and Dilaudid two tablets by mouth every two hours to help reduce his pain. He also is currently taking Neurontin 1600 mg three times a day, Effexor XR 250 mg once a day, Cytomel 25 mcg once a day, Seroquel 100 mg p.o. q. day, levothyroxine 300 mcg p.o. q. day, Prinivil 20 mg p.o. q. day, and Mevacor 40 mg p.o. q day.,I appreciate your assistance in determining if hyperbaric oxygen is a reasonable treatment course for this unfortunate situation. Dr. Z and I have both tried to stress the fact that amputation may be an abrupt and irreversible treatment course that may not reach any significant conclusion. He has been evaluated by Dr. X for rehab concerns to determine. He agrees that a less aggressive form of therapy may be most appropriate.,I thank you kindly for your prompt evaluation of this kind gentleman in an unfortunate situation. If you have any questions regarding his care please feel free to call me at my office. Otherwise, I look forward to hearing back from you shortly after your evaluation. Please feel free to call me if it is possible or if you have any questions about anything. neurology, rsd, reflex sympathetic dystrophy, orthopedic, oxygenationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. Neurology Followup left-sided rotator cuff tear and cervical spinal stenosis. Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis. Rotator Cuff Tear REASON FOR VISIT: , Followup left-sided rotator cuff tear and cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS: , Ms. ABC returns today for followup regarding her left shoulder pain and left upper extremity C6 radiculopathy. I had last seen her on 06/21/07.,At that time, she had been referred to me Dr. X and Dr. Y for evaluation of her left-sided C6 radiculopathy. She also had a significant rotator cuff tear and is currently being evaluated for left-sided rotator cuff repair surgery, I believe on, approximately 07/20/07. At our last visit, I only had a report of her prior cervical spine MRI. I did not have any recent images. I referred her for cervical spine MRI and she returns today.,She states that her symptoms are unchanged. She continues to have significant left-sided shoulder pain for which she is being evaluated and is scheduled for surgery with Dr. Y.,She also has a second component of pain, which radiates down the left arm in a C6 distribution to the level of the wrist. She has some associated minimal weakness described in detail in our prior office note. No significant right upper extremity symptoms. No bowel, bladder dysfunction. No difficulty with ambulation.,FINDINGS: , On examination, she has 4 plus over 5 strength in the left biceps and triceps muscle groups, 4 out of 5 left deltoid, 5 out of 5 otherwise in both muscle groups and all muscle groups of upper extremities. Light touch sensation is minimally decreased in the left C6 distribution; otherwise, intact. Biceps and brachioradialis reflexes are 1 plus. Hoffmann sign normal bilaterally. Motor strength is 5 out of 5 in all muscle groups in lower extremities. Hawkins and Neer impingement signs are positive at the left shoulder.,An EMG study performed on 06/08/07 demonstrates no evidence of radiculopathy or plexopathy or nerve entrapment to the left upper extremity.,Cervical spine MRI dated 06/28/07 is reviewed. It is relatively limited study due to artifact. He does demonstrate evidence of minimal-to-moderate stenosis at the C5-C6 level but without evidence of cord impingement or cord signal change. There appears to be left paracentral disc herniation at the C5-C6 level, although axial T2-weighted images are quite limited.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.,I agree with the plan to go ahead and continue with rotator cuff surgery. With regard to the radiculopathy, I believe this can be treated non-operatively to begin with. I am referring her for consideration of cervical epidural steroid injections. The improvement in her pain may help her recover better from the shoulder surgery.,I will see her back in followup in 3 months, at which time she will be recovering from a shoulder surgery and we will see if she needs any further intervention with regard to the cervical spine.,I will also be in touch with Dr. Y to let him know this information prior to the surgery in several weeks. neurology, upper extremity, radiculopathy, rotator cuff repair, cervical spinal stenosis, rotator cuff tear, physical examination, cuff, impingement, stenosis, extremity, surgery, tear, shoulder, rotator, cervical, Neurology Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts. Phenol Neurolysis & Botulinum Toxin Injection - 3 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. neurology, botulinum toxin injection bilateral, toxin injection bilateral rectus, neurolysis of bilateral obturator, short leg fiberglass casts, muscles phenol neurolysis, botulinum toxin injection, gastrocnemius soleus muscles, short leg fiberglass, femoris medial, cerebral palsy, active emg, emg stimulation, phenol neurolysis, toxin injection, rectus femoris, gastrocnemius soleus, soleus muscles, obturator nerves, leg fiberglass, fiberglass casts, botulinum toxin, hamstrings, gastrocnemius, obturator, nerves, fiberglass, casts, muscles, botulinum, phenol, bilateral, injection, toxin Neurology Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma. Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus. Pituitary Adenomectomy 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. Neurology Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles. Phenol Neurolysis & Botulinum Toxin Injection - 2 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. neurology, femoris and vastus medialis, intermedius and right pectoralis, rectus femoris and vastus, vastus medialis intermedius, botulinum toxin injection, medialis intermedius, major muscles, cerebral palsy, active emg, emg stimulation, phenol neurolysis, toxin injection, obturator nerve, rectus femoris, pectoralis major, botulinum toxin, pectoralis, botulinum, phenol, injection, toxin Neurology Status post brain tumor removal. The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness. Physical Therapy - Brain Tumor Removal DIAGNOSIS:, Status post brain tumor removal.,HISTORY:, The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. The patient reports that on 10/24/08 she had a brain tumor removed and had left-sided weakness. The patient was being seen in physical therapy from 11/05/08 to 11/14/08 then she began having complications. The patient reports that she was admitted to Hospital on 12/05/08. At that time, they found massive swelling on the brain and a second surgery was performed. The patient then remained in acute rehab until she was discharged to home on 01/05/09. The patient's husband, Al, is also present and he reports that during rehabilitation the patient did have a DVT in the left calf that has since been resolved.,PAST MEDICAL HISTORY: , Unremarkable.,MEDICATIONS: ,Coumadin, Keppra, Decadron, and Glucophage.,SUBJECTIVE: , The patient reports that the pain is not an issue at this time. The patient states that her primary concern is her left-sided weakness as related to her balance and her walking and her left arm weakness.,PATIENT GOAL: ,To increase strength in her left leg for better balance and walking.,OBJECTIVE:,RANGE OF MOTION: Bilateral lower extremities are within normal limits.,STRENGTH: Bilateral lower extremities are grossly 5/5 with one repetition, except left hip reflexion 4+/5.,BALANCE: The patient's balance was assessed with a Berg balance test. The patient has got 46/56 points, which places her at moderate risk for falls.,GAIT: The patient ambulates with contact guard assist. The patient ambulates with a reciprocal gait pattern with good bilateral foot clearance. However, the patient has been reports that with increased fatigue, left footdrop tends to occur. A 6-minute walk test will be performed at the next visit due to time constraints.,ASSESSMENT: , The patient is a 64-year-old female referred to Physical Therapy status post brain surgery. Examination indicates deficits in strength, balance, and ambulation. The patient will benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN: , The patient will be seen three times per week for 4 weeks and then reduce it to two times per week for 4 additional weeks. Interventions include:,1. Therapeutic exercise.,2. Balance training.,3. Gait training.,4. Functional mobility training.,SHORT TERM GOAL TO BE COMPLETED IN 4 WEEKS:,1. The patient is to tolerate 30 repetitions of all lower extremity exercises.,2. The patient is to improve balance with a score of 50/56 points.,3. The patient is to ambulate 1000 feet in a 6-minute walk test with standby assist.,LONG TERM GOAL TO BE ACHIEVED IN 8 WEEKS:,1. The patient is to ambulate independently within her home and standby to general supervision within the community.,2. Berg balance test to be 52/56.,3. The patient is to ambulate a 6-minute walk test for 1500 feet independently including safe negotiation of corners and busy areas.,4. The patient is to demonstrate safely stepping over and around objects without loss of balance.,Prognosis for the above-stated goals is good. The above treatment plan has been discussed with the patient and her husband. They are in agreement. Neurology Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years. Suspected Seizure Activity XYZ Street,City, State,Dear Dr. CD:,Thank you for seeing Mr. XYZ, a pleasant 19-year-old male who has seen you in 2005 for suspected seizure activity. He comes to my office today continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years. He is requesting to come off the Dilantin at this point. Upon reviewing your 2005 note there was some discrepancy as to the true nature of his episodes to the emergency room and there was consideration to reconsider medication use. His physical exam, neurologically, is normal at this time. His Dilantin level is slightly low at 12.5.,I will appreciate your evaluation and recommendation as to whether we need to continue the Dilantin at this time. I understand this will probably entail repeating his EEG and so please coordinate this through Health Center. I await your response and whether we should continue this medication. If you require any laboratory, we use ABC Diagnostic and any further testing that is needed should be coordinated at Health Center prior to scheduling. neurology, eeg, suspected seizure activity, seizure activity, seizure episode, seizure, dilantinNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. Neurology The patient with pseudotumor cerebri without papilledema, comes in because of new onset of headaches. Pseudotumor Cerebri REASON FOR VISIT: ,The patient is a 38-year-old woman with pseudotumor cerebri without papilledema who comes in because of new onset of headaches. She comes to clinic by herself.,HISTORY OF PRESENT ILLNESS: , Dr. X has cared for her since 2002. She has a Codman-Hakim shunt set at 90 mmH2O. She last saw us in clinic in January 2008 and at that time we recommended that she followup with Dr. Y for medical management of her chronic headaches. We also recommended that the patient see a psychiatrist regarding her depression, which she stated that she would followup with that herself. Today, the patient returns to clinic because of acute onset of headaches that she has had since her shunt was adjusted after an MRI on 04/18/08. She states that since that time her headaches have been bad. They woke her up at night. She has not been able to sleep. She has not had a good sleep cycle since that time. She states that the pain is constant and is worse with coughing, straining, and sneezing as well as on standing up. She states that they feel a little bit better when lying down. Medication shave not helped her. She has tried taking Imitrex as well as Motrin 800 mg twice a day, but she states it has not provided much relief. The pain is generalized, but also noted to be quite intense in the frontal region of her head. She also reports ringing in the ears and states that she just does not feel well. She reports no nausea at this time. She also states that she has been experiencing intermittent blurry vision and dimming lights as well. She tells me that she has an appointment with Dr. Y tomorrow. She reports no other complaints at this time.,MAJOR FINDINGS:, On examination today, this is a pleasant 38-year-old woman who comes back from the clinic waiting area without difficulty. She is well developed, well nourished, and kempt.,Vital Signs: Blood pressure 153/86, pulse 63, and respiratory rate 16.,Cranial Nerves: Intact for extraocular movements. Facial movement, hearing, head turning, tongue, and palate movements are all intact. I did not know any papilledema on exam bilaterally.,I examined her shut site, which is clean, dry, and intact. She did have a small 3 mm to 4 mm round scab, which was noted farther down from her shunt reservoir. It looks like there is a little bit of dry blood there.,ASSESSMENT:, The patient appears to have had worsening headaches since shunt adjustment back after an MRI.,PROBLEMS/DIAGNOSES:,1. Pseudotumor cerebri without papilledema.,2. Migraine headaches.,PROCEDURES:, I programmed her shunt to 90 mmH2O.,PLAN:, It was noted that the patient began to have an acute onset of headache pain after her shunt adjustment approximately a week and a half ago. I had programmed her shunt back to 90 mmH2O at that time and confirmed it with an x-ray. However, the picture of the x-ray was not the most desirable picture. Thus, I decided to reprogram the shunt back to 90 mmH2O today and have the patient return to Sinai for a skull x-ray to confirm the setting at 90. In addition, she told me that she is scheduled to see Dr. Y tomorrow, so she should followup with him and also plan on contacting the Wilmer Eye Institute to setup an appointment. She should followup with the Wilmer Eye Institute as she is complaining of blurry vision and dimming of the lights occasionally.,Total visit time was approximately 60 minutes and about 10 minutes of that time was spent in counseling the patient. neurology, migraine headaches, pseudotumor cerebri without papilledema, onset of headaches, blurry vision, shunt adjustment, pseudotumor cerebri, headaches, pseudotumor, cerebri, papilledema Neurology Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors. Phenol Neurolysis & Botulinum Toxin Injection - 1 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. neurology, spastic quadriparesis, emg stimulation, emg, botulinum toxin injection, traumatic brain, brain injury, phenol neurolysis, toxin injection, musculocutaneous nerve, obturator nerves, pectoralis major, wrist flexors, knee extensors, active emg, botulinum toxin, toxin, injection, stimulus, neurolysis, musculocutaneous, extensors, botulinum, phenol Neurology MRI L-Spine - Bilateral lower extremity numbness Normal L-Spine MRI 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. neurology, bilateral lower extremity numbness, mri l spine, bilateral lower extremity, lower extremity numbness, bilateral, spine, mri, extremities, numbness Neurology Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain. Radiologic Exam - Spine EXAM: , Cervical, lumbosacral, thoracic spine flexion and extension.,HISTORY: , Back and neck pain.,CERVICAL SPINE,FINDINGS: ,AP, lateral with flexion and extension, and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable. neurology, radiologic exam, ap, back, cervical, oblique views, alignment, disc space, extension, fixation, flexion, foramina, intervertebral, lateral views, lumbosacral, neck, neck pain, oblique, odontoid view, pain, physiologic, projections, spine, subluxation, thoracic, flexion and extension, thoracic spine, vertebral Neurology Squamous cell carcinoma of right temporal bone/middle ear space. Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3. Skull Base Reconstruction 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. neurology, rectus abdominis myocutaneous, skull base defect, squamous cell carcinoma, skull base, squamous cell, rectus sheath, abdominis, muscle, rectus, sheath Neurology 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. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning. Neuropsychological Evaluation - 4 "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" Neurology Patient was referred for a neuropsychological evaluation 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. Neuropsychological Evaluation - 3 "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" Neurology A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures. New Onset Seizure REASON FOR CONSULTATION: , New-onset seizure.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old female with a history of known febrile seizures, who was placed on Keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures. Although this has been a very successful treatment in terms of her febrile seizure control, she is now having occasional brief periods of pauses and staring, where she becomes unresponsive, but does not lose her postural tone. The typical spell according to dad last anywhere from 10 to 15 seconds, mom says 3 to 4 minutes, which likely means probably somewhere in the 30- to 40-second period of time. Mom did note that an episode had happened outside of a store recently, was associated with some perioral cyanosis, but there has never been a convulsive activity noted. There have been no recent changes in her Keppra dosing and she is currently only at 20 mg/kg per day, which is overall a low dose for her.,PAST MEDICAL HISTORY: , Born at 36 weeks' gestation by C-section delivery at 8 pounds 3 ounces. She does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue.,PAST SURGICAL HISTORY: , She has undergone no surgical procedures.,FAMILY MEDICAL HISTORY: , There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt. There is no other significant neurological history on the paternal side of the family.,SOCIAL HISTORY: , Currently lives with her mom, dad, and two siblings. She is at home full time and does not attend day care.,REVIEW OF SYSTEMS: ,Clear review of 10 systems are taken and revealed no additional findings other than those mentioned in the history of present illness.,PHYSICAL EXAMINATION:,Vital Signs: Weight was 15.6 kg. She was afebrile. Remainder of her vital signs were stable and within normal ranges for her age as per the medical record.,General: She was awake, alert, and oriented. She was in no acute distress, only slightly flustered when trying to place the EEG leads.,HEENT: Showed normocephalic and atraumatic head. Her conjunctivae were nonicteric and sclerae were clear. Her eye movements were conjugate in nature. Her tongue and mucous membranes were moist.,Neck: Trachea appeared to be in the midline.,Chest: Clear to auscultation bilaterally without crackles, wheezes or rhonchi.,Cardiovascular: Showed a normal sinus rhythm without murmur.,Abdomen: Showed soft, nontender, and nondistended, with good bowel sounds. There was no hepatomegaly or splenomegaly, or other masses noted on examination.,Extremities: Showed IV placement in the right upper extremity with appropriate restraints from the IV. There was no evidence of clubbing, cyanosis or edema throughout. She had no functional deformities in any of her peripheral limbs.,Neurological: From neurological standpoint, her cranial nerves were grossly intact throughout. Her strength was good in the bilateral upper and lower extremities without any distal to proximal variation. Her overall resting tone was normal. Sensory examination was grossly intact to light touch throughout the upper and lower extremities. Reflexes were 1+ in bilateral patella. Toes were downgoing bilaterally. Coordination showed accurate striking ability and good rapid alternating movements. Gait examination was deferred at this time due to EEG lead placement.,ASSESSMENT:, A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.,RECOMMENDATIONS,1. For now, we will go ahead and try to capture EEG as long as she tolerates it; however, if she would require sedation, I would defer the EEG until further adjustments to seizure medications are made and we will see her response to these medications.,2. As per the above, I will increase her Keppra to 300 mg p.o. b.i.d. bringing her to a total daily dose of just under 40 mg/kg per day. If further spells are noted, we may increase upwards again to around 4.5 to 5 mL each day.,3. I do not feel like any specific imaging needs to be done at this time until we see her response to the medication and review her EEG findings. EEG, hopefully, will be able to be reviewed first thing tomorrow morning; however, I would not delay discharge the patient to wait on the EEG results. The patient has been discharged and we will contact the family as an outpatient.,4. The patient will need followup arrangement with me in 5 to 6 weeks' time, so we may recheck and see how she is doing and arrange for further followup then. Neurology A neuropsychological evaluation to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope. Neuropsychological Evaluation - 2 "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" Neurology Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion. Neurology - Discharge Summary 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. neurology, interhemispheric, frontal lobe, head injury, brain, contusion Neurology Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke. Neuropsychological Evaluation "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" Neurology Organic brain syndrome in the setting of multiple myeloma. The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words. Organic Brain Syndrome REASON FOR CONSULT:, Organic brain syndrome in the setting of multiple myeloma.,SOURCE OF HISTORY: ,The patient himself is not able to give a good history. History has obtained through discussion with Dr. X over the phone and the nurse taking care of the patient despite reviewing the chart on the floor.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words. Not a very clear history at this time and the patient himself is not able to give any history despite no family member was present in the room. Neurology consult was called to evaluate any organic brain syndrome in the setting of multiple myeloma. The patient since the morning has improved, but still not completely back to the baseline. Even I evaluated the patient previously, hence not very sure about his baseline.,PAST MEDICAL HISTORY:, History of IgG subtype multiple myeloma.,SURGICAL HISTORY:, Nothing significant.,PSYCHIATRIC HISTORY: ,Nothing significant.,SOCIAL HISTORY: ,No history of any smoking, alcohol or drug abuse.,ALLERGIES: , CODEINE AND FLAGYL.,IMMUNIZATION HISTORY: , Nothing significant.,FAMILY HISTORY: , Unobtainable.,REVIEW OF SYSTEMS: ,The patient was considered to ask question for systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy/immunology, endocrinology, toxicology, oncology, and found to be positive for the symptoms mentioned in the history of the presenting illness. The patient himself is not able to give any history only source is the chart. For details, please review the chart.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure of 97/54, heart rate of 97, respiratory rate of 19, and temperature 98.5. The patient on supplemental oxygen was FiO2 on 2 L 96%. Limited physical examination.,HEENT: Head, normocephalic and atraumatic. Throat clear. No discharge from the ear and the nose. No discoloration of conjunctivae and the sclerae.,NECK: Supple. No signs of any meningismus. Though a limited examination, the patient does appear to have arthritic changes, questioning contracture deformities, as not able to follow the commands to show full range of motion. No bruit auscultated over the neck and the orbits.,LUNGS: Clear to auscultation.,HEART: Normal heart sounds.,ABDOMEN: Benign.,EXTREMITIES: No edema, clubbing or cyanosis. No rash. No leptomeningeal or neurocutaneous disorder.,NEUROLOGIC: Examination is limited. Mental state examination, the patient is awake, alert, and oriented to himself, not able follow commands, and give a proper history, and still appeared to be confuse and disoriented. Cranial nerve examination limited, but apparently nonfocal. Motor examination is very limited except for the grips, which were strong enough. I was not able to obtain much. Deep tendon reflexes were not reliable. Toes equivocal and downgoing. Sensory examination is not reliable, though intact for painful stimuli with limited examination. Coordination could not be tested. Gait could not be tested.,IMPRESSION:, History of multiple myeloma and altered mental status in multiple myeloma setting. Rule out brain metastasis including lepto-meningismus, possible transient ischemic attack related to hyperviscosity syndrome or provoked seizure related to ischemia, and delirium related to any electrolyte imbalance or underlying infarction.,PLAN AND RECOMMENDATIONS: , The patient is to continue with current level of management. I will review the chart before ordering any further testing that may include a CT scan of the brain, if has not been ordered, EEG, urine test, and the latest CBC with diff. to rule out any urinary tract infection or indication of any other seen of infection. No other intervention at this time. The patient may be started on aspirin, if it is okay with Dr. X. Neurology Sample for Neuropsychological Evaluation Neuropsychological Evaluation - 1 REASON FOR EVALUATION: , The patient is a 37-year-old white single male admitted to the hospital through the emergency room. I had seen him the day before in my office and recommended him to go into the hospital. He had just come from a trip to Taho in Nevada and he became homicidal while there. He started having thoughts about killing his mother. He became quite frightened by that thought and called me during the weekend we were able to see him on that Tuesday after talking to him.,HISTORY OF PRESENT ILLNESS: , This is a patient that has been suffering from a chronic psychotic condition now for a number of years. He began to have symptoms when he was approximately 18 or 19 with auditory and visual hallucinations and paranoid delusions. He was using drugs and smoking marijuana at that time has experimenting with LXV and another drugs too. The patient has not used any drugs since age 25. However, he has continued having intense and frequent psychotic bouts. I have seen him now for approximately one year. He has been quite refractory to treatment. We tried different types of combination of medications, which have included Clozaril, Risperdal, lithium, and Depakote with partial response and usually temporary. The patient has had starting with probably has had some temporary relief of the symptoms and they usually do not last more than a few days. The dosages that we have used have been very high. He has been on Clozaril 1200 mg combined with Risperdal up to 9 mg and lithium at a therapeutic level. However, he has not responded.,He has delusions of antichrist. He strongly believes that the dogs have a home in the neighborhood are communicating with him and criticizing him and he believes that all the people can communicate to him with telepathy including the animals. He has paranoid delusions. He also gets homicidal like prior to this admission.,PAST PSYCHIATRIC HISTORY:, As mentioned before, this patient has been psychotic off and on for about 20 years now. He has had years in which he did better on Clozaril and also his other medications.,With typical anti-psychotics, he has done well at times, but he eventually gets another psychotic bout.,PAST MEDICAL HISTORY: , He has a history of obesity and also of diabetes mellitus. However, most recently, he has not been treated for diabetes since his last regular weight since he stopped taking Zyprexa. The patient has chronic bronchitis. He smokes cigarettes constantly up to 60 a day.,DRUG HISTORY:, He stopped using drugs when he was 25. He has got a lapse, but he was more than 10 years and he has been clean ever since then. As mentioned before, he smokes cigarettes quite heavily and which has been a problem for his health since he also has chronic bronchitis.,PSYCHOSOCIAL STATUS: , The patient lives with his mother and has been staying with her for a few years now. We have talked to her. She is very supportive. His only sister is also very supportive of him. He has lived in the ABCD houses in the past. He has done poorly in some of them.,MENTAL STATUS EXAMINATION:, The patient appeared alert, oriented to time, place, and person. His affect is flat. He talked about auditory hallucinations, which are equivocal in nature. He is not homicidal in the hospital as he was when he was at home. His voice and speech are normal. He believes in telepathy. His memory appears intact and his intelligence is calculated as average.,INITIAL DIAGNOSES:,AXIS I: Schizophrenia.,AXIS II: Deferred.,AXIS III: History of diabetes mellitus, obesity, and chronic bronchitis.,AXIS IV: Moderate.,AXIS V: GAF of 35 on admission.,INITIAL TREATMENT AND PLAN:, Since, the patient has been on high dosages of medications, we will give him a holiday and a structured environment. We will put him on benzodiazepines and make a decision anti-psychotic later. We will make sure that he is safe and that he addresses his medical needs well. neurology, neuropsychological, gaf, schizophrenia, anti-psychotic, chronic psychotic condition, delusions, hallucination, homicidal, marijuana, psychological, psychotic, smokes cigarettes, smoking, neuropsychological evaluation, clozaril, bronchitis, axis, Neurology Approximately one and a half years ago, patient fell down while walking in the living room from the bedroom. At that time, he reports both legs gave away on him and he fell. He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him. Neurologic Consultation - 5 HISTORY OF PRESENT ILLNESS: ,The patient is a 79-year-old right-handed man who reports that approximately one and a half years ago, he fell down while walking in the living room from the bedroom. At that time, he reports both legs gave away on him and he fell. He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him. He was able to get up shortly after falling and according to the patient and his son, subsequently returned back to normal.,He was then well until the 3rd of July 2008 when his legs again gave way on him. This was not preceded by lightheadedness. He was rushed to the hospital and was found to have pneumonia, and the fall was blamed on the pneumonia. He started using a walker from that time, prior to that he was able to walk approximately two miles per day. He again had a fall in August of 2008 after his legs gave way. Again, there was no lightheadedness associated with this. He was again found to have pneumonia and again was admitted to hospital after which he went to rehabilitation and was able to use his walker again after this. He did not, however, return to the pre-July baseline. In October of 2008, after another fall, he was found to have pneumonia again and shingles. He is currently in a Chronic Rehabilitation Unit. He cannot use a walker and uses a wheelchair for everything. He states that his hands have been numb, involving all the fingers of both hands for the past three weeks. He is also losing muscle bulk in his hands and has noticed some general weakness of his hands. He does, however, note that strength in his hands has not been normal since July 2008, but it is clearly getting worse. He has been aware of some fasciculations in his legs starting in August 2008, these are present both in the lower legs and the thighs. He does not report any cramps, problems with swallowing or problems with breathing. He reports that he has had constipation alternating with diarrhea, although there has been no loss of control of either his bowel or bladder. He has had some problems with blood pressure drops, and does feel presyncopal when he stands. He also reports that he has no feeling in his feet, and that his feet feel like sponges. This has been present for about nine months. He has also lost joint position sense in his feet for approximately nine months.,PAST MEDICAL HISTORY:,1. Pneumonia. He has had recurrent episodes of pneumonia, which started at approximately age 20. These have been treated repeatedly over the years, and on average he has tended to have an episode of pneumonia once every five years, although this has been far more frequent in the past year. He is usually treated with antibiotics and then discharged. There is no known history of bronchiectasis, inherited lung disease or another chronic pulmonary cause for the repeated pneumonia.,2. He has had a catheter placed for urinary retention, his urologist has told him that he thinks that this may be due to prostate enlargement. The patient does not have any history of diabetes and does not report any other medical problems. He has lost approximately 18 pounds in the past month.,3. He had an appendectomy in the 1940s.,4. He had an ankle resection in 1975.,SOCIAL HISTORY: ,The patient stopped smoking 27 years ago, he smoked approximately two packs a day with combined cigarettes and cigars. He has not smoked for the past 27 years. He hardly ever uses alcohol. He is currently retired.,FAMILY HISTORY: , There is no family history of neuropathy, pes cavus, foot deformities, or neuromuscular diseases. His aunt has a history of type II diabetes.,CURRENT MEDICATIONS: , Fludrocortisone 0.1 mg p.o. q.d., midodrine 5 mg p.o. q.i.d., Cymbalta 30 mg p.o. per day, Prilosec 20 mg p.o. per day, Lortab 10 mg p.o. per day, Amoxil 500 mg p.o. per day, vitamin B12 1000 mcg weekly, vitamin D 1000 units per day, Metamucil p.r.n., enteric-coated aspirin once a day, Colace 200 mg p.o. q.d., Senokot three tablets p.o. p.r.n., Reglan 10 mg p.o. q.6h., Xanax 0.25 mg p.o. q.8h. p.r.n., Ambien 5 mg p.o. q.h.s. p.r.n. and Dilaudid 2 mg tablets p.o. q.3h. p.r.n., Protonix 40 mg per day, and Megace 400 mg per day.,ALLERGIES:, He has no medication or food allergies.,REVIEW OF SYSTEMS:, Please see the health questionnaire and clinical notes from today.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS: BP was 137/60, P was 89, and his weight could not be measured because he was in a wheelchair. His pain score was 0.,APPEARANCE: No acute distress. He is pleasant and well-groomed.,HEENT: Atraumatic, normocephalic. No carotid bruits appreciated.,LUNGS: There were few coarse crackles in both lung bases.,CARDIOVASCULAR: Revealed a normal first and second heart sound, with no third or fourth heart sound and no murmurs. The pulse was regular and of normal volume.,ABDOMEN: Soft with no masses and normal bowel sounds. There were no carotid bruits.,EXTREMITIES: No contractures appreciated.,NEUROLOGICAL EXAM:,MSE: His orientation, language, calculations, 100-7 tests were all normal. There was atrophy and fasciculations in both the arms and legs.,CRANIAL NERVES: Cranial nerve examination was normal with the exception that there was some mild atrophy of his tongue and possible fasciculations. His palatal movement was normal and gag reflex was normal.,MOTOR: Strength was decreased in all muscle groups as follows: Deltoid 4/4, biceps 4+/4+, triceps 5/5, wrist extensors 4+/4+, finger extensors 4-/4-, finger flexors 4-/4-, interossei 4-/4-, hip flexors 4+/4+, hip extensors 4+/4+, knee extensors 4/4, and knee flexors 4/4. Foot dorsiflexion, plantar flexion, eversion, toe extension and toe flexion was all 0 to 1. There was atrophy in both hands and general atrophy of the lower limb muscles. The feet were both cold and showed dystrophic features. Fasciculations were present mainly in the hands. There was evidence of dysmetria and past pointing in the left hand.,REFLEXES: Reflexes were 0 in all sites in the arms and legs. The jaw reflex was 2+. Vibration was severely decreased at the elbow and wrist and was absent in the fingers. Vibration was absent in the toes and ankle bilaterally and was severely decreased at the knee. Joint position sense was absent in the toes and severely decreased in the fingers. Pin perception was absent in the feet and was decreased to the upper thighs. Pin was decreased or absent in the fingers and decreased above the elbows. The same distribution of sensory loss was found with monofilament testing.,COORDINATION: Coordination was barely normal in the right hand. Rapid alternating movements were decreased in the left hand greater than the right hand. The patient was unable to stand and therefore gait, Romberg's test and balance could not be assessed.,DIAGNOSTIC STUDIES: , Previous diagnostic studies and patient reports. There were extensive patient reports, all of which were reviewed. A previous x-ray study of the lateral chest performed in October 2008 showed poor inspiration with basilar atelectasis and an infiltrate. An x-ray of the cervical, thoracic and lumbar spine showed some evidence of lumbar spinal stenosis. A CTA of the neck with and without contrast performed in November 2008 showed minor stenosis in the left carotid, a mild hard and soft plaque in the right carotid with approximately 55% stenosis. The posterior circulation showed a slightly dominant right vertebral artery with no stenosis. There was no significant stenosis, but there was minor extracranial stenosis noted. An MRI of the brain with and without contrast performed in November 2008 showed no evidence of an acute infarct, major vascular occlusion, and no abnormal enhancement with gadolinium administration. There was also no significant sinusitis or mastoiditis. This was an essentially normal brain MRI. A CBC performed in January 2009 showed an elevated white cell count of 11.3, a low red cell count of 3.43, elevated MCH of 32.4 and the rest of the study was normal. An electrolyte study performed in January 2009 showed a sodium which was low at 127, a calcium which was low at 8.3, and a low protein of 5.2 and albumin of 3.1. The glucose was 86. TSH performed in January 2009 was 1.57, which is within the normal range. Vitamin B12 was greater than a 1000, which is normal and the folate was 18.2, which was normal. A myocardial stress study performed in December 2008 showed normal myocardial perfusion with Persantine Cardiolite SPECT. The ECG was non-diagnostic. There was normal regional wall motion of the left ventricle. The left ventricular ejection fraction was 68%, which is within the normal range for males. A CT of the lumbar spine without contrast performed in December 2008 showed a broad-based disc bulge at L1-L2, L2-L3, L3-L4 and L4-L5. At L5-S1, in addition to the broad-based disc bulge, there was also an osteophyte complex and evidence of flavum hypertrophy without canal stenosis. There was severe bilateral neural foraminal stenosis at L5-S1 and moderate neural foraminal stenosis at L1-L4. An echocardiogram was performed in November 2008 and showed mild left atrial enlargement, normal left ventricular systolic function, mild concentric left ventricular hypertrophy, scleral degenerative changes in the aortic and mitral apparatus, mild mitral regurgitation, mild tricuspid regurgitation and mild to moderate aortic regurgitation.,DIAGNOSTIC IMPRESSION: ,The patient presents with a severe neuropathy with marked large fiber sensory as well as motor findings. He is diffusely weak as well as atrophic in all muscle groups both in his upper and lower extremities, although he is disproportionately weak in his lower extremities. His proprioceptive and vibratory loss is severe in both the distal upper and lower extremities, signifying that he either has a severe sensory neuropathy or has involvement of the dorsal root ganglia. According to the history, which was carefully checked, the initial onset of these symptoms goes back one and a half years, although there has only been significant progression in his condition since July 2008. As indicated below, further diagnostic studies including a detailed nerve conduction and EMG test today showed evidence of a severe sensory, motor, and axonal neuropathy and in addition there was evidence of a diffuse polyradiculopathy. There was no involvement of the tongue on EMG. The laboratory testing as indicated below failed to show a specific cause for the neuropathy. We are still, however, waiting for the paraneoplastic antibodies, which were send out lab to the Mayo Clinic. This type of very severe sensorimotor neuropathy with significant proprioceptive loss may be seen in several conditions including peripheral nerve vasculitis due to a variety of disorders such as SLE, Sjogren's, rheumatoid arthritis, and mixed connective tissue disease. In addition, it may also be seen with certain toxins, particularly chemotherapeutic agents. The patient did not receive any of these. It may also be seen as part of a paraneoplastic syndrome. Although the patient does not have any specific clinical symptoms of a cancer, it is noted that he has had an 18-pound weight loss in the past month and does have a remote history of smoking. We have requested that he obtain a CT of his chest, abdomen and pelvis while he is in Acute Rehabilitation. The verbal reports of these possibly did not show any evidence of a cancer. We did also request that he obtain a gallium scan to see if there was any evidence of an unsuspected neoplasm. The patient did undergo a nerve and muscle biopsy, this was a radial nerve and biceps muscle biopsy from the left arm. This showed evidence of severe axonal loss. There was no evidence of a vasculitis. The vessels did show some mild intimal changes that would be consistent with atherosclerosis. There were a few perivascular changes; however, there was no clear evidence of a necrotizing vasculitis even on multiple sections. The muscle biopsy showed severe muscle fiber atrophy, with evidence of fiber grouping. Again, there was no evidence of inflammation or vasculitis. Evaluation so far has also shown no evidence of an amyloid neuropathy, no evidence of a monoclonal gammopathy, of sarcoidosis, and again there is no past history of a significant toxin or infective cause for the neuropathy. Specifically, there is no history of HIV exposure. We would await the results of the gallium scan and of the paraneoplastic antibodies to see if these are helpful in making a diagnosis. At this point, because of the severity and the axonal nature of the neuropathy, there is no specific therapy that will reverse the course of the illness, unless we find a specific etiology that can be stopped or reversed. I have discussed these issues at length with the patient and with his son. We also addressed whether or not there might be a previously undiagnosed inherited neuropathy. I think this is unlikely given the short history and the rapid progression of the disorder.,There is also no family history that we can detect a neuropathy, and the patient does not have the typical phenotype for a chronic inherited neuropathy such as Charcot-Marie-Tooth disease type 2. However, since I have only seen the patient on one occasion and do not know what his previous examination showed two years ago, I cannot be certain that there may not have been the presence of a neuropathy preceding this.,PLAN:,1. Nerve conduction and EMG will be performed today. The results were indicated above.,2. The following laboratory studies were requested including electrolytes, CBC, thyroid function tests, B12, ANA, C-reactive protein, complement, cryoglobulins, double-stranded DNA antibodies, folate level, hemoglobin A1c, immunofixation electrophoresis, P-ANCA, C-ANCA, protein electrophoresis, rheumatoid factor, paraneoplastic antibody studies requested from the Mayo Clinic, B12. These studies showed minor changes, which included a low sodium level of 129 as previously noted, a low creatinine of 0.74, low calcium of 8.6, low total protein of 5.7. The B12 was greater than 2000. The immunoelectrophoresis, ANA, double-stranded DNA, ANCA, hemoglobin A1c, folate, cryoglobulins, complement, C-reactive protein were all normal or negative. The B12 level was greater than 2000. Liver function tests were normal. The glucose was 90. ESR was 10. Hemoglobin A1c was 5.5.,3. A left radial sensory and left biceps biopsy were requested and have been performed and interpreted as indicated above.,4. CT of chest, abdomen and pelvis.,5. Whole body gallium scan for evidence of an underlying neoplasm.,6. The patient will go to the Rehabilitation Facility for Acute Rehabilitation and Training.,7. We have not made any changes to his medication. He does have some mild orthostatic changes; however, he is adequately controlled with midodrine at a dose of 2.5 mg three times a day as needed up to 5 mg four times a day. Usually, he uses a lower dose of 2.5 three times a day to 5 mg three times a day.,8. Followup will be as determined by the family. Neurology Muscle twitching, clumsiness, progressive pain syndrome, and gait disturbance. Probable painful diabetic neuropathy. Symptoms are predominantly sensory and severely dysfunctioning, with the patient having inability to ambulate independently as well as difficulty with grip and temperature differentiation in his upper extremities. Neurologic Consultation - 4 REASON FOR NEUROLOGICAL CONSULTATION:, Muscle twitching, clumsiness, progressive pain syndrome, and gait disturbance.,HISTORY OF PRESENT ILLNESS: , The patient is a 62-year-old African-American male with a significant past medical history of diabetes, hypertension, previous stroke in 2002 with minimal residual right-sided weakness as well as two MIs, status post pacemaker insertion who first presented with numbness in his lower extremities in 2001. He states that since that time these symptoms have been progressive and now involving his legs above his knees as well as his hands. More recently, he describes a burning sensation along with numbness. This has become a particular problem and of all the problems he has he feels that pain is his primary concern. Over the last six months, he has noticed that he cannot feel hot objects in his hands and that objects slip out of his hands. He denies any weakness per se, just clumsiness and decreased sensation. He has also been complaining of brief muscle jerks, which occur in both hands and his shoulders. This has been a fairly longstanding problem, and again has become more prevalent recently. He does not have any tremor. He denies any neck pain. He walks with the aid of a walker because of unsteadiness with gait.,Recently, he has tried gabapentin, but this was not effective for pain control. Oxycodone helps somewhat and gives him at least three hours pain relief. Because of the pain, he has significant problems with fractured sleep. He states he has not had a good night's sleep in many years. About six months ago, after an MI and pacemaker insertion, he was transferred to a nursing facility. At that facility, his insulin was stopped. Since then he has only been on oral medication for his diabetes. He denies any back pain, neck pain, change in bowel or bladder function, or specific injury pre-dating these symptoms., ,PAST MEDICAL HISTORY: , Diabetes, hypertension, coronary artery disease, stroke, arthritis, GERD, and headaches.,MEDICATIONS: , Trazodone, simvastatin, hydrochlorothiazide, Prevacid, lisinopril, glipizide, and gabapentin.,FAMILY HISTORY: , Discussed above and documented on the chart.,SOCIAL HISTORY: , Discussed above and documented on the chart. He does not smoke. He lives in a senior citizens building with daily nursing aids. He previously was a security guard, but is currently on disability.,REVIEW OF SYSTEMS: , Discussed above and documented on the chart.,PHYSICAL EXAMINATION: , On examination, blood pressure 150/80, pulse of 80, respiratory rate 22, and weight 360 pounds. Pain scale 7/10. A full general and neurological examination was performed on the patient and is documented on the chart.,The patient is obese with significant ankle edema.,Neurological examination reveals normal cognitive exam and normal cranial nerve examination. Motor examination reveals mild atrophy in bilateral FDIs, but still has a strong grip. Individual muscle strength is close to normal with only subtle weakness found in ankle plantar and dorsiflexion. Tone and bulk are normal. Sensory examination reveals a severe decrease to all modalities in his lower extremities from just above the knees distally. He has no vibration sense at his knees. Similarly, there is decrease to all sensory modalities in his both upper extremities from just above the wrist distally. The only reflexes I could obtain with trace reflexes in his biceps. Remaining reflexes were unelicitable. No Babinski. The patient walks normally with the aid of a cane. He has severe sensory ataxia with inability to walk unaided. Positive Romberg with eyes open and closed.,IMPRESSION AND PLAN:,1. Probable painful diabetic neuropathy. Symptoms are predominantly sensory and severely dysfunctioning, with the patient having inability to ambulate independently as well as difficulty with grip and temperature differentiation in his upper extremities. He has relative preservation of motor function. Because these symptoms are progressive and, by report, he came off his insulin, suggesting somewhat mild diabetes, I would like to rule out other causes of progressive neuropathy.,2. He has history of myoclonic jerks. I did not see any on my examination today and I feel that these are benign and probably secondary to his severe insomnia, which he states is secondary to the painful neuropathy. I would like to rule out other causes such as hepatic encephalopathy., ,I have recommended the following:,1. EMG/nerve conduction study to assess severity of neuropathy and to characterize neuropathy.,2. Blood work, looking for other causes of neuropathy and myoclonus, to include CBC, CMP, TSH, LFT, B12, RPR, ESR, Lyme titer, and HbA1c, and ammonia level.,3. Neurontin and oxycodone have not been effective, and I have recommended Cymbalta starting at 30 mg q.d. for five days and then increasing to 60 mg q.d. Side effect profile of this medication was discussed with the patient.,4. I have explained to him that progression of diabetic neuropathy is closely related to diabetic control and I have recommended tight diabetic control.,5. I will see him at followup at the EMG. Neurology Neurologic examination sample. Neurologic Examination NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented. There is no evidence of cognitive or language dysfunction. Cranial nerves: Visual fields are full. Funduscopic examination is normal. Extraocular movements full. Pupils equal, round, react to light. There is no evidence of nystagmus noted. Fifth nerve function is normal. There is no facial asymmetry noted. Lower cranial nerves are normal. ,Manual motor testing reveals good tone and bulk throughout. There is no evidence of pronator drift or decreased fine finger movements. Muscle strength is 5/5 throughout. Deep tendon reflexes are 2+ throughout with downgoing toes. Sensory examination is intact to all modalities including stereognosis, graphesthesia.,TESTING OF STATION AND GAIT:, The patient is able to walk toe-heel and tandem walk. Finger-to-nose and heel-to-shin moves are normal. Romberg sign negative. I appreciate no carotid bruits or cardiac murmurs.,Noncontrast CT scan of the head shows no evidence of acute infarction, hemorrhage or extra-axial collection. neurology, station, motor testing, nerve function, neurologic examination, cranial nerves, cranial, extraocular, movementsNOTE Neurology The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. Neuropsychological Evaluation - 5 "PROBLEMS AND ISSUES:,1. Headaches, nausea, and dizziness, consistent with a diagnosis of vestibular migraine, recommend amitriptyline for prophylactic treatment and Motrin for abortive treatment.,2. Some degree of peripheral neuropathy, consistent with diabetic neuropathy, encouraged her to watch her diet and exercise daily.,HISTORY OF PRESENT ILLNESS: , The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. I obtained and documented a full history and physical examination. I reviewed the new patient questionnaire, which she completed prior to her arrival today. I also reviewed the results of tests, which she had brought with her.,Briefly, she is a 60-year-old woman initially from Ukraine, who had headaches since age 25. She recalls that in 1996 when her husband died her headaches became more frequent. They were pulsating. She was given papaverine, which was successful in reducing the severity of her symptoms. After six months of taking papaverine, she no longer had any headaches. In 2004, her headaches returned. She also noted that she had ""zig-zag lines"" in her vision. Sometimes she would not see things in her peripheral visions. She had photophobia and dizziness, which was mostly lightheadedness. On one occasion she almost had a syncope. Again she has started taking Russian medications, which did help her. The dizziness and headaches have become more frequent and now occur on average once to twice per week. They last two hours since she takes papaverine, which stops the symptoms within 30 minutes.,PAST MEDICAL HISTORY: ,Her past medical history is significant for injury to her left shoulder, gastroesophageal reflux disorder, diabetes, anxiety, and osteoporosis.,MEDICATIONS:, Her medications include hydrochlorothiazide, lisinopril, glipizide, metformin, vitamin D, Centrum multivitamin tablets, Actos, lorazepam as needed, Vytorin, and Celexa.,ALLERGIES: , She has no known drug allergies.,FAMILY HISTORY: ,There is family history of migraine and diabetes in her siblings.,SOCIAL HISTORY: , She drinks alcohol occasionally.,REVIEW OF SYSTEMS: , Her review of systems was significant for headaches, pain in her left shoulder, sleeping problems and gastroesophageal reflex symptoms. Remainder of her full 14-point review of system was unremarkable.,PHYSICAL EXAMINATION:, On examination, the patient was pleasant. She was able to speak English fairly well. Her blood pressure was 130/84. Heart rate was 80. Respiratory rate was 16. Her weight was 188 pounds. Her pain score was 0/10. Her general exam was completely unremarkable. Her neurological examination showed subtle weakness in her left arm due to discomfort and pain. She had reduced vibration sensation in her left ankle and to some degree in her right foot. There was no ataxia. She was able to walk normally. Reflexes were 2+ throughout.,She had had a CT scan with constant, which per Dr. X's was unremarkable. She reports that she had a brain MRI two years ago which was also unremarkable.,IMPRESSION AND PLAN:, The patient is a delightful 60-year-old chemist from Ukraine who has had episodes of headaches with nausea, photophobia, and dizziness since her 20s. She has had some immigration problems in recent months and has experienced increased frequency of her migraine symptoms. Her diagnosis is consistent with vestibular migraine. I do not see evidence of multiple sclerosis, Ménière's disease, or benign paroxysmal positional vertigo.,I talked to her in detail about the importance of following a migraine diet. I gave her instructions including a list of foods times, which worsen migraine. I reviewed this information for more than half the clinic visit. I would like to start her on amitriptyline at a dose of 10 mg at time. She will take Motrin at a dose of 800 mg as needed for her severe headaches.,She will make a diary of her migraine symptoms so that we can find any triggering food items, which worsen her symptoms. I encouraged her to walk daily in order to improve her fitness, which helps to reduce migraine symptoms." neurology, nausea, dizziness, migraine, peripheral neuropathy, diabetic neuropathy, neuropathy, positional vertigo, photophobia and dizziness, neurology consultation, tunnel vision, vestibular migraine, migraine symptoms, headaches, photophobia, ataxia, Neurology Neurologic consultation was requested to evaluate her seizure medication and lethargy. Neurologic Consultation REASON FOR CONSULTATION: , Neurologic consultation was requested by Dr. X to evaluate her seizure medication and lethargy.,HISTORY OF PRESENT ILLNESS: , The patient is well known to me. She has symptomatic partial epilepsy secondary to a static encephalopathy, cerebral palsy, and shunted hydrocephalus related to prematurity. She also has a history of factor V Leiden deficiency. She was last seen at neurology clinic on 11/16/2007. At that time, instructions were given to mom to maximize her Trileptal dose if seizures continue. She did well on 2 mL twice a day without any sedation. This past Friday, she had a 25-minute seizure reportedly. This consisted of eye deviation, unresponsiveness, and posturing. Diastat was used and which mom perceived was effective. Her Trileptal dose was increased to 3 mL b.i.d. yesterday.,According to mom since her shunt revision on 12/18/2007, she has been sleepier than normal. She appeared to be stable until this past Monday about six days ago, she became more lethargic and had episodes of vomiting and low-grade fevers. According to mom, she had stopped vomiting since her hospitalization. Reportedly, she was given a medication in the emergency room. She still is lethargic, will not wake up spontaneously. When she does awaken however, she is appropriate, and interacts with them. She is able to eat well; however her overall p.o. intake has been diminished. She has also been less feisty as her usual sounds. She has been seizure free since her admission.,LABORATORY DATA: , Pertinent labs obtained here showed the following: CRP is less than 0.3, CMP normal, and CBC within normal limits. CSF cultures so far is negative. Dr. Limon's note refers to a CSF, white blood cell count of 2, 1 RBC, glucose of 55, and protein of 64. There are no imaging studies in the computer. I believe that this may have been done at Kaweah Delta Hospital and reviewed by Dr. X, who indicated that there was no evidence of shunt malfunction or infection.,CURRENT MEDICATIONS: , Trileptal 180 mg b.i.d., lorazepam 1 mg p.r.n., acetaminophen, and azithromycin.,PHYSICAL EXAMINATION:,GENERAL: The patient was asleep, but easily aroused. There was a brief period of drowsiness, which she had some jerky limb movements, but not seizures. She eventually started crying and became agitated. She made attempts to sit by bending her neck forward. Fully awake, she sucks her bottle eagerly.,HEENT: She was obviously visually impaired. Pupils were 3 mm, sluggishly reactive to light.,EXTREMITIES: Bilateral lower extremity spasticity was noted. There was increased flexor tone in the right upper extremity. IV was noted on the left hand.,ASSESSMENT: ,Seizure breakthrough due to intercurrent febrile illness. Her lethargy could be secondary to a viral illness with some component of medication effect since her Trileptal dose was increased yesterday and these are probable explanations if indeed shunt malfunction has been excluded.,I concur with Dr. X's recommendations. I do not recommend any changes in Trileptal for now. I will be available while she remains hospitalized., neurology, lethargy, encephalopathy, cerebral palsy, shunted hydrocephalus, seizure breakthrough, shunt malfunction, neurologic consultation, neurologic, seizure, trileptal Neurology The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection. Neuroblastoma - Consult 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. Neurology Patient has trouble with walking and balance, with bladder control, and with thinking and memory. Neurologic Consultation - 2 "REASON FOR VISIT: ,The patient is a 76-year-old man referred for neurological consultation by Dr. X. The patient is companied to clinic today by his wife and daughter. He provides a small portion of his history; however, his family provides virtually all of it.,HISTORY OF PRESENT ILLNESS: , He has trouble with walking and balance, with bladder control, and with thinking and memory. When I asked him to provide me detail, he could not tell me much more than the fact that he has trouble with his walking and that he has trouble with his bladder. He is vaguely aware that he has trouble with his memory.,According to his family, he has had difficulty with his gait for at least three or four years. At first, they thought it was weakness and because of he was on the ground (for example, gardening) he was not able to get up by himself. They did try stopping the statin that he was taking at that time, but because there was no improvement over two weeks, they resumed the statin. As time progressed, he developed more and more difficulty. He started to shuffle. He started using a cane about two and a half years ago and has used a walker with wheels in the front since July of 2006. At this point, he frequently if not always has trouble getting in or out of the seat. He frequently tends to lean backwards or sideways when sitting. He frequently if not always has trouble getting in or out a car, always shuffles or scuffs his feet, always has trouble turning or changing direction, always has trouble with uneven surfaces or curbs, and always has to hold on to someone or something when walking. He has not fallen in the last month. He did fall earlier, but there seemed to be fewer opportunities for him to fall. His family has recently purchased a lightweight wheelchair to use if he is traveling long distances. He has no stairs in his home, however, his family indicates that he would not be able to take stairs. His handwriting has become smaller and shakier.,In regard to the bladder, he states, ""I wet the bed."" In talking with his family, it seems as if he has no warning that he needs to empty his bladder. He was diagnosed with a small bladder tumor in 2005. This was treated by Dr. Y. Dr. X does not think that the bladder tumor has anything to do with the patient's urinary incontinence. The patient has worn a pad or undergarment for at least one to one and a half years. His wife states that they go through two or three of them per day. He has been placed on medications; however, they have not helped.,He has no headaches or sensation of head fullness.,In regard to the thinking and memory, at first he seemed forgetful and had trouble with dates. Now he seems less spontaneous and his family states he seems to have trouble expressing himself. His wife took over his medications about two years ago. She stopped his driving about three years ago. She discovered that his license had been expired for about a year and she was concerned enough at that time that she told him he could drive no more. Apparently, he did not object. At this point, he frequently has trouble with memory, orientation, and everyday problems solving at home. He needs coaching for his daily activities such as reminders to brush his teeth, put on his clothes, and so forth. He is a retired office machine repairman. He is currently up and active about 12 hours a day and sleeping or lying down about 12 hours per day.,He has not had PT or OT and has not been treated with medications for Parkinson's disease or Alzheimer's disease. He has been treated for the bladder. He has not had lumbar puncture.,Past medical history and review of all 14 systems from the form they completed for this visit that I reviewed with them is negative with the exception that he has had hypertension since 1985, hypercholesterolemia since 1997, and diabetes since 1998. The bladder tumor was discovered in 2005 and was treated noninvasively. He has lost weight from about 200 pounds to 180 pounds over the last two or three years. He had a period of depression in 1999 and was on Prozac for a while, but this was then stopped. He used to drink a significant amount of alcohol. This was problematic enough that his wife was concerned. She states he stopped when she retired and she was at home all day.,SOCIAL HISTORY: ,He quit smoking in 1968. His current weight is 183 pounds. His tallest height is 5 feet 10 inches.,FAMILY HISTORY: ,His grandfather had arthritis. His father had Parkinson's disease. His mother had heart disease and a sister has diabetes.,He does not have a Living Will and indicates he would wish his wife to make decisions for him if he could not make them for himself.,REVIEW OF HYDROCEPHALUS RISK FACTORS: , None.,ALLERGIES: , None.,MEDICATIONS: , Metformin 500 mg three times a day, Lipitor 10 mg per day, lisinopril 20 mg per day, metoprolol 50 mg per day, Uroxatral 10 mg per day, Detrol LA 4 mg per day, and aspirin 81 mg per day.,PHYSICAL EXAM: , On examination today, this is a pleasant 76-year-old man who is guided back from the clinic waiting area walking with his walker. He is well developed, well nourished, and kempt.,Vital Signs: His weight is 180 pounds.,Head: The head is normocephalic and atraumatic. The head circumference is 59 cm, which is the ,75-90th percentile for an adult man whose height is 178 cm.,Spine: The spine is straight and not tender. I can easily palpate the spinous processes. There is no scoliosis.,Skin: No neurocutaneous stigmata.,Cardiovascular Examination: No carotid or vertebral bruits.,Mental Status: Assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge. The Mini-Mental State Exam score was 17/30. He did not know the year, season, or day of the week nor did he know the building or specialty or the floor. There was a tendency for perseveration during the evaluation. He could not copy the diagram of intersecting pentagons.,Cranial Nerve Exam: No evidence of papilledema. The pupillary light reflex is intact as are extraocular movements without nystagmus, facial expression and sensation, hearing, head turning, tongue, and palate movement.,Motor Exam: Normal bulk and strength, but the tone is marked by significant paratonia. There is no atrophy, fasciculations, or drift. There is tremulousness of the outstretched hands.,Sensory Exam: Is difficult to interpret. Either he does not understand the test or he is mostly guessing.,Cerebellar Exam: Is intact for finger-to-nose, heel-to-knee, and rapid alternating movement tests. There is no dysarthria.,Reflexes: Trace in the arms, 2+ at the knees, and 0 at the ankles. It is not certain whether there is a Babinski sign or simply withdrawal.,Gait: Assessed using the Tinetti assessment tool that shows a balance score of 7-10/16 and a gait score of 2-5/12 for a total score of 9-15/28, which is significantly impaired.,REVIEW OF X-RAYS: , I personally reviewed the MRI scan of the brain from December 11, 2007 at Advanced Radiology. It shows the ventricles are enlarged with a frontal horn span of 5.0 cm. The 3rd ventricle contour is flat. The span is enlarged at 12 mm. The sylvian aqueduct is patent. There is a pulsation artifact. The corpus callosum is effaced. There are extensive T2 signal abnormalities that are confluent in the corona radiata. There are also scattered T2 abnormalities in the basal ganglia. There is a suggestion of hippocampal atrophy. There is also a suggestion of vermian atrophy.,ASSESSMENT: , The patient has a clinical syndrome that raises the question of idiopathic normal pressure hydrocephalus. His examination today is notable for moderate-to-severe dementia and moderate-to-severe gait impairment. His MRI scan raises the question of hydrocephalus, however, is also consistent with cerebral small vessel disease.,PROBLEMS/DIAGNOSES:,1. Possible idiopathic normal pressure hydrocephalus (331.5).,2. Probable cerebral small-vessel disease (290.40 & 438).,3. Gait impairment (781.2).,4. Urinary urgency and incontinence (788.33).,5. Dementia.,6. Hypertension.,7. Hypercholesterolemia." Neurology The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness. Neuro Consult - Leg Weakness HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness. He has difficulty recollecting the exact details and chronology of his problem. To the best of his recollection, he thinks that about six months ago he developed weakness of his right leg. He describes that he is reaching to get something from a cabinet and he noticed that he was unable to stand on his right toe. Since that time, he has had difficulty pushing off when he walks. He has mild tingling and numbness in his toes, but this has been a chronic problem and nothing new since he has developed the weakness. He has chronic mild back pain, but this has been persistent for many years and has not changed. He has experienced cramps in both calves for the past year. This dissipated about two months ago. He does not think that his left leg is weak. He does not have any bowel or bladder incontinence. There is no radicular pain. He does not think that the problem is progressive, meaning that the weakness that he perceives in his right leg is no different than when it was six months ago.,He first sought medical attention for this problem in October. He then saw you a couple of months later. He has undergone an EMG and nerve conduction studies. Unfortunately, he cannot undergo an MRI of his spine because he has an ear implant. He has had a CT scan that shows degenerative changes, but nothing obviously abnormal.,In addition, the patient has hyperCKemia. He tells me that he has had an elevated CK prior to starting taking stat medications, although this is not entirely clear to me. He thinks that he is not taking Lipitor for about 15 months and thought that his CK was in the 500 or 600s prior to starting it. Once it was started, it increased to about 800 and then came down to about 500 when it was stopped. He then had a recent bump again up to the 1000 and since Lipitor has been stopped, his CK apparently has returned to about the 500 or 600s. I do no have any laboratory data to support these statements by the patient, but he seems to be up to speed on this. More recently, he has been started taking Zetia. He does not have any proximal weakness. He denies any myalgias., ,PAST MEDICAL HISTORY:, He has coronary artery disease and has received five stents. He has hypertension and hypercholesterolemia. He states that he was diagnosed with diabetes based on the results of an abnormal oral glucose tolerance test. He believes that his glucose shot up to over 300 with this testing. He does not take any medications for this and his blood glucoses are generally normal when he checks it. He has had plastic surgery on his face from an orbital injury. He also had an ear graft when he developed an ear infection during his honeymoon., ,CURRENT MEDICATIONS:, He takes amlodipine, Diovan, Zetia, hydrochlorothiazide, Lovaza (fish oil), Niaspan, aspirin, and Chantix. , ,ALLERGIES:, He has no known drug allergies., ,SOCIAL HISTORY:, He lives with his wife. He works at Shepherd Pratt doing network engineering. He smokes a pack of cigarettes a day and is working on quitting. He drinks four alcoholic beverages per night. Prior to that, he drank significantly more. He denies illicit drug use. He was athletic growing up., ,FAMILY HISTORY:, His mother died of complications from heart disease. His father died of heart disease in his 40s. He has two living brothers. One of them he does not speak too much with and does not know about his medical history. The other is apparently healthy. He has one healthy child. His maternal uncles apparently had polio. When I asked him to tell me further details about this, he states that one of them had to wear crutches due to severe leg deformans and then the other had leg deformities in only one leg. He is fairly certain that they had polio. He is unaware of any other family members with neurological conditions.,REVIEW OF SYSTEMS: , He has occasional tinnitus. He has difficulty sleeping. Otherwise, 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: Neurology Neurologic consultation was requested to assess and assist with seizure medication. Neurologic Consultation - 3 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. neurology, eye blinking, status epilepticus, seizure medication, valproic acid, allergic reactions, neurologic consultation, seizure, neurologic, seizures, Neurology Patient with juvenile myoclonic epilepsy and recent generalized tonic-clonic seizure. Myoclonic Epilepsy DIAGNOSES:,1. Juvenile myoclonic epilepsy.,2. Recent generalized tonic-clonic seizure.,MEDICATIONS:,1. Lamictal 250 mg b.i.d.,2. Depo-Provera.,INTERIM HISTORY: , The patient returns for followup. Since last consultation she has tolerated Lamictal well, but she has had a recurrence of her myoclonic jerking. She has not had a generalized seizure. She is very concerned that this will occur. Most of the myoclonus is in the mornings. Recent EEG did show polyspike and slow wave complexes bilaterally, more prominent on the left. She states that she has been very compliant with the medications and is getting a good amount of sleep. She continues to drive.,Social history and review of systems are discussed above and documented on the chart.,PHYSICAL EXAMINATION: , Vital signs are normal. Pupils are equal and reactive to light. Extraocular movements are intact. There is no nystagmus. Visual fields are full. Demeanor is normal. Facial sensation and symmetry is normal. No myoclonic jerks noted during this examination. No myoclonic jerks provoked by tapping on her upper extremity muscles. Negative orbit. Deep tendon reflexes are 2 and symmetric. Gait is normal. Tandem gait is normal. Romberg negative.,IMPRESSION AND PLAN:, Recurrence of early morning myoclonus despite high levels of Lamictal. She is tolerating the medication well and has not had a generalized tonic-clonic seizure. She is concerned that this is a precursor for another generalized seizure. She states that she is compliant with her medications and has had a normal sleep-wake cycle.,Looking back through her notes, she initially responded very well to Keppra, but did have a breakthrough seizure on Keppra. This was thought secondary to severe insomnia when her baby was very young. Because she tolerated the medication well and it was at least partially affective, I have recommended adding Keppra 500 mg b.i.d. Side effect profile of this medication was discussed with the patient.,I will see in followup in three months. neurology, generalized tonic-clonic seizure, juvenile myoclonic epilepsy, tonic clonic seizure, myoclonic epilepsy, tonic clonic, juvenile, myoclonus, epilepsy, myoclonic, seizure Neurology Neurologic consultation and follow-up. Neurologic Consultation - 1 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. neurology, neurologic consultation, stamina, preponderance, neurologic, consultation, copaxone, Neurology Neuro Consult - Depression & Dementia "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:" Neurology The patient is with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue. His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves. Multiple Neurological Symptoms "HISTORY OF PRESENT ILLNESS: , The patient is a 63-year-old left-handed gentleman who presents for further evaluation of multiple neurological symptoms. I asked him to discuss each symptom individually as he had a very hard time describing the nature of his problems. He first mentioned that he has neck pain. He states that he has had this for at least 15 years. It is worse with movement. It has progressed very slowly over the course of 15 years. It is localized to the base of his neck and is sharp in quality. He also endorses a history of gait instability. This has been present for a few years and has been slightly progressively worsening. He describes that he feels unsteady on his feet and ""walks like a duck."" He has fallen about three or four times over the past year and a half.,He also describes that he has numbness in his feet. When I asked him to describe this in more detail, the numbness is actually restricted to his toes. Left is slightly more affected than the right. He denies any tingling or paresthesias. He also described that he is slowly losing control of his hands. He thinks that he is dropping objects due to weakness or incoordination in his hands. This has also been occurring for the past one to two years. He has noticed that buttoning his clothes is more difficult for him. He also does not have any numbness or tingling in the hands. He does have a history of chronic low back pain.,At the end of the visit, when I asked him which symptom was most bothersome to him, he actually stated that his fatigue was most troublesome. He did not even mention this on the initial part of my history taking. When I asked him to describe this further, he states that he experiences a general exhaustion. He basically lays in bed all day everyday. I asked him if he was depressed, he states that he is treated for depression. He is unsure if this is optimally treated. As I just mentioned, he stays in bed almost all day long and does not engage in any social activities. He does not think that he is necessarily sad. His appetite is good. He has never undergone any psychotherapy for depression.,When I took his history, I noticed that he is very slow in responding to my questions and also had a lot of difficulty recalling details of his history as well as names of physicians who he had seen in the past. I asked if he had ever been evaluated for cognitive difficulties and he states that he did undergo testing at Johns Hopkins a couple of years ago. He states that the results were normal and that specifically he did not have any dementia.,When I asked him when he was first evaluated for his current symptoms, he states that he saw Dr. X several years ago. He believes that he was told that he had neuropathy but that it was unclear if it was due to his diabetes. He told me that more recently he was evaluated by you after Dr. Y referred him for this evaluation. He also saw Dr. Z for neurosurgical consultation a couple of weeks ago. He reports that she did not think there was any surgical indication in his neck or back at this point in time.,PAST MEDICAL HISTORY: , He has had diabetes for five years. He also has had hypercholesterolemia. He has had Crohn's disease for 25 or 30 years. He has had a colostomy for four years. He has arthritis, which is reportedly related to the Crohn's disease. He has hypertension and coronary artery disease and is status post stent placement. He has depression. He had a kidney stone removed about 25 years ago.,CURRENT MEDICATIONS: , He takes Actos, Ambien, baby aspirin, Coreg, Entocort, folic acid, Flomax, iron, Lexapro 20 mg q.h.s., Lipitor, Pentasa, Plavix, Protonix, Toprol, Celebrex and Zetia.,ALLERGIES: , He states that Imuran caused him to develop tachycardia.,SOCIAL HISTORY:, He previously worked with pipeline work, but has been on disability for five years. He is unsure which symptoms led him to go on disability. He has previously smoked about two packs of cigarettes daily for 20 years, but quit about 20 years ago. He denies alcohol or illicit drug use. He lives with his wife. He does not really have any hobbies.,FAMILY HISTORY: , His father died of a cerebral hemorrhage at age 49. His mother died in her 70s from complications of congestive heart failure. He has one sister who died during a cardiac surgery two years ago. He has another sister with diabetes. He has one daughter with hypercholesterolemia. He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , He has dyspnea on exertion. He states that he was evaluated by a pulmonologist and had a normal evaluation. He has occasional night sweats. His hearing is poor. He occasionally develops bloody stools, which he attributes to his Crohn's disease. He also was diagnosed with sleep apnea. He does not wear his CPAP machine on a regular basis. He has a history of anemia. Otherwise, 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 160/86 HR 100 RR 16 Wt 211 pounds Pain 3/10,General Appearance: He is well appearing in no acute distress. He has somewhat of a flat affect.,Cardiovascular: He has a regular rhythm without murmurs, gallops, or rubs. There are no carotid bruits.,Chest: The lungs are clear to auscultation bilaterally.,Skin: There are no rashes or lesions.,Musculoskeletal: He has no joint deformities or scoliosis.,NEUROLOGICAL EXAMINATION:,Mental Status: His speech is fluent without dysarthria or aphasia. He is alert and oriented to name, place, and date. Attention, concentration, and fund of knowledge are intact. He has 3/3 object registration and 1/3 recall in 5 minutes.,Cranial Nerves: Pupils are equal, round, and reactive to light and accommodation. Visual fields are full. Optic discs are normal. Extraocular movements are intact without nystagmus. Facial sensation is normal. There is no facial, jaw, palate, or tongue weakness. Hearing is grossly intact. Shoulder shrug is full.,Motor: He has normal muscle bulk and tone. There is no atrophy. He has few fasciculations in his calf muscles bilaterally. Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities. There is no action or percussion myotonia or paramyotonia.,Sensory: He has absent vibratory sensation at the left toe. This is diminished at the right toe. Joint position sense is intact. There is diminished sensation to light touch and temperature at the feet to the knees bilaterally. Pinprick is intact. Romberg is absent. There is no spinal sensory level.,Coordination: This is intact by finger-nose-finger or heel-to-shin testing. He does have a slight tremor of the head and outstretched arms.,Deep Tendon Reflexes: They are 2+ at the biceps, triceps, brachioradialis, patellas, and ankles. Plantar reflexes are flexor. There is no ankle clonus, finger flexors, or Hoffman's signs. He has crossed adductors bilaterally.,Gait and Stance: He has a slightly wide-based gait. He has some difficulty with toe walking, but he is able to walk on his heels and tandem walk. He has difficulty with toe raises on the left.,RADIOLOGIC DATA: , MRI of the cervical spine, 09/30/08: Chronic spondylosis at C5-C6 causing severe bilateral neuroforamining and borderline-to-mold cord compression with normal cord signal. Spondylosis of C6-C7 causing mild bilateral neuroforamining and left paracentral disc herniation causing borderline cord compression.,Thoracic MRI spine without contrast: Minor degenerative changes without stenosis.,I do not have the MRI of the lumbar spine available to review.,LABORATORY DATA: , 10/07/08: Vitamin B1 210 (87-280), vitamin B6 6, ESR 6, AST 25, ALT 17, vitamin B12 905, CPK 226 (0-200), T4 0.85, TSH 3.94, magnesium 1.7, RPR nonreactive, CRP 4, Lyme antibody negative, SPEP abnormal (serum protein electrophoresis), but no paraprotein by manifestation, hemoglobin A1c 6.0, aldolase 3.9 and homocystine 9.0.,ASSESSMENT: , The patient is a 63-year-old gentleman with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue. His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves. He has fairly normal or very mild increased reflexes including notably the presence of normal ankle jerks.,I think that the etiology of his symptoms is multifactorial. He probably does have a mild peripheral neuropathy, but the sparing of ankle jerks suggested either the neuropathy is mild or that there is a superimposed myelopathic process such as a cervical or lumbosacral myelopathy. He really is most concerned about the fatigue and I think it is possible due to suboptimally treated depression and suboptimally treated sleep apnea. Whether he has another underlying muscular disorder such as a primary myopathy remains to be seen.,RECOMMENDATIONS:,1. I scheduled him for repeat EMG and nerve conduction studies to evaluate for evidence of neuropathy or myopathy.,2. I will review his films at our spine conference tomorrow although I am confident in Dr. Z's opinion that there is no surgical indication.,3. I gave him a prescription for physical therapy to help with gait imbalance training as well as treatment for his neck pain.,4. I believe that he needs to undergo psychotherapy for his depression. It may also be worthwhile to adjust his medications, but I will defer to his primary care physician for managing this or for referring him to a therapist. The patient is very open about proceeding with this suggestion.,5. He does need to have his sleep apnea better controlled. He states that he is not compliant because the face mask that he uses does not fit him well. This should also be addressed." Neurology Patient with stable expressive aphasia and decreased vision. Multiple Meningiomas "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." neurology, sphenoid wing meningioma, sphenoid wing, expressive aphasia, meningiomas, aphasia, sphenoidNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. Neurology Patient status post vehicular trauma. Low Back syndrome and Cervicalgia. Neck & Lower Back Pain - Consult 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. Neurology MRI T-spine and CXR - Aortic Dissection. MRI T-Spine "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." neurology, mri, a&o, aortic dissection, cxr, irregular rate and rhythm, mri scan, neurology service, t-spine, carotid bruitts, epidural hemorrhage, mediastinum, paraplegia, person, place, stocking distribution, time, weakness, mri t spine, sensory level, spine, Neurology MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal. MRI T-Spine - Spinal Mets 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. Neurology MRI T-L spine - L2 conus medullaris lesion and syndrome secondary to Schistosomiasis. MRI T-L Spine - Schistosomiasis "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." Neurology The thoracic spine was examined in the AP, lateral and swimmer's projections. MRI T-Spine - 1 EXAM: ,Thoracic Spine.,REASON FOR EXAM: , Injury.,INTERPRETATION: , The thoracic spine was examined in the AP, lateral and swimmer's projections. There is mild chronic-appearing anterior wedging of what is believed to represent T11 and 12 vertebral bodies. A mild amount of anterior osteophytic lipping is seen involving the thoracic spine. There is a suggestion of generalized osteoporosis. The intervertebral disc spaces appear generally well preserved.,The pedicles appear intact.,IMPRESSION:,1. Mild chronic-appearing anterior wedging of what is believed to represent the T11 and 12 vertebral bodies.,2. Mild degenerative changes of the thoracic spine.,3. Osteoporosis. neurology, thoracic spine, swimmer's projections, osteoporosis, osteophytic lipping, anterior wedging, vertebral bodies, thoracic, spine, Neurology MRI of lumbar spine without contrast to evaluate chronic back pain. MRI of Lumbar Spine w/o Contrast EXAM: , MRI of lumbar spine without contrast.,HISTORY:, A 24-year-old female with chronic back pain.,TECHNIQUE: , Noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting.,FINDINGS: , The visualized cord is normal in signal intensity and morphology with conus terminating in proper position. Visualized osseous structures are normal in marrow signal intensity and morphology without evidence for fracture/contusion, compression deformity, or marrow replacement process. There are no paraspinal masses.,Disc heights, signal, and vertebral body heights are maintained throughout the lumbar spine.,L5-S1: Central canal, neural foramina are patent.,L4-L5: Central canal, neural foramina are patent.,L3-L4: Central canal, neural foramen is patent.,L2-L3: Central canal, neural foramina are patent.,L1-L2: Central canal, neural foramina are patent.,The visualized abdominal aorta is normal in caliber. Incidental note has been made of multiple left-sided ovarian, probable physiologic follicular cysts.,IMPRESSION: , No acute disease in the lumbar spine. neurology, mri, central canal, noncontrast, abdominal aorta, axial, back pain, contrast, follicular cysts, images, lumbar spine, morphology, neural foramina, sagittal, signal intensity, without contrast, mri of lumbar spine, mri of lumbar, lumbar, foramina, neural, patent, spine Neurology MRI of the Cervical, Thoracic, and Lumbar Spine MRI Spine 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., neurology, cervical spine, mri, cervical, thoracic, lumbar, transversing nerve root, vertebral body height, vertebral body, disc protrusion, foraminal compromise, central, foraminal, disc, spineNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. Neurology MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding. MRI L-Spine - Subarachnoid Seeding "CC:, Progressive lower extremity weakness.,HX: ,This 52y/o RHF had a h/o right frontal glioblastoma multiforme (GBM) diagnosed by brain biopsy/partial resection, on 1/15/1991. She had been healthy until 1/6/91, when she experienced a generalized tonic-clonic type seizure during the night. She subsequently underwent an MRI brain scan and was found to have a right frontal enhancing lesion in the mesial aspect of the right frontal lobe at approximately the level of the coronal suture. There was minimal associated edema and no mass effect. Following extirpation of the tumor mass, she underwent radioactive Iodine implantation and 6020cGy radiation therapy in 35 fractions. In 11/91 she received BCNU and Procarbazine chemotherapy protocols. This was followed by four courses of 5FU/Carboplatin (3/92, 6/92, 9/92 ,10/92) chemotherapy.,On 10/12/92 she presented for her 4th course of 5FU/Carboplatin and complained of non-radiating dull low back pain, and proximal lower extremity weakness, but was still able to ambulate. She denied any bowel/bladder difficulty.,PMH: ,s/p oral surgery for wisdom tooth extraction.,FHX/SHX: ,1-2 ppd cigarettes. rare ETOH use. Father died of renal CA.,MEDS: ,Decadron 12mg/day.,EXAM: ,Vitals unremarkable.,MS: Unremarkable.,Motor: 5/5 BUE, LE: 4+/5- prox, 5/5 distal to hips. Normal tone and muscle bulk.,Sensory: No deficits appreciated.,Coord: Unremarkable.,Station: No mention in record of being tested.,Gait: Mild difficulty climbing stairs.,Reflexes: 1+/1+ throughout and symmetric. Plantar responses were down-going bilaterally.,INITIAL IMPRESSION:, Steroid myopathy. Though there was enough of a suspicion of ""drop"" metastasis that an MRI of the L-spine was obtained.,COURSE:, The MRI L-spine revealed fine linear enhancement along the dorsal aspect of the conus medullaris, suggestive of subarachnoid seeding of tumor. No focal mass or cord compression was visualized. CSF examination revealed: 19RBC, 22WBC, 17 Lymphocytes, and 5 histiocytes, Glucose 56, Protein 150. Cytology (negative). The patient was discharged home on 10/17/92, but experienced worsening back pain and lower extremity weakness and became predominantly wheelchair bound within 4 months. She was last seen on 3/3/93 and showed signs of worsening weakness (left hemiplegia: R > L) as her tumor grew and spread. She then entered a hospice." neurology, glioblastoma multiforme, gbm, steroid myopathy, hemiplegia, progressive lower extremity weakness, mri l spine, lower extremity weakness, frontal glioblastoma, subarachnoid seeding, lower extremity, glioblastoma, subarachnoid, spine, mri, lower, weakness, Neurology MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis. MRI Spine - Epidural Lipoma "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." Neurology MRI L-S-Spine for Cauda Equina Syndrome secondary to L3-4 disc herniation - Low Back Pain (LBP) with associated BLE weakness. MRI L-S Spine - Cauda Equina Syndrome "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." neurology, ble weakness, carotid doppler, disc herniation, guillain-barre syndrome, amyotrophy, polymyositis, epidural hematoma, mri l s spine, cauda equina syndrome, flexors & extensors, cauda equina, herniation, cauda, equina, extensors, reflexes, mri, hip, flexors, weakness, Neurology MRI of the brain without contrast to evaluate daily headaches for 6 months in a 57-year-old. MRI of Brain w/o Contrast. 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. neurology, mri, diffusion, posterior fossa, axial, brain, contrast, extraaxial, flow, fluid collections, headaches, hydrocephalus, intraorbital, morphology, paranasal, sagittal, sinuses, vascular, weighting, without contrast, mri of the brain, noncontrast, Neurology MRI Head W&WO Contrast. MRI Head EXAM:, MRI Head W&WO Contrast.,REASON FOR EXAM:, Dyspnea.,COMPARISON:, None. ,TECHNIQUE:, MRI of the head performed without and with 12 ml of IV gadolinium (Magnevist). ,INTERPRETATION: , There are no abnormal/unexpected foci of contrast enhancement. There are no diffusion weighted signal abnormalities. There are minimal, predominantly periventricular, deep white matter patchy foci of FLAIR/T2 signal hyperintensity, the rest of the brain parenchyma appearing unremarkable in signal. The ventricles and sulci are prominent, but proportionate. Per T2 weighted sequence, there is no hyperdense vascularity. There are no calvarial signal abnormalities. There is no significant mastoid air cell fluid. No significant sinus mucosal disease per MRI.,IMPRESSION:,1. No abnormal/unexpected foci of contrast enhancement; specifically, no evidence for metastases or masses. ,2. No evidence for acute infarction. ,3. Mild, scattered, patchy, chronic small vessel ischemic disease changes. ,4. Diffuse cortical volume loss, consistent with patient's age. ,5. Preliminary report was issued at the time of dictation. , neurology, dyspnea, mri of the head, foci of contrast, patchy foci, white matter, w&wo contrast, mri head, mri Neurology MRI head without contrast. MRI Head - 1 EXAM:, MRI head without contrast.,REASON FOR EXAM: , Severe headaches.,INTERPRETATION:, Imaging was performed in the axial and sagittal planes using numerous pulse sequences at 1 tesla. Correlation is made with the head CT of 4/18/05.,On the diffusion sequence, there is no significant bright signal to indicate acute infarction. There is a large degree of increased signal involving the periventricular white matter extending around to the subcortical regions in symmetrical fashion consistent with chronic microvascular ischemic disease. There is mild chronic ischemic change involving the pons bilaterally, slightly greater on the right, and when correlating with the recent scan, there is an old tiny lacunar infarct of the right brachium pontis measuring roughly 4 mm in size. There are prominent perivascular spaces of the lenticulostriate distribution compatible with the overall degree of moderate to moderately advanced atrophy. There is an old moderate-sized infarct of the mid and lateral aspects of the right cerebellar hemisphere as seen on the recent CT scan. This involves mostly the superior portion of the hemisphere in the superior cerebellar artery distribution. No abnormal mass effect is identified. There are no findings to suggest active hydrocephalus. No abnormal extra-axial collection is identified. There is normal flow void demonstrated in the major vascular systems.,The sagittal sequence demonstrates no Chiari malformation. The region of the pituitary/optic chiasm grossly appears normal. The mastoids and paranasal sinuses are clear.,IMPRESSION:,1. No definite acute findings identified involving the brain.,2. There is prominent chronic cerebral ischemic change as described with mild chronic pontine ischemic changes. There is an old moderate-sized infarct of the superior portion of the right cerebellar hemisphere.,3. Moderate to moderately advanced atrophy. neurology, severe headaches, chiari malformation, cerebral ischemic change, mri head without contrast, cerebellar hemisphere, superior portion, mri head, cerebellar, infarction, ischemic Neurology MRI C-spine: C4-5 Transverse Myelitis. MRI C-spine "CC:, Left hemibody numbness.,HX:, This 44y/o RHF awoke on 7/29/93 with left hemibody numbness without tingling, weakness, ataxia, visual or mental status change. She had no progression of her symptoms until 7/7/93 when she notices her right hand was stiff and clumsy. She coincidentally began listing to the right when walking. She denied any recent colds/flu-like illness or history of multiple sclerosis. She denied symptoms of Lhermitte's or Uhthoff's phenomena.,MEDS:, none.,PMH:, 1)Bronchitis twice in past year (last 2 months ago).,FHX:, Father with HTN and h/o strokes at ages 45 and 80; now 82 years old. Mother has DM and is age 80.,SHX:, Denies Tobacco/ETOH/illicit drug use.,EXAM:, BP112/76 HR52 RR16 36.8C,MS: unremarkable.,CN: unremarkable.,Motor: 5/5 strength throughout except for slowing of right hand fine motor movement. There was mildly increased muscle tone in the RUE and RLE.,Sensory: decreased PP below T2 level on left and some dysesthesias below L1 on the left.,Coord: positive rebound in RUE.,Station/Gait: unremarkable.,Reflexes: 3+/3 throughout all four extremities. Plantar responses were flexor, bilaterally.,Rectal exam not done.,Gen exam reportedly ""normal."",COURSE:, GS, CBC, PT, PTT, ESR, Serum SSA/SSB/dsDNA, B12 were all normal. MRI C-spine, 7/145/93, showed an area of decreased T1 and increased T2 signal at the C4-6 levels within the right lateral spinal cord. The lesion appeared intramedullary and eccentric, and peripherally enhanced with gadolinium. Lumbar puncture, 7/16/93, revealed the following CSF analysis results: RBC 0, WBC 1 (lymphocyte), Protein 28mg/dl, Glucose 62mg/dl, CSF Albumin 16 (normal 14-20), Serum Albumin 4520 (normal 3150-4500), CSF IgG 4.1mg/dl (normal 0-6.2), CSF IgG, % total CSF protein 15% (normal 1-14%), CSF IgG index 1.1 (normal 0-0.7), Oligoclonal bands were present. She was discharged home.,The patient claimed her symptoms resolved within one month. She did not return for a scheduled follow-up MRI C-spine." neurology, mri c-spine, c-spine, lhermitte's, myelitis, transverse myelitis, uhthoff's, ataxia, clumsy, hemibody numbness, mental status, numbness, tingling, weakness, mri c spine, hemibody, mri, spine, csf, Neurology MRI Brain: Subacute right thalamic infarct. MRI Brain: Thalamic Infarct CC:, Left hemiplegia.,HX: , A 58 y/o RHF awoke at 1:00AM on 10/23/92 with left hemiplegia and dysarthria which cleared within 15 minutes. She was seen at a local ER and neurological exam and CT Brain were reportedly unremarkable. She was admitted locally. She then had two more similar spells at 3AM and 11AM with resolution of the symptoms within an hour. She was placed on IV Heparin following the 3rd episode and was transferred to UIHC. She had not been taking ASA.,PMH:, 1)HTN. 2) Psoriasis.,SHX:, denied ETOH/Tobacco/illicit drug use.,FHX:, Unknown.,MEDS:, Heparin only.,EXAM:, BP160/90 HR145 (supine). BP105/35 HR128 (light headed, standing) RR12 T37.7C,MS: Dysarthria only. Lucid thought process.,CN: left lower facial weakness only.,Motor: mild left hemiparesis with normal muscle bulk. Mildly increased left sided muscle tone.,Sensory: unremarkable.,Coordination: impaired secondary to weakness on left. Otherwise unremarkable.,Station: left pronator drift. Romberg testing not done.,Gait: not tested.,Reflexes: symmetric; 2+ throughout.,Gen Exam: CV: Tachycardic without murmur.,COURSE:, The patients signs and symptoms worsening during and after standing to check orthostatic blood pressures. She was immediately placed in a reverse Trendelenburg position and given IV fluids. Repeat neurologic exam at 5PM on the day of presentation revealed a return to the initial presentation of signs and symptoms. PT/PTT/GS/CBC/ABG were unremarkable. EKG revealed sinus tachycardia with rate dependent junctional changes. CXR unremarkable. MRI Brain was obtained and showed an evolving right thalamic/lentiform nucleus infarction best illustrated by increased signal on the Proton density weighted images. Over the ensuing days of admission she had significant fluctuations of her BP (200mmHG to 140mmHG systolic). Her symptoms worsened with falls in BP. Her BP was initially controlled with esmolol or labetalol. Renal Ultrasound, abdominal/pelvic CT, renal function scan, serum and urine osmolality, urine catecholamines/metanephrine studies were unremarkable. Carotid doppler study revealed 0-15%BICA stenosis and antegrade vertebral artery flow, bilaterally. Transthoracic echocardiogram was unremarkable. Cerebral angiogram was performed to r/o vasculitis. This revealed narrowing of the M1 segment of the right MCA. This was thought secondary to atherosclerosis and not vasculitis. She was discharged on ASA, Procardia XL, and Labetalol. neurology, mri brain, ct brain, heparin, dysarthria, hemiplegia, infarct, neurological exam, thalamic, thalamic infarct, mri, brain, Neurology MRI C-spine to evaluate right shoulder pain - C5-6 disk herniation. MRI C-Spine - C5-6 Disk Herniation 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. neurology, shoulder pain, stiffness, numbness, lhermitte's phenomena, c-spine lesion, disk herniation, mri c spine, reflexes, biceps, mri, disk, shoulder, spine, herniation, Neurology MRI report Cervical Spine (Chiropractic Specific) MRI Cervical Spine - Chiropractic Specific FINDINGS:,Normal foramen magnum.,Normal brainstem-cervical cord junction. There is no tonsillar ectopia. Normal clivus and craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: There is disc desiccation but no loss of disc space height, disc displacement, endplate spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina.,C3-4: There is disc desiccation with a posterior central disc herniation of the protrusion type. The small posterior central disc protrusion measures 3 x 6mm (AP x transverse) in size and is producing ventral thecal sac flattening. CSF remains present surrounding the cord. The residual AP diameter of the central canal measures 9mm. There is minimal right-sided uncovertebral joint arthrosis but no substantial foraminal compromise.,C4-5: There is disc desiccation, slight loss of disc space height with a right posterior lateral pre-foraminal disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis. The disc osteophyte complex measures approximately 5mm in its AP dimension. There is minimal posterior annular bulging measuring approximately 2mm. The AP diameter of the central canal has been narrowed to 9mm. CSF remains present surrounding the cord. There is probable radicular impingement upon the exiting right C5 nerve root.,C5-6: There is disc desiccation, moderate loss of disc space height with a posterior central disc herniation of the protrusion type. The disc protrusion measures approximately 3 x 8mm (AP x transverse) in size. There is ventral thecal sac flattening with effacement of the circumferential CSF cleft. The residual AP diameter of the central canal has been narrowed to 7mm. Findings indicate a loss of the functional reserve of the central canal but there is no cord edema. There is bilateral uncovertebral and apophyseal joint arthrosis with moderate foraminal compromise.,C6-7: There is disc desiccation, mild loss of disc space height with 2mm of posterior annular bulging. There is bilateral uncovertebral and apophyseal joint arthrosis (left greater than right) with probable radicular impingement upon the bilateral exiting C7 nerve roots.,C7-T1, T1-2: There is disc desiccation with no disc displacement. Normal central canal and intervertebral neural foramina.,T3-4: There is disc desiccation with minimal 2mm posterior annular bulging but normal central canal and CSF surrounding the cord.,IMPRESSION:,Multilevel degenerative disc disease with uncovertebral joint arthrosis with foraminal compromise as described above.,C3-4 posterior central disc herniation of the protrusion type but no cord impingement.,C4-5 right posterior lateral disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis with probable radicular impingement upon the right C5 nerve root.,C5-6 degenerative disc disease with a posterior central disc herniation of the protrusion type producing borderline central canal stenosis with effacement of the circumferential CSF cleft indicating a limited functional reserve of the central canal.,C6-7 degenerative disc disease with annular bulging and osseous foraminal compromise with probable impingement upon the bilateral exiting C7 nerve roots.,T3-4 degenerative disc disease with posterior annular bulging. neurology, exiting c nerve roots, loss of disc space, posterior central disc herniation, herniation of the protrusion, uncovertebral and apophyseal joint, intervertebral neural foramina, ventral thecal sac, thecal sac flattening, disc osteophyte complex, disc space height, central disc herniation, apophyseal joint arthrosis, posterior annular bulging, degenerative disc disease, posterior central disc, csf cleft, osteophyte complex, radicular impingement, disc disease, central disc, annular bulging, disc desiccation, joint arthrosis, central canal, cervical, degenerative, csf, foraminal, bulging, impingement, protrusion, uncovertebral, arthrosis, canal Neurology MRI Cervical Spine without contrast. MRI Cervical Spine - 2 EXAM:,MRI SPINAL CORD CERVICAL WITHOUT CONTRAST,CLINICAL:,Right arm pain, numbness and tingling.,FINDINGS:,Vertebral alignment and bone marrow signal characteristics are unremarkable. The C2-3 and C3-4 disk levels appear unremarkable.,At C4-5, broad based disk/osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour. A discrete cord signal abnormality is not identified. There may also be some narrowing of the neuroforamina at this level.,At C5-6, central disk-osteophyte contacts and mildly impresses on the ventral cord contour. Distinct neuroforaminal narrowing is not evident.,At C6-7, mild diffuse disk-osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface. Distinct cord compression is not evident. There may be mild narrowing of the neuroforamina at his level.,A specific abnormality is not identified at the C7-T1 level.,IMPRESSION:,Disk/osteophyte at C4-5 through C6-7 with contact and may mildly indent the ventral cord contour at these levels. Some possible neuroforaminal narrowing is also noted at levels as stated above. neurology, mri cervical spine, ventral cord contour, cervical spine, spinal cord, cord contour, ventral cord, mri, narrowing, ventral, cord Neurology MRI Brain & MRI C-T spine: Multiple hemangioblastoma in Von Hippel Lindau Disease. MRI Brain and C-T Spine 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 Neurology Left third digit numbness and wrist pain. MRI C3 - Cord Compression. 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. Neurology MRI cervical spine. MRI Cervical Spine - 1 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. neurology, borderline central canal stenosis, mri cervical spine, borderline central canal, central canal stenosis, degenerative disc, annular bulging, ap diameter, endplate spondylosis, borderline central, canal stenosis, disc desiccation, central canal, cervical, disc, spondylosis, stenosis, cord, canal, Neurology MRI brain (Atrophy Left fronto-temporal lobe) and HCT (Left frontal SDH) MRI Brain - Progressive Aphasia "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." Neurology MRI Brain: Left Basal Ganglia, Posterior temporal lobe, and Left cerebellar (lacunar) infarctions with Wernickes Aphasia. MRI Brain - Wernicke aphasia "CC: ,Difficulty with speech.,HX:, This 72 y/o RHM awoke early on 8/14/95 to prepare to play golf. He felt fine. However, at 6:00AM, on 8/14/95, he began speaking abnormally. His wife described his speech as ""word salad"" and ""complete gibberish."" She immediately took him to a local hospital . Enroute, he was initially able to understand what was spoken to him. By the time he arrived at the hospital at 6:45AM, he was unable to follow commands. His speech was reportedly unintelligible the majority of the time, and some of the health care workers thought he was speaking a foreign language. There were no other symptoms or signs. He had no prior history of cerebrovascular disease. Blood pressure 130/70 and Pulse 82 upon admission to the local hospital on 8/14/95.,Evaluation at the local hospital included: 1)HCT scan revealed an old left putaminal hypodensity, but no acute changes or evidence of hemorrhage, 2) Carotid Duplex scan showed ICA stenosis of 40%, bilaterally. He was placed on heparin and transferred to UIHC on 8/16/95.,In addition, he had noted memory and word finding difficulty for 2 months prior to presentation. He had undergone a gastrectomy 16 years prior for peptic ulcer disease. His local physician found him vitamin B12 deficient and he was placed on vitamin B12 and folate supplementation 2 months prior to presentation. He and his wife felt that this resulted in improvement of his language and cognitive skills.,MEDS:, Heparin IV, Vitamin B12 injection q. week, Lopressor, Folate, MVI.,PMH:, 1)Hypothyroidism (reportedly resolved), 2) Gastrectomy, 3)Vitamin B12 deficiency.,FHX: ,Mother died of MI, age 70. Father died of prostate cancer, age 80. Bother died of CAD and prostate cancer, age 74.,SHX:, Married. 3 children who are alive and well. Semi-retired Attorney. Denied h/o tobacco/ETOH/illicit drug use.,EXAM:, BP 110/70, HR 50, RR 14, Afebrile.,MS: A&O to person and place, but not time. Oral comprehension was poor beyond the simplest of conversational phrases. Speech was fluent, but consisted largely of ""word salad."" When asked how he was, he replied: ""abadeedleedlebadle."" Repetition was defective, especially with long phrases. On rare occasions, he uttered short comments appropriately. Speech was marred by semantic and phonemic paraphasias. He named colors and described most actions well, although he described a ""faucet dripping"" as a ""faucet drop."" He called ""red"" ""reed."" Reading comprehension was better than aural comprehension. He demonstrated excellent written calculations. Spoken calculations were accurate except when the calculations became more complex. For example, he said that ten percent of 100 was equal to ""1,200."",CN: Pupils 2/3 decreasing to 1/1 on exposure to light. VFFTC. There were no field cuts or evidence of visual neglect. EOM were intact. Face moved symmetrically. The rest of the CN exam was unremarkable.,MOTOR: Full strength throughout with normal muscle tone and bulk. There was no evidence of drift.,SENSORY: unremarkable.,COORD: unremarkable.,Station: unremarkable. Gait: mild difficulty with TW.,Reflexes: 2/2 in BUE. 2/2+ patellae, 1/1 Achilles. Plantar responses were flexor on the left and equivocal on the right.,Gen Exam: unremarkable.,COURSE:, Lab data on admission: Glucose 97, BUN 20, Na 134, K 4.0, Cr 1.3, Chloride 98, CO2 24, PT 11, PTT 42, WBC 12.0 (normal differential), Hgb 11.4, Hct 36%, Plt=203k. UA normal. TSH 6.0, FT4 0.88, Vit B12 876, Folate 19.1. He was admitted and continued on heparin. MRI scan, 8/16/95, revealed increased signal on T2-weighted images in Wernicke's area in the left temporal region. Transthoracic echocardiogram on 8/17/95 was unremarkable. Transesophageal echocardiogram on 8/18/95 revealed a sclerotic aortic valve and myxomatous degeneration of the anterior leaflet of the mitral valve. LAE 4.8cm, and spontaneous echo contrast in the left atrium were noted. There was no evidence of intracardiac shunt or clot. Carotid duplex scan on 8/16/95 revealed 0-15% BICA stenosis with anterograde vertebral artery flow, bilaterally. Neuropsychologic testing revealed a Wernicke's aphasia.,The impression was that the patient had had a cardioembolic stroke involving a lower-division branch of the left MCA. He was subsequently placed on warfarin. Thoughout his hospital stay he showed continued improvement of language skills and was enrolled in speech therapy following discharge, 8/21/95.,He has had no further stroke like episodes up until his last follow-up visit in 1997." neurology, mri brain, difficulty with speech, left basal ganglia, posterior temporal lobe, wernicke's area, wernickes aphasia, cerebellar, infarctions, lacunar, word finding difficulty, carotid duplex scan, aphasia, wernicke's, mri, brain, Neurology MRI Brain & T-spine - Demyelinating disease. MRI Brain & T-spine - Demyelinating disease. "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." neurology, sensory loss, lumbar puncture, peritrigonal region, centrum semiovale, mri brain, white matter, demyelinating disease, csf, demyelinating, mri, brain, Neurology MRI brain & Cerebral Angiogram: CNS Vasculitis with evidence of ischemic infarction in the right and left frontal lobes. MRI Brain & Cerebral Angiogram "CC:, Difficulty with word finding.,HX: ,This 27y/o RHF experienced sudden onset word finding difficulty and slurred speech on the evening of 2/19/96. She denied any associated dysphagia, diplopia, numbness or weakness of her extremities. She went to sleep with her symptoms on 2/19/96, and awoke with them on 2/20/96. She also awoke with a headache (HA) and mild neck stiffness. She took a shower and her HA and neck stiffness resolved. Throughout the day she continued to have difficulty with word finding and had worsening of her slurred speech. That evening, she began to experience numbness and weakness in the lower right face. She felt like there was a ""rubber-band"" wrapped around her tongue.,For 3 weeks prior to presentation, she experienced transient episodes of a ""boomerang"" shaped field cut in the left eye. The episodes were not associated with any other symptoms. One week prior to presentation, she went to a local ER for menorrhagia. She had just resumed taking oral birth control pills one week prior to the ER visit after having stopped their use for several months. Local evaluation included an unremarkable carotid duplex scan. However, a HCT with and without contrast reportedly revealed a left frontal gyriform enhancing lesion. An MRI brain scan on 2/20/96 revealed nonspecific white matter changes in the right periventricular region. EEG reportedly showed diffuse slowing. CRP was reportedly ""too high"" to calibrate.,MEDS:, Ortho-Novum 7-7-7 (started 2/3/96), and ASA (started 2/20/96).,PMH:, 1)ventral hernia repair 10 years ago, 2)mild ""concussion"" suffered during a MVA; without loss of consciousness, 5/93, 3) Anxiety disorder, 4) One childbirth.,FHX: ,She did not know her father and was not in contact with her mother.,SHX:, Lives with boyfriend. Smokes one pack of cigarettes every three days and has done so for 10 years. Consumes 6 bottles of beers, one day a week. Unemployed and formerly worked at an herbicide plant.,EXAM: ,BP150/79, HR77, RR22, 37.4C.,MS: A&O to person, place and time. Speech was dysarthric with mild decreased fluency marked by occasional phonemic paraphasic errors. Comprehension, naming and reading were intact. She was able to repeat, though her repetition was occasionally marked by phonemic paraphasic errors. She had no difficulty with calculation.,CN: VFFTC, Pupils 5/5 decreasing to 3/3. EOM intact. No papilledema or hemorrhages seen on fundoscopy. No RAPD or INO. There was right lower facial weakness. Facial sensation was intact, bilaterally. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits.,Coord/Station/Gait: unremarkable.,Reflexes 2/2 throughout. Plantar responses were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, CRP 1.2 (elevated), ESR 10, RF 20, ANA 1:40, ANCA <1:40, TSH 2.0, FT4 1.73, Anticardiolipin antibody IgM 10.8GPL units (normal <10.9), Anticardiolipin antibody IgG 14.8GPL (normal<22.9), SSA and SSB were normal. Urine beta-hCG pregnancy and drug screen were negative. EKG, CXR and UA were negative.,MRI brain, 2/21/96 revealed increased signal on T2 imaging in the periventricular white matter region of the right hemisphere. In addition, there were subtle T2 signal changes in the right frontal, right parietal, and left parietal regions as seen previously on her local MRI can. In addition, special FLAIR imaging showed increased signal in the right frontal region consistent with ischemia.,She underwent Cerebral Angiography on 2/22/96. This revealed decreased flow and vessel narrowing the candelabra branches of the RMCA supplying the right frontal lobe. These changes corresponded to the areas of ischemic changes seen on MRI. There was also segmental narrowing of the caliber of the vessels in the circle of Willis. There was a small aneurysm at the origin of the LPCA. There was narrowing in the supraclinoid portion of the RICA and the proximal M1 and A1 segments. The study was highly suggestive of vasculitis.,2/23/96, Neuro-ophthalmology evaluation revealed no evidence of retinal vasculitic change. Neuropsychologic testing the same day revealed slight impairment of complex attention only. She was started on Prednisone 60mg qd and Tagamet 400mg qhs.,On 2/26/96, she underwent a right frontal brain biopsy. Pathologic evaluation revealed evidence of focal necrosis (stroke/infarct), but no evidence of vasculitis. Immediately following the brain biopsy, while still in the recovery room, she experienced sudden onset right hemiparesis and transcortical motor type aphasia. Initial HCT was unremarkable. An EEG was consistent with a focal lesion in the left hemisphere. However, a 2/28/96 MRI brain scan revealed new increased signal on T2 weighted images in a gyriform pattern from the left precentral gyrus to the superior frontal gyrus. This was felt consistent with vasculitis.,She began q2month cycles of Cytoxan (1,575mg IV on 2/29/96. She became pregnant after her 4th cycle of Cytoxan, despite warnings to the contrary. After extensive discussions with OB/GYN it was recommended she abort the pregnancy. She underwent neuropsychologic testing which revealed no significant cognitive deficits. She later agreed to the abortion. She has undergone 9 cycles of Cytoxan ( one cycle every 2 months) as of 4/97. She had complained of one episode of paresthesias of the LUE in 1/97. MRI then showed no new signs ischemia." Neurology MRI Brain: Thrombus in torcula of venous sinuses. MRI Brain - Thrombus "CC: ,Motor vehicle-bicycle collision.,HX:, A 5 y/o boy admitted 10/17/92. He was struck while riding his bicycle by a motor vehicle traveling at a high rate of speed. First responders found him unconscious with left pupil 6 mm and unreactive and the right pupil 3 mm and reactive. He had bilateral decorticate posturing and was bleeding profusely from his nose and mouth. He was intubated and ventilated in the field, and then transferred to UIHC.,PMH/FHX/SHX:, unremarkable.,MEDS:, none,EXAM:, BP 127/91 HR69 RR30,MS: unconscious and intubated,Glasgow coma scale=4,CN: Pupils 6/6 fixed. Corneal reflex: trace OD, absent OS. Gag present on manipulation of endotracheal tube.,MOTOR/SENSORY: bilateral decorticate posturing to noxious stimulation (chest).,Reflexes: bilaterally.,Laceration of mid forehead exposing calvarium.,COURSE:, Emergent Brain CT scan revealed: Displaced fracture of left calvarium. Left frontoparietal intraparenchymal hemorrhage. Right ventricular collection of blood. Right cerebral intraparenchymal hemorrhage. Significant mass effect with deviation of the midline structures to right. The left ventricle was compressed with obliteration of the suprasellar cistern. Air within the soft tissues in the left infra temporal region. C-spine XR, Abdominal/Chest CT were unremarkable.,Patient was taken to the OR emergently and underwent bifrontal craniotomy, evacuation of a small epidural and subdural hematomas, and duraplasty. He was given mannitol enroute to the OR and hyperventilated during and after the procedure. Postoperatively he continued to manifest decerebrate posturing . On 11/16/92 he underwent VP shunting with little subsequent change in his neurological status. On 11/23/92 he underwent tracheostomy. On 12/11/92 he underwent bifrontal acrylic prosthesis implantation for repair of the bifrontal craniectomy. By the time of discharge, 1/14/93, he tracked relatively well OD, but had a CN3 palsy OS. He had relatively severe extensor rigidity in all extremities (R>L). His tracheotomy was closed prior to discharge. A 11/16/92 Brain MRI demonstrated infarction in the upper brain stem (particularly in the Pons), left cerebellum, right basil ganglia and thalamus.,He was initially treated for seizure prophylaxis with DPH, but developed neutropenia, so it was discontinued. He developed seizures within several months of discharge and was placed on VPA (Depakene). This decreased seizure frequency but his liver enzymes became elevated and he changed over to Tegretol. 10/8/93 Brain MRI (one year after MVA) revealed interval appearance of hydrocephalus, abnormal increased T2 signal (in the medulla, right pons, both basal ganglia, right frontal and left occipital regions), a small mid-brain, and a right subdural fluid collection. These findings were consistent with diffuse axonal injury of the white matter and gray matter contusion, and signs of a previous right subdural hematoma.,He was last seen 10/30/96 in the pediatric neurology clinic--age 9 years. He was averaging 2-3 seizures per day---characterized by extension of BUE with tremor and audible cry or laughter---on Tegretol and Diazepam. In addition he experiences 24-48hour periods of ""startle response (myoclonic movement of the shoulders)"" with or without stimulation every 6 weeks. He had limited communication skills (sparse speech). On exam he had disconjugate gaze, dilated/fixed left pupil, spastic quadriplegia." neurology, mri brain, brain mri, thrombus, intraparenchymal hemorrhage, motor vehicle, prophylaxis, sinuses, torcula venous sinuses, venous, brain thrombus, bilateral decorticate, decorticate posturing, subdural hematomas, subdural, mri, brain, torcula Neurology MRI Brain: Probable CNS Lymphoma v/s toxoplasmosis in a patient with AIDS/HIV. MRI Brain - Toxoplasmosis "CC:, Lethargy.,HX:, This 28y/o RHM was admitted to a local hospital on 7/14/95 for marked lethargy. He had been complaining of intermittent headaches and was noted to have subtle changes in personality for two weeks prior to 7/14/95. On the morning of 7/14/95, his partner found him markedly lethargic and complaingin of abdominal pain and vomiting. He denied fevers, chills, sweats, cough, CP, SOB or diarrhea. Upon evaluation locally, he had a temperature of 99.5F and appeared lethargic. He also had anisocoria with left pupil 0.5mm bigger than the right. There was also question of left facial weakness. An MRI was obtained and revealed a large left hemispheric mass lesion with surrounding edema and mass effect. He was given 10mg of IV Decardron,100gm of IV Mannitol, intubated and hyperventilated and transferred to UIHC.,He was admitted to the Department of Medicine on 7/14/95, and transferred to the Department of Neurology on 7/17/95, after being extubated.,MEDS ON ADMISSION:, Bactrim DS qd, Diflucan 100mg qd, Acyclovir 400mg bid, Xanax, Stavudine 40mg bid, Rifabutin 300mg qd.,PMH:, 1) surgical correction of pyoloric stenosis, age 1, 2)appendectomy, 3) HIV/AIDS dx 1991. He was initially treated with AZT, then DDI. He developed chronic diarrhea and was switched to D4T in 1/95. However, he developed severe neuropathy and this was stopped 4/95. The diarrhea recured. He has Acyclovir resistant genital herpes and generalized psoriasis. He most recent CD4 count (within 1 month of admission) was 20.,FHX:, HTN and multiple malignancies of unknown type.,SHX:, Homosexual, in monogamous relationship with an HIV infected partner for the past 3 years.,EXAM: ,7/14/95 (by Internal Medicine): BP134/80, HR118, RR16 on vent, 38.2C, Intubated.,MS: Somnolent, but opened eyes to loud voices and would follow most commands.,CN: Pupils 2.5/3.0 and ""equally reactive to light."" Mild horizontal nystagmus on rightward gaze. EOM were otherwise intact.,MOTOR: Moved 4 extremities well.,Sensory/Coord/Gait/Station/Reflexes: not done.,Gen EXAM: Penil ulcerations.,EXAM:, 7/17/96 (by Neurology): BP144/73, HR59, RR20, 36.0, extubated.,MS: Alert and mildly lethargic. Oriented to name only. Thought he was a local hospital and that it was 1/17/1994. Did not understand he had a brain lesion.,CN: Pupils 6/5.5 decreasing to 4/4 on exposure to light. EOM were full and smooth. No RAPD or light-near dissociation. papilledema (OU). Right lower facial weakness and intact facial sensation to PP testing. Gag-shrug and corneal responses were intact, bilaterally. Tongue midline.,MOTOR: Grade 5- strength on the right side.,Sensory: no loss of sensation on PP/VIB/PROP testing.,Coord: reduced speed and accuracy on right FNF and right HKS movements.,Station: RUE pronator drift.,Gait: not done.,Reflexes: 2+/2 throughout. Babinski sign present on right and absent on left.,Gen Exam: unremarkable except for the genital lesion noted by Internal medicine.,COURSE:, The outside MRI was reviewed and was notable for the left frontal/parietal mass lesion with surround edema. The mass inhomogenously enhanced with gadolinium contrast.,The findings were consistent most with lymphoma, though toxoplasmosis could not be excluded. He refused brain biopsy and was started on empiric treatment for toxoplasmosis. This consisted of Pyrimethamine 75mg qd and Sulfadiazine 2 g bid. He later became DNR and was transferred at his and his partner's request Back to a local hospital.,He never returned for follow-up." Neurology MRI Brain and Brainstem - Falling (Multiple System Atrophy) MRI Brain and Brainstem "CC:, Falling.,HX:, This 67y/o RHF was diagnosed with Parkinson's Disease in 9/1/95, by a local physician. For one year prior to the diagnosis, the patient experienced staggering gait, falls and episodes of lightheadedness. She also noticed that she was slowly ""losing"" her voice, and that her handwriting was becoming smaller and smaller. Two months prior to diagnosis, she began experienced bradykinesia, but denied any tremor. She noted no improvement on Sinemet, which was started in 9/95. At the time of presentation, 2/13/96, she continued to have problems with coordination and staggering gait. She felt weak in the morning and worse as the day progressed. She denied any fever, chills, nausea, vomiting, HA, change in vision, seizures or stroke like events, or problems with upper extremity coordination.,MEDS:, Sinemet CR 25/100 1tab TID, Lopressor 25mg qhs, Vitamin E 1tab TID, Premarin 1.25mg qd, Synthroid 0.75mg qd, Oxybutynin 2.5mg has, isocyamine 0.125mg qd.,PMH:, 1) Hysterectomy 1965. 2) Appendectomy 1950's. 3) Left CTR 1975 and Right CTR 1978. 4) Right oophorectomy 1949 for ""tumor."" 5) Bladder repair 1980 for unknown reason. 6) Hypothyroidism dx 4/94. 7) HTN since 1973.,FHX: ,Father died of MI, age 80. Mother died of MI, age73. Brother died of Brain tumor, age 9.,SHX: ,Retired employee of Champion Automotive Co.,Denies use of TOB/ETOH/Illicit drugs.,EXAM: ,BP (supine)182/113 HR (supine)94. BP (standing)161/91 HR (standing)79. RR16 36.4C.,MS: A&O to person, place and time. Speech fluent and without dysarthria. No comment regarding hypophonia.,CN: Pupils 5/5 decreasing to 2/2 on exposure to light. Disks flat. Remainder of CN exam unremarkable.,Motor: 5/5 strength throughout. NO tremor noted at rest or elicited upon movement or distraction,Sensory: Unremarkable PP/VIB testing.,Coord: Did not show sign of dysmetria, dyssynergia, or dysdiadochokinesia. There was mild decrement on finger tapping and clasping/unclasping hands (right worse than left).,Gait: Slow gait with difficulty turning on point. Difficulty initiating gait. There was reduced BUE swing on walking (right worse than left).,Station: 3-4step retropulsion.,Reflexes: 2/2 and symmetric throughout BUE and patellae. 1/1 Achilles. Plantar responses were flexor.,Gen Exam: Inremarkable. HEENT: unremarkable.,COURSE:, The patient continued Sinemet CR 25/100 1tab TID and was told to monitor orthostatic BP at home. The evaluating Neurologist became concerned that she may have Parkinsonism plus dysautonomia.,She was seen again on 5/28/96 and reported no improvement in her condition. In addition she complained of worsening lightheadedness upon standing and had an episode, 1 week prior to 5/28/96, in which she was at her kitchen table and became unable to move. There were no involuntary movements or alteration in sensorium/mental status. During the episode she recalled wanting to turn, but could not. Two weeks prior to 5/28/96 she had an episode of orthostatic syncope in which she struck her head during a fall. She discontinued Sinemet 5 days prior to 5/28/96 and felt better. She felt she was moving slower and that her micrographia had worsened. She had had recent difficulty rolling over in bed and has occasional falls when turning. She denied hypophonia, dysphagia or diplopia.,On EXAM: BP (supine)153/110 with HR 88. BP (standing)110/80 with HR 96. (+) Myerson's sign and mild hypomimia, but no hypophonia. There was normal blinking and EOM. Motor strength was full throughout. No resting tremor, but mild postural tremor present. No rigidity noted. Mild decrement on finger tapping noted. Reflexes were symmetric. No Babinski signs and no clonus. Gait was short stepped with mild anteroflexed posture. She was unable to turn on point. 3-4 step Retropulsion noted. The Parkinsonism had been unresponsive to Sinemet and she had autonomic dysfunction suggestive of Shy-Drager syndrome. It was recommended that she liberalize dietary salt use and lie with head of the bed elevate at 20-30 degrees at night. Indomethacin was suggested to improve BP in future." neurology, myerson's sign, falling, dysautonomia, mri brain and brainstem, brain and brainstem, mri brain, sinemet cr, mri, brainstem, ctr, tumor, retropulsion, parkinsonism, brain, lightheadedness, hypophonia, standing, sinemet, Neurology MRI Brain - Right frontal white matter infarct in patient with Anticardiolipin antibody syndrome and SLE. MRI Brain - SLE & Stroke "CC:, Episodic monocular blindness, OS.,HX:, This 29 y/o RHF was in her usual healthy state until 2 months prior to her 3/11/96 presentation when she developed episodic arthralgias of her knees and ankles, bilaterally. On 3/3/96, she experienced sudden onset monocular blindness, OS, lasting 5-10 minutes in duration. Her vision ""greyed out"" from the periphery to center of her visual field, OS; and during some episodes progressed to complete blindness (not even light perception). This resolved within a few minutes. She had multiple episodes of vision loss, OS, every day until 3/7/96 when she was placed on heparin for suspected LICA dissection. She saw a local ophthalmologist on 3/4/96 and was told she had a normal funduscopic exam. She experienced 0-1 spell of blindness (OS) per day from 3/7/96 to 3/11/96. In addition, she complained of difficulty with memory since 3/7/96. She denied dysarthria, aphasia or confusion, but had occasional posterior neck and bioccipital-bitemporal headaches.,She had no history of deep venous or arterial thrombosis.,3/4/96, ESR=123. HCT with and without contrast on 3/7/96 and 3/11/96, and Carotid Duplex scan were ""unremarkable."" Rheumatoid factor=normal. 3-vessel cerebral angiogram (done locally) was reportedly ""unremarkable."",She was thought to have temporal arteritis and underwent Temporal Artery biopsy (which was unremarkable), She received Prednisone 80 mg qd for 2 days prior to presentation.,On admission she complained of a left temporal headache at the biopsy site, but no loss of vision or weakness,She had been experiencing mild fevers and chills for several weeks prior to presentation. Furthermore, she had developed cyanosis of the distal #3 toes on feet, and numbness and rash on the lateral aspect of her left foot. She developed a malar rash on her face 1-2 weeks prior to presentation.,MEDS:, Depo-Provera, Prednisone 80mg qd, and Heparin IV.,PMH:, 1)Headaches for 3-4 years, 2)Heart murmur, 3) cryosurgery of cervix, 4)tonsillectomy and adenoidectomy, 5) elective abortion. She had no history of spontaneous miscarriage and had used oral birth control pill for 10 years prior to presentation.,FHX:, Migraine headaches on maternal side, including her mother. No family history of thrombosis.,SHX:, works as a metal grinder and was engaged to be married. She denied any tobacco or illicit drug use. She consumed 1 alcoholic drink per month.,EXAM: ,BP147/74, HR103, RR14, 37.5C.,MS: A&O to person, place and time. Speech was fluent without dysarthria. Repetition, naming and comprehension were intact. 2/3 recall at 2 minutes.,CN: unremarkable.,Motor: unremarkable.,Coord: unremarkable.,Sensory: decreased LT, PP, TEMP, along the lateral aspect of the left foot.,Gait: narrow-based and able to TT, HW and TW without difficulty.,Station: unremarkable.,Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally.,Skin: Cyanosis of the distal #3 toes on both feet. There was a reticular rash about the lateral aspect of her left foot. There were splinter-type hemorrhages under the fingernails of both hands.,COURSE: , ESR=108 (elevated), Hgb 11.3, Hct 33%, WBC 10.0, Plt 148k, MCV 92 (low) Cr 1.3, BUN 26, CXR and EKG were unremarkable. PTT 42 (elevated). PT normal. The rest of the GS and CBC were normal. Dilute Russell Viper venom time was elevated at 27 and a 1:1 prothrombin time mix corrected to only 36.,She was admitted to the Neurology service. Blood cultures were drawn and were negative. Transthoracic and transesophageal echocardiography on 3/12/96 was unremarkable.,Her symptoms and elevated PTT suggested an ischemic syndrome involving anticardiolipin antibody and/or lupus anticoagulant. Her signs of rash and cyanosis suggested SLE. ANA was positive at 1:640 (speckled), RF (negative), dsDNA, 443 (elevated). Serum cryoglobulins were positive at 1% (fractionation data lost). Serum RPR was positive, but FTA-ABS was negative (thereby confirming a false-positive RPR). Anticardiolipin antibodies IgM and IgG were positive at 56.1 and 56.3 respectively. Myeloperoxidase antibody was negative, ANCA was negative and hepatitis screen unremarkable.,The Dermatology Service felt the patient's reticular foot rash was livedo reticularis. Rheumatology felt the patient met criteria for SLE. Hematology felt the patient met criteria for Anticardiolipin Antibody and/or Lupus anticoagulant Syndrome. Neurology felt the episodic blindness was secondary to thromboembolic events.,Serum Iron studies revealed: FeSat 6, Serum Fe 15, TIBC 237, Reticulocyte count 108.5. The patient was placed on FeSO4 225mg tid.,She was continued on heparin IV, but despite this she continued to have occasional episodes of left monocular blindness or ""gray outs"" up to 5 times per day. She was seen by the Neuro-ophthalmology Service. The did not think she had evidence of vasculitis in her eye. They recommended treatment with ASA 325mg bid. She was placed on this 3/15/96 and tapered off heparin. She continued to have 0-4 episodes of monocular blindness (OS) for 5-10 seconds per episodes. She was discharged home.,She returned 3/29/96 for episodic diplopia lasting 5-10 minutes per episode. The episodes began on 3/27/96. During the episodes her left eye deviated laterally while the right eye remained in primary gaze. She had no prior history of diplopia or strabismus. Hgb 10.1, Hct 30%, WBC 5.2, MCV 89 (low), Plt 234k. ESR 113mm/hr. PT 12, PTT 45 (high). HCT normal. MRI brain, 3/30/96, revealed a area of increased signal on T2 weighted images in the right frontal lobe white matter. This was felt to represent a thromboembolic event. She was place on heparin IV and treated with Solu-Medrol 125mg IV q12 hours. ASA was discontinued. Hematology, Rheumatology and Neurology agreed to place her on Warfarin. She was placed on Prednisone 60mg qd following the Solu-Medrol. She continued to have transient diplopia and mild vertigo despite INR's of 2.0-2.2. ASA 81mg qd was added to her regimen. In addition, Rheumatology recommended Plaquenil 200mg bid. The neurologic symptoms decreased gradually over the ensuing 3 days. Warfarin was increased to achieve INR 2.5-3.5.,She reported no residual symptoms or new neurologic events on her 5/3/96 Neurology Clinic follow-up visit. She continues to be event free on Warfarin according to her Hematology Clinic notes up to 12/96." Neurology MRI Brain - Pilocytic Astrocytoma in thalamus and caudate. MRI Brain - Pilocytic Astrocytoma "CC:, Headache.,HX: ,The patient is an 8y/o RHM with a 2 year history of early morning headaches (3:00-6:00AM) intermittently relieved by vomiting only. He had been evaluated 2 years ago and an EEG was ""normal"" then, but no brain imaging was performed. His headaches progressively worsened, especially in the past two months prior to this presentation. For 2 weeks prior to his 1/25/93 evaluation at UIHC, he would awake screaming. His parent spoke with a local physician who thought this might be due to irritability secondary to pinworms and,Vermox was prescribed and arrangements were made for a neurologic evaluation. On the evening of 1/24/93 the patient awoke screaming and began to vomit. This was followed by a 10 min period of tonic-clonic type movements and postictal lethargy. He was taken to a local ER and a brain CT revealed an intracranial mass. He was given Decadron and Phenytoin and transferred to UIHC for further evaluation.,MEDS:, noted above.,PMH: ,1)Born at 37.5 weeks gestation by uncomplicated vaginal delivery to a G1P0 mother. Pregnancy complicated by vaginal bleeding at 7 months. Met developmental milestones without difficulty. 2) Frequent otitis media, now resolved. 3) Immunizations were ""up to date."",FHX:, non-contributory.,SHX:, lives with biologic father and mother. No siblings. In 3rd grade (mainstream) and maintaining good marks in schools.,EXAM:, BP121/57mmHg HR103 RR16 36.9C,MS: Sleepy, but cooperative.,CN: EOM full and smooth. Advanced papilledema, OU. VFFTC. Pupils 4/4 decreasing to 2/2. Right lower facial weakness. Tongue midline upon protrusion. Corneal reflexes intact bilaterally.,Motor: 5/5 strength. Slightly increased muscle on right side.,Sensory. No deficit to PP/VIB noted.,Coord: normal FNF, HKS and RAM, bilaterally.,Station: Mild truncal ataxia. Tends to fall backward.,Reflexes: BUE 2+/2+, Patellar 3/3, Ankles 3+/3+ with 6 beats of nonsustained clonus bilaterally.,Gen exam: unremarkable.,COURSE:, The patient was continued on Dilantin 200mg qd and Decadron 5mg IV q6hrs. Brain MRI, 1/26/93, revealed a large mass lesion in the region of the left caudate nucleus and thalamus which was hyperintense on T2 weighted images. There were areas of cystic formation at its periphery. The mass appeared to enhance on post gadolinium images. there was associated white matter edema and compression of the left lateral ventricle, and midline shift to the right. There was no sign of uncal herniation. He underwent bilateral VP shunting on 1/26/93; and then, subtotal resection (left frontal craniotomy with excision of the left caudate and thalamus with creation of an opening in the septum pellucidum) on 1/28/93. He then received 5040cGy of radiation therapy in 28 fractions completed on 3/25/93. A 3/20/95 neuropsychological evaluation revealed low average intellect on the WISC-III. There were also signs of memory, attention, reading and spelling deficits; and mild right-sided motor incoordination and mood variability. He remained in mainstream classes at school, but his physical and cognitive performance began to deteriorate in 4/95. Neurosurgical evaluation in 4/95 noted increased right hemiplegia and right homonymous hemianopia. MRI revealed tumor progression and he was subsequently placed on Carboplatin/VP-16 (CG 9933 protocol chemotherapy, regimen A). He was last seen on 4/96 and was having difficulty in the 6th grade; he was also undergoing physical therapy for his right hemiplegia." neurology, mri brain, pilocytic astrocytoma, caudate, thalamus, headache, astrocytoma, hemiplegia, pilocytic, mri, Neurology Right pontine pyramidal tract infarct. MRI Brain - Pontine Stroke "CC:, Left sided weakness.,HX:, 74 y/o RHF awoke from a nap at 11:00 AM on 11/22/92 and felt weak on her left side. She required support on that side to ambulate. In addition, she felt spoke as though she ""was drunk."" Nevertheless, she was able to comprehend what was being spoken around her. Her difficulty with speech completely resolved by 12:00 noon. She was brought to UIHC ETC at 8:30AM on 11/23/92 for evaluation.,MEDS:, none. ,ALLERGIES:, ASA/ PCN both cause rash.,PMH:, 1)?HTN. 2)COPD. 3)h/o hepatitis (unknown type). 4)Macular degeneration.,SHX:, Widowed; lives alone. Denied ETOH/Tobacco/illicit drug use.,FHX:, unremarkable.,EXAM: , BP191/89 HR68 RR16 37.2C,MS: A & O to person, place and time. Speech fluent; without dysarthria. Intact naming, comprehension, and repetition.,CN: Central scotoma, OS (old). Mild upper lid ptosis, OD (old per picture). Lower left facial weakness.,Motor: Mild Left hemiparesis (4+ to 5- strength throughout affected side). No mention of muscle tone in chart.,Sensory: unremarkable.,Coord: impaired FNF and HKS movement secondary to weakness.,Station: Left pronator drift. No Romberg sign seen.,Gait: Left hemiparetic gait with decreased LUE swing.,Reflexes: 3/3+ biceps and triceps. 3/3+ patellae. 2/3+ ankles with 3-4beats of non-sustained ankle clonus on left. Plantars: Left babinski sign; and flexor on right.,General Exam: 2/6 SEM at left sternal border.,COURSE:, GS, CBC, PT, PTT, CK, ESR were within normal limits. ABC 7.4/46/63 on room air. EKG showed a sinus rhythm with right bundle branch block. MRI brain, 11/23/95, revealed a right pontine pyramidal tract infarction. She was treated with Ticlopidine 250mg bid. On 11/26/92, her left hemiparesis worsened. A HCT, 11/27/92, was unremarkable. The patient was treated with IV Heparin. This was discontinued the following day when her strength returned to that noted on 11/23/95. On 11/27/92, she developed angina and was ruled out for MI by serial EKG and cardiac enzyme studies. Carotid duplex showed 0-15% bilateral ICA stenosis and antegrade vertebral artery flow bilaterally. Transthoracic echocardiogram revealed aortic insufficiency only. Transesophageal echocardiogram revealed trivial mitral and tricuspid regurgitation, aortic valvular fibrosis. There was calcification and possible thrombus seen in the descending aorta. Cardiology did not feel the later was an indication for anticoagulation. She was discharged home on Isordil 20 tid, Metoprolol 25mg q12hours, and Ticlid 250mg bid." neurology, mri brain, pontine stroke, difficulty with speech, hemiparesis, pontine pyramidal tract infarct, weakness, mri, brain, pyramidal, echocardiogram, pontine, infarct, Neurology A middle-aged male with increasing memory loss and history of Lyme disease. MRI Brain - Lyme Disease 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. neurology, increasing memory loss, intrasellar mass lesion, memory loss, sella turcica, cavernous sinus, sphenoid sinus, ct imaging, white matter, retention cyst, maxillary antrum, lyme disease, mass lesion, disease, cavernous, cortical, mass, lesion, Neurology MRI Brain - Progressive Multifocal Leukoencephalopathy (PML) occurring in an immunosuppressed patient with polymyositis. MRI Brain - Leukoencephalopathy "CC: ,Progressive left visual field loss.,HX:, This 46y/o RHF with polymyositis since 1988, presented with complaint of visual field loss since 12/94. The visual field loss was of gradual onset and within a month of onset became a left homonymous hemianopsia. She began experiencing stiffness, numbness, tingling and incoordination of her left hand, 6 weeks prior to this admission,. These symptoms were initially attributed to carpal tunnel syndrome. MRI scan of the brain (done locally) on 6/23/95 revealed increased periventricular white matter signal on T2 images, particularly in the left temporo-occipital and right parietal lobes. There was ring enhancement of a lesion in the left occipital lobe on T1 gadolinium contrast enhanced images. There was gyral enhancement near the right Sylvian fissure. Cerebral angiogram on 7/19/95 (done locally) was unremarkable. Lumbar puncture on 7/19/95 was unremarkable. She complained of frequent holocranial throbbing headaches for the past 6 months; the HA's are associated with photophobia, phonophobia and nausea, but no vomiting. She has also been experiencing chills and night sweats for the past 2-3 weeks. She denies weight loss, but acknowledged decreased appetite and increased generalized fatigue for the past 3-4 months.,She was diagnosed with polymyositis in 1988 with slowly progressive bilateral lower extremity weakness. She has been on immunosuppressive drugs since 1988, including Prednisone, Prednisone and methotrexate, Cyclosporin, Imuran, Cytoxan, and Plaquenil. At present she in ambulatory with use of walker. Her last CK=3,125 and ESR=16, on 6/28/95.,MEDS:, Prednisone 20mg qd, Cytoxan 75mg qd, Zantac 150mg bid, Vasotec 10mg bid, Premarin 0.625 qd, Provera 2.5mg qd, CaCO3 500mg bid, Vit D 50,000units qweek, Vit E qd, MVI 1 tab qd.,PMH:, 1)polymyositis diagnosed in 1988 by muscle biopsy. 2)hypertension. 3)lichen planus. 4)Lower extremity deep venous thrombosis one year ago--placed on Coumadin and this resulted in postmenopausal bleeding.,FHX:, Mother is alive and has a h/o HTN and stroke. Father died in motor vehicle accident at age 40 years.,SHX:, Married, 3 children who are healthy. She denied any Tobacco/ETOH/Illicit drug use.,EXAM:, BP160/74 HR95 RR12 35.8C Wt. 86.4kg Ht. 5'6"",MS: A&O to person, place and time. Speech was normal. Mood euthymic with appropriate affect.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light. No RAPD noted. Optic Disk were flat. EOM testing unremarkable. Confrontational visual field testing revealed a left homonymous hemianopsia. The rest of the CN exam was unremarkable.,MOTOR: Upper extremities: 5/5 proximally, 5/4 @ elbow/wrist/hand. Lower extremities: 4/4 proximally and 5/5 @ and below knees.,SENSORY: unremarkable.,COORD: Dyssynergia of LUE FNF movement. Slowed finger tapping on left. HNS movements were normal, bilaterally.,Station: LUE drift and fix on arm roll. No Romberg sign elicited.,Gait: Waddling gait, but could TT and stand on both heels. She had difficulty with tandem walking, but did not fall to any particular side.,Reflexes: 2/2 brachioradialis and biceps. 2/2+ triceps, 1+/1+ patellae, 1/1 Achilles. Plantar responses were flexor on the right and withdrawal response on the left.,GEN EXAM: No rashes. II/VI systolic ejection murmur at the left sternal border.,COURSE:, Electrolytes, PT/PTT, Urinalysis and CXR were normal. ESR=38 (normal<20), CRP1.4 (normal<0.4). CK 2,917, LDH 356, AST 67. MRI Brain, 8/8/95, revealed slight improvement of the abnormal white matter changes seen on previous outside MRI. In addition new sphenoid sinus disease suggestive of sinusitis was seen. She underwent stereotactic biopsy of the right parietal region on 8/10/95 which on H&E and LFB stained sections revealed multiple discrete areas of demyelination, containing dense infiltrates of foamy macrophages in association with scattered large oligodendroglia with deeply basophilic, ground-glass nuclei, enlarged astrocytes, and sparse perivascular lymphocytic infiltrates. In situ hybridization performed on block A2 (at the university of Pittsburgh) is positive for JC virus. The ultrastructural studies demonstrated no viral particles.,She was tapered off all immunosuppressive medications and her polymyositis remained clinically stable. She had a seizure in 12/95 and was placed on Dilantin. Her neurologic deficits worsened slightly, but reached a plateau by 10/96, as indicated by a 4/14/97 Neurology clinic visit note.,1/22/96, MRI Brain demonstrated widespread hyperintense signal on T2 and Proton Density weighted images throughout the deep white matter in both hemispheres, worse on the right side. There was interval progression of previously noted abnormalities and extension into the right frontal and left parieto-occipital regions. There was progression of abnormal signal in the Basal Ganglia, worse on the right, and new involvement of the brainstem." neurology, mri brain, pml, progressive multifocal leukoencephalopathy, polymyositis, visual field loss, leukoencephalopathy, lower extremity, field loss, white matter, visual field, signal, brain, mri, Neurology Progressive loss of color vision OD. Meningioma CC: ,Progressive loss of color vision OD,HX:, 58 y/o female presents with a one year history of progressive loss of color vision. In the past two months she has developed blurred vision and a central scotoma OD. There are no symptoms of photopsias, diplopia, headache, or eye pain. There are no other complaints. There have been mild fluctuations of her symptoms, but her vision has never returned to its baseline prior to symptom onset one year ago.,EXAM: ,Visual acuity with correction: 20/25+1 OD; 20/20-1 OS. Pupils were 3.5mm OU. There was a 0.8 log unit RAPD OD. Intraocular pressures were 25 and 24, OD and OS respectively; and there was an increase to 27 on upgaze OD, but no increase on upgaze OS. Optic disk pallor was evident OD, but not OS. Additionally, there was a small area of peripheral chorioretinal scarring in the inferotemporal area of the right eye. Foveal flicker fusion occurred at a frequency of 21.9 OD and 30.7 OS. Color plate testing scores: 6/14 OD and 10/14 OS. Goldman visual field examination showed an enlarged and deepened blind spot with an infero-temporal defect especially in the smaller diopters.,IMPRESSION ON 2/6/89: ,Optic neuropathy/atrophy OD, rule out mass lesion affecting optic nerve. Particular attention was paid to the area of the optic canal, cavernous sinus and sphenoid sinus.,BRAIN CT W/CONTRAST, 2/13/89:, Enhancing calcified lesion in the posterior aspect of the right optic nerve, probable meningioma.,MRI ORBITS W/ AND W/OUT GADOLINIUM CONTRAST, 4/26/89:, 7x3mm irregular soft tissue mass just inferior and lateral to the optic nerve OD. The mass is just proximal to the orbital apex. There is relatively homogeneous enhancement of the mass. The findings are most consistent with meningioma.,MRI 1995:, Mild enlargement of tumor with possible slight extension into the right cavernous sinus.,COURSE: ,Resection and biopsy were deferred due to risk of blindness, and suspicion that the tumor was a slow growing meningioma. 3 years after initial evaluation Hertel measurements indicated a 3mm proptosis OD. Visual field testing revealed gradual worsening of deficits seen on her initial Goldman visual field exam. There was greater red color desaturation of the temporal field OD. Visual acuity had decreased from 20/20 to 20/64, OD. All other deficits seen on her initial exam remained stable or slightly worsened. By 1996 she continued to be followed at 6 months intervals and had not undergone surgical resection. neurology, goldman visual field examination, loss of color vision, visual field examination, visual acuity, cavernous sinus, color vision, visual field, optic nerve, meningioma, Neurology A middle-aged female with memory loss. MRI Brain - Memory Loss FINDINGS:,There is moderate to severe generalized neuronal loss of the cerebral hemispheres with moderate to severe ventricular enlargement and prominent CSF within the subarachnoid spaces. There is confluent white matter hyperintensity in a bi-hemispherical centrum semiovale distribution extending to the lateral ventricles consistent with severe vasculopathic small vessel disease and extensive white matter ischemic changes. There is normal enhancement of the dural sinuses and cortical veins and there are no enhancing intra-axial or extraaxial mass lesions. There is a cavum velum interpositum (normal variant).,There is a linear area of T1 hypointensity becoming hyperintense on T2 images in a left para-atrial trigonal region representing either a remote lacunar infarction or prominent perivascular space.,Normal basal ganglia and thalami. Normal internal and external capsules. Normal midbrain.,There is amorphus hyperintensity of the basis pontis consistent with vasculopathic small vessel disease. There are areas of T2 hyperintensity involving the bilateral brachium pontis (left greater than right) with no enhancement following gadolinium augmentation most compatible with areas of chronic white matter ischemic changes. The area of white matter signal alteration in the left brachium pontis is of some concern in that is has a round morphology. Interval reassessment of this lesion is recommended.,There is a remote lacunar infarction of the right cerebellar hemisphere. Normal left cerebellar hemisphere and vermis.,There is increased CSF within the sella turcica and mild flattening of the pituitary gland but no sellar enlargement. There is elongation of the basilar artery elevating the mammary bodies but no dolichoectasia of the basilar artery.,Normal flow within the carotid arteries and circle of Willis.,Normal calvarium, central skull base and temporal bones. There is no demonstrated calvarium metastases.,IMPRESSION:,Severe generalized cerebral atrophy.,Extensive chronic white matter ischemic changes in a bi-hemispheric centrum semiovale distribution with involvement of the basis pontis and probable bilateral brachium pontis. The area of white matter hyperintensity in the left brachium pontis is of some concern is that it has a round morphology but no enhancement following gadolinium augmentation. Interval reassessment of this lesion is recommended.,Remote lacunar infarction in the right cerebellar hemisphere.,Linear signal alteration of the left periatrial trigonal region representing either a prominent vascular space or,lacunar infarction.,No demonstrated calvarial metastases. neurology, white matter ischemic, remote lacunar infarction, memory loss, matter ischemic, remote lacunar, cerebellar hemisphere, lacunar infarction, brachium pontis, white matter, basilar, calvarium, ischemic, enhancement, cerebellar, hemispheres, hyperintensity, infarction, brachium, Neurology MRI Brain: Ventriculomegaly of the lateral, 3rd and 4th ventricles secondary to obstruction of the foramen of Magendie secondary to Cryptococcus (unencapsulated) in a non-immune suppressed, HIV negative, individual. MRI Brain - Cryptococcus 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. neurology, ventriculomegaly, foramen of magendie, mri brain, blurred vision, headache, brain, ventricles, cryptococcus, foramen, csf, Neurology Problems with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently. Malignant Meningioma - Consult 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. neurology, seizures, hemiparesis, tumor, seizures hemiparesis, malignant meningioma, chemotherapy, malignant, meningioma, aspirin Neurology MRI Brain to evaluate sudden onset blindness - Basilar/bilateral thalamic strokes. MRI Brain - Bilateral Thalamic Strokes "CC:, Sudden onset blindness.,HX:, This 58 y/o RHF was in her usual healthy state, until 4:00PM, 1/8/93, when she suddenly became blind. Tongue numbness and slurred speech occurred simultaneously with the loss of vision. The vision transiently improved to ""severe blurring"" enroute to a local ER, but worsened again once there. While being evaluated she became unresponsive, even to deep noxious stimuli. She was transferred to UIHC for further evaluation. Upon arrival at UIHC her signs and symptoms were present but markedly improved.,PMH:, 1) Hysterectomy many years previous. 2) Herniorrhaphy in past. 3) DJD, relieved with NSAIDs.,FHX/SHX:, Married x 27yrs. Husband denied Tobacco/ETOH/illicit drug use for her.,Unremarkable FHx.,MEDS:, none.,EXAM:, Vitals: 36.9C. HR 93. BP 151/93. RR 22. 98% O2Sat.,MS: somnolent, but arousable to verbal stimulation. minimal speech. followed simple commands on occasion.,CN: Blinked to threat from all directions. EOM appeared full, Pupils 2/2 decreasing to 1/1. +/+Corneas. Winced to PP in all areas of Face. +/+Gag. Tongue midline. Oculocephalic reflex intact.,Motor: UE 4/5 proximally. Full strength in all other areas. Normal tone and muscle bulk.,Sensory: Withdrew to PP in all extremities.,Gait: ND.,Reflexes: 2+/2+ throughout UE, 3/3 patella, 2/2 ankles, Plantar responses were flexor bilaterally.,Gen exam: unremarkable.,COURSE: ,MRI Brain revealed bilateral thalamic strokes. Transthoracic echocardiogram (TTE) showed an intraatrial septal aneurysm with right to left shunt. Transesophageal echocardiogram (TEE) revealed the same. No intracardiac thrombus was found. Lower extremity dopplers were unremarkable. Carotid duplex revealed 0-15% bilateral ICA stenosis. Neuroophthalmologic evaluation revealed evidence of a supranuclear vertical gaze palsy OU (diminished up and down gaze). Neuropsychologic assessment 1/12-15/93 revealed severe impairment of anterograde verbal and visual memory, including acquisition and delayed recall and recognition. Speech was effortful and hypophonic with very defective verbal associative fluency. Reading comprehension was somewhat preserved, though she complained that despite the ability to see type clearly, she could not make sense of words. There was impairment of 2-D constructional praxis. A follow-up Neuropsychology evaluation in 7/93 revealed little improvement. Laboratory studies, TSH, FT4, CRP, ESR, GS, PT/PTT were unremarkable. Total serum cholesterol 195, Triglycerides 57, HDL 43, LDL 141. She was placed on ASA and discharged1/19/93.,She was last seen on 5/2/95 and was speaking fluently and lucidly. She continued to have mild decreased vertical eye movements. Coordination and strength testing were fairly unremarkable. She continues to take ASA 325 mg qd." neurology, blindness, mri, transthoracic echocardiogram, transesophageal echocardiogram, tsh, ft4, crp, esr, gs, pt/ptt, bilateral thalamic strokes, sudden onset blindness, mri brain, thalamic strokes, brain, thalamic, strokes, Neurology MRI Brain - Olfactory groove meningioma. MRI Brain - Meningioma (Olfactory) 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. neurology, mri brain, olfactory, groove, headaches, meningioma, nasal discharge, numbness, visual loss, weakness, weight loss, visual acuity, mri, brain, isointense, sinuses, visual, Neurology Patient with sudden onset dizziness and RUE clumsiness. Giant Left MCA Aneurysm. MCA Aneurysm 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. neurology, mca aneurysm, rue clumsiness, white matter, aneurysm, mca, dizziness, aphasia, matter, clumsiness, brain, peripheral, Neurology Briefly, the patient has a lumbosacral polyradiculopathy that is temporally related to the epidural anesthesia given to her in October of 2008. Lumbosacral Polyradiculopathy HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old woman who reports that on the 30th of October 2008, she had a rupture of her membranes at nine months of pregnancy, and was admitted to hospital and was given an epidural anesthetic. I do not have the records from this hospital admission, but apparently the epidural was administered for approximately 14 to 18 hours. She was sitting up during the epidural.,She did not notice any difference in her lower extremities at the time she had the epidural; however, she reports that she was extremely sleepy and may not have been aware of any change in strength or sensation in her lower extremities at that time. She delivered on the 31st of October, by Cesarean section, because she had failed to progress and had pyrexia.,She also had a Foley catheter placed at that time. On the 1st of November 2008, they began to mobilize her and it was at that time that she first noticed that she could not walk. She was aware that she could not move her legs at all, and then within a few days, she was aware that she could move toes in the left foot but could not move her right foot at all. Since that time, there has been a gradual improvement in strength to the point that she now has limited movement in her left leg and severely restricted movement in her right leg. She is not able to walk by herself, and needs assistance to stand. She was discharged from hospital after the Cesarean section on the 3rd of November. Unfortunately, we do not have the records and we do not know what the discussion was between the anesthesiologist and the patient at the time of discharge. She was then seen at ABC Hospital on November 05, 2008. She had an MRI scan of her spine, which showed no evidence of an abnormality, specifically there were no cord changes and no evidence of a hematoma. She also had an EMG study at that time by Dr. X, which was abnormal but not diagnostic and this was repeated again in December. At the present time, she also complains of a pressure in both her legs and in her thighs. She complains that her right foot hurts and that she has some hyperesthesia there. She has been taking gabapentin to try to reduce the discomfort, although she is on a very low dose and the effect is minimal. She has no symptoms in her arms, her bowel and bladder function is normal, and her bulbar function is normal. There is no problem with her vision, swallowing, or respiratory function.,PAST MEDICAL HISTORY: , Unremarkable except as noted above. She has seasonal allergies.,CURRENT MEDICATIONS:, Gabapentin 300 mg b.i.d., Centrum once a day, and another multivitamin.,ALLERGIES: , She has no medication allergies, but does have seasonal allergies.,FAMILY HISTORY: , There is a family history of diabetes and hypertension. There is no family history of a neuropathy or other neurological disease. She has one child, a son, born on October 31, 2008.,SOCIAL HISTORY: , The patient is a civil engineer, who currently works from home. She is working approximately half time because of limitations imposed on her by her disability, need to attend frequent physical therapy, and also the needs of looking after her baby. She does not smoke and does not drink and has never done either.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS: P 74, BP 144/75, and a pain score of 0.,GENERAL: Her general physical examination was unremarkable.,CARDIOVASCULAR: Normal first and second heart sound, regular pulse with normal volume.,RESPIRATORY: Unremarkable, both lung bases were clear, and respiration was normal.,GI: Unremarkable, with no organomegaly and normal bowel sounds.,NEUROLOGICAL EXAM:,MSE: The patient's orientation was normal, fund of knowledge was normal, memory was normal, speech was normal, calculation was normal, and immediate and long-term recall was normal. Executive function was normal.,CRANIAL NERVES: The cranial nerve examination II through XII was unremarkable. Both disks were normal, with normal retina. Pupils were equal and reactive to light. Eye movements were full. Facial sensation and strength was normal. Bulbar function was normal. The trapezius had normal strength.,MOTOR: Muscle tone showed a slight increase in tone in the lower extremities, with normal tone in the upper extremities. Muscle strength was 5/5 in all muscle groups in the upper extremities. In the lower extremities, the hip flexors were 1/5 bilaterally, hip extensors were 1/5 bilaterally, knee extension on the right was 1/5 and on the left was 3-/5, knee flexion was 2/5 on the right and 3-/5 on the left, foot dorsiflexion was 0/5 on the right and 1/5 on the left, foot plantar flexion was 4-/5 on the right and 4+/5 on the left, toe extension was 0/5 on the right and 4-/5 on the left, toe flexion was 4-/5 on the right and 4+/5 on the left.,REFLEXES: Reflexes in the upper extremities were 2+ bilaterally. In the lower extremities, they were 0 bilaterally at the knee and ankles. The abdominal reflexes were present above the umbilicus and absent below the umbilicus. The plantar responses were mute. The jaw reflex was normal.,SENSATION: Vibration was moderately decreased in the right great toe and was mildly decreased in the left great toe. There was a sensory level to light touch at approximately T7 posteriorly and approximately T9 anteriorly. There was a range of sensation, but clearly there was a decrease in sensation below this level but not complete loss of sensation. To pain, the sensory level is even less clear, but appeared to be at about T7 on the right side. In the lower extremities, there was a slight decrease in pin and light touch in the right great toe compared to the left. There was no evidence of allodynia or hyperesthesia. Joint position sense was mildly reduced in the right toe and normal on the left.,COORDINATION: Coordination for rapid alternating movements and finger-to-nose testing was normal. Coordination could not be tested in the lower extremities.,GAIT: The patient was unable to stand and therefore we were unable to test gait or Romberg's. There was no evidence of focal back tenderness.,REVIEW OF OUTSIDE RECORDS: , I have reviewed the records from ABC Hospital, including the letter from Dr. Y and the EMG report dated 12/17/2008 from Dr. X. The EMG report shows evidence of a lumbosacral polyradiculopathy below approximately T6. The lower extremity sensory responses are essentially normal; however, there is a decrease in the amplitude of the motor responses with minimal changes in latency. I do have the MRI of lumbar spine report from 11/06/2008 with and without contrast. This showed a minimal concentric disc bulge of L4-L5 without disc herniation, but was otherwise unremarkable. The patient brought a disc with a most recent MRI study; however, we were unable to open this on our computers. The verbal report is that the study was unremarkable except for some gadolinium enhancement in the lumbar nerve roots. A Doppler of the lower extremities showed no evidence of deep venous thrombosis in either lower extremity. Chest x-ray showed some scoliosis on the lumbar spine, curve to the left, but no evidence of other abnormalities. A CT pelvis study performed on November 07, 2008 showed some nonspecific fluid in the subcutaneous fat of the back, posterior to L4 and L5 levels; however, there were no pelvic masses or other abnormalities. We were able to obtain an update of the report from the MRI of the lumbar spine with and without contrast dated 12/30/2008. The complete study included the cervical, thoracic, and lumbar spine. There was diffuse enhancement of the nerve roots of the cauda equina that had increased in enhancement since prior exam in November. It was also reported that the patient was given intravenous methylprednisolone and this had had no effect on strength in her lower extremities.,IMPRESSION: , The patient has a condition that is temporarily related to the epidural injection she was given at the end of October 2008, prior to her Cesarean section. It appears she became aware of weakness within two days of the administration of the epidural, she was very tired during the epidural and may have missed some change in her neurological function. She was severely weak in both lower extremities, slightly worse on the right than the left. There has been some interval improvement in her strength since the beginning of November 2008. Her EMG study from the end of December is most consistent with a lumbosacral polyradiculopathy. The MRI findings of gadolinium enhancement in the lumbar nerve roots would be most consistent with an inflammatory radiculitis most likely related to the epidural anesthesia or administration of the epidural. There had been no response to IV methylprednisolone given to her at ABC. The issue of having a lumbar puncture to look for evidence of inflammatory cells or an elevated protein had been discussed with her at both ABC and by myself. The patient did not wish to consider a lumbar puncture because of concerns that this might worsen her condition. At the present time, she is able to stand with aid but is unable to walk. There is no evidence on her previous EMG of a demyelinating neuropathy.,RECOMMENDATIONS:,1. The diagnostic issues were discussed with the patient at length. She is informed that this is still early in the course of the problem and that we expect her to show some improvement in her function over the next one to two years, although it is unclear as to how much function she will regain.,2. She is strongly recommended to continue with vigorous physical therapy, and to continue with the plan to mobilize her as much as possible, with the goal of trying to get her ambulatory. If she is able to walk, she will need bilateral AFOs for her ankles, to improve her overall mobility. I am not prescribing these because at the present time she does not need them.,3. We discussed increasing the dose of gabapentin. The paresthesias that she has may indicate that she is actually regaining some sensory function, although there is a concern that as recovery continues, she may be left with significant neuropathic pain. If this is the case, I have advised her to increase her gabapentin dose from 300 mg b.i.d. gradually up to 300 mg four times a day and then to 600 mg to 900 mg four times a day. She may need other neuropathic pain medications as needed. She will determine whether her current symptoms are significant enough to require this increase in dosage.,4. The patient will follow up with Dr. Y and his team at ABC Hospital. She will also continue with physical therapy within the ABC system. Neurology The patient with gradual onset of a headache problem, located behind both eyes. Migraine without Aura - Consult 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: Neurology " A 21-month-old male presented for delayed motor development, ""jaw quivering"" and ""lazy eye."" " Lobar Holoprosencephaly "CC: ,Delayed motor development.,HX:, This 21 month old male presented for delayed motor development, ""jaw quivering"" and ""lazy eye."" He was an 8 pound 10 ounce product of a full term, uncomplicated pregnancy-labor-spontaneous vaginal delivery to a G3P3 married white female mother. There had been no known toxic intrauterine exposures. He had no serious illnesses or hospitalizations since birth. He sat independently at 7 months, stood at 11 months, crawled at 16 months, but did not cruise until 18 months.,He currently cannot walk and easily falls. His gait is reportedly marked by left ""intoeing."" His upper extremity strength and coordination reportedly appear quite normal and he is able to feed himself, throw and transfer objects easily. He knows greater than 20 words and speaks two-word phrases.,No seizures or unusual behavior were reported except for ""quivering"" movement of his jaw. This has occurred since birth. In addition the parents have noted transient left exotropia.,PMH: ,As above.,FHX:, Many family members with ""lazy eye."" No other neurologic diseases declared.,9 and 5 year old sisters who are healthy.,SHX:, lives with parents and sisters.,EXAM:, BP83/67 HR122 36.4C Head circumference 48.0cm Weight 12.68kg (70%) Height 86.0cm (70%),MS: fairly cooperative.,CN: Minimal transient esotropia OS. Tremulous quivering of jaw--increased with crying. No obvious papilledema, though difficult to evaluate due to patient movement.,Motor: sat independently with normal posture and no truncal ataxia. symmetric and normal strength and muscle bulk throughout.,Sensory: withdrew to vibration.,Coordination: unremarkable in BUE.,Station: no truncal ataxia.,Gait: On attempting to walk, his right foot rotated laterally at almost 70degrees. Both lower extremities could rotate outward to 90degrees. There was marked passive eversion at the ankles as well.,Reflexes: 2+/2+ throughout.,Musculoskeletal: pes planovalgus bilaterally.,COURSE: ,CK normal. The parents decided to forego an MRI in 8/90. The patient returned 12/11/92 at age 4 years. He was ambulatory and able to run awkwardly. His general health had been good, but he showed signs developmental delay. Formal evaluation had tested his IQ at 87 at age 3.5 years. He was weakest on tasks requiring visual/motor integration and fine motor and visual discrimination skills. He was 6 months delayed in cognitive development at that time. On exam, age 4 years, he displayed mild right ankle laxity on eversion and inversion, but normal gait. The rest of the neurological exam was normal. Head circumference was 49.5cm (50%) and height and weight were in the 90th percentile. Fragile X analysis and karyotyping were unremarkable." neurology, delayed motor development, jaw quivering, head circumference, truncal ataxia, delayed motor, motor development, lazy eye, jaw, quivering, delayed, intrauterine, Neurology Lumbar puncture with moderate sedation. Lumbar Puncture - 1 "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." neurology, moderate sedation, lumbar puncture, needle, lumbar, Neurology Patient with a 1-year history of progressive anterograde amnesia Limbic Encephalitis CC:, Rapidly progressive amnesia.,HX: ,This 63 y/o RHM presented with a 1 year history of progressive anterograde amnesia. On presentation he could not remember anything from one minute to the next. He also had some retrograde memory loss, in that he could not remember the names of his grandchildren, but had generally preserved intellect, language, personality, and calculating ability. He underwent extensive evaluation at the Mayo Clinic and an MRI there revealed increased signal on T2 weighted images in the mesiotemporal lobes bilaterally. There was no mass affect. The areas mildly enhanced with gadolinium.,PMH:, 1) CAD; MI x 2 (1978 and 1979). 2) PVD; s/p aortic endarterectomy (3/1991). 3)HTN. 4)Bilateral inguinal hernia repair.,FHX/SHX:, Mother died of a stroke at age 58. Father had CAD and HTN. The patient quit smoking in 1991, but was a heavy smoker (2-3ppd) for many years. He had been a feed salesman all of his adult life.,ROS:, Unremarkable. No history of cancer.,EXAM:, BP 136/75 HR 73 RR12 T36.6,MS: Alert but disoriented to person, place, time. He could not remember his birthdate, and continually asked the interviewer what year it was. He could not remember when he married, retired, or his grandchildren's names. He scored 18/30 on the Follutein's MMSE with severe deficits in orientation and memory. He had moderate difficulty naming. He repeated normally and had no constructional apraxia. Judgement remained good.,CN: unremarkable.,Motor: Full strength throughout with normal muscle tone and bulk.,Sensory: Intact to LT/PP/PROP,Coordination: unremarkable.,Station: No pronator drift, truncal ataxia or Romberg sign.,Gait: unremarkable.,Reflexes: 3+ throughout with downgoing plantar responses bilaterally.,Gen Exam: unremarkable.,STUDIES:, MRI Brain revealed hyperintense T2 signal in the mesiotemporal regions bilaterally, with mild enhancement on the gadolinium scans. MRI and CT of the chest and CT of the abdomen showed no evidence of lymphadenopathy or tumor. EEG was normal awake and asleep. Antineuronal antibody screening was unremarkable. CSF studies were unremarkable and included varicella zoster, herpes zoster, HIV and HTLV testing, and cytology. The patient underwent stereotactic brain biopsy at the Mayo Clinic which showed inflammatory changes, but no organism or etiology was concluded. TFT, B12, VDRL, ESR, CRP, ANA, SPEP and Folate studies were unremarkable. Neuropsychologic testing revealed severe anterograde memory (verbal and visual)loss, and less severe retrograde memory loss. Most other cognitive abilities were well preserved and the findings were consistent with mesiotemporal dysfunction bilaterally.,IMPRESSION:, Limbic encephalitis secondary to cancer of unknown origin.,He was last seen 7/26/96. MMSE 20/30 and category fluency 20 . Disinhibited affect. Mild right grasp reflex. The clinical course was benign and non-progressive, and unusual for such a diagnosis, though not unheard of . neurology, mri brain, progressive anterograde amnesia, retrograde memory loss, limbic encephalitis, anterograde amnesia, memory loss, limbic, encephalitis, amnesia, anterograde, memory, Neurology Lumbar discogram L2-3, L3-4, L4-5, and L5-S1. Low back pain. Lumbar Discogram 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. neurology, back pain, c-arm, fluoroscopic projections, disc space, lumbar discogram, fluoroscopic, needle, Neurology Possible CSF malignancy. This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. The patient has gradually stopped walking even with her walker and her left arm has become gradually less functional. She is not able to use the walker because her left arm is so weak. Lumbar Puncture REASON FOR VISIT: ,This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. She is accompanied by her daughter.,HISTORY OF PRESENT ILLNESS:, The patient' daughter tells me that over the last month the patient has gradually stopped walking even with her walker and her left arm has become gradually less functional. She is not able to use the walker because her left arm is so weak. She has not been having any headaches. She has had a significant decrease in appetite. She is known to have lung cancer, but Ms. Wilson does not know what kind. According to her followup notes, it is presumed non-small cell lung cancer of the left upper lobe of the lung. The last note I have to evaluate is from October 2008. CT scan from 12/01/2009 shows atrophy and small vessel ischemic change, otherwise a normal head CT, no mass lesion. I also reviewed the MRI from September 2009, which does not suggest normal pressure hydrocephalus and shows no mass lesion.,Blood tests from 11/18/2009 demonstrate platelet count at 132 and INR of 1.0.,MAJOR FINDINGS: , The patient is a pleasant and cooperative woman who answers the questions the best she can and has difficulty moving her left arm and hand. She also has pain in her left arm and hand at a level of 8-9/10.,VITAL SIGNS: , Blood pressure 126/88, heart rate 70, respiratory rate 16, and weight 95 pounds.,I screened the patient with questions to determine whether it is likely she has abnormal CSF pressure and she does not have any of the signs that would suggest this, so we performed the procedure in the upright position.,PROCEDURE:, Lumbar puncture, diagnostic (CPT 62270).,PREOPERATIVE DIAGNOSIS: , Possible CSF malignancy.,POSTOPERATIVE DIAGNOSIS: ,To be determined after CSF evaluation.,PROCEDURE PERFORMED: , Lumbar puncture.,ANESTHESIA: , Local with 2% lidocaine at the L4-L5 level.,SPECIMEN REMOVED: ,15 cc of clear CSF.,ESTIMATED BLOOD LOSS: , None.,DESCRIPTION OF THE PROCEDURE: ,I explained the procedure, its rationale, risks, benefits, and alternatives to the patient and her daughter. The patient' daughter remained present throughout the procedure. The patient provided written consent and her daughter signed as witness to the consent.,I located the iliac crest and spinous processes before the procedure and determined the level I planned for the puncture. During the procedure, I spoke constantly with the patient to explain what was happening and to warn when there might be pain or discomfort. The skin was prepped with chlorhexidine solution with the patient seated on the chair leaning forward with her face resting on the exam table. Using local anesthetic and aseptic technique, I inserted a 20-gauge spinal needle at the L4-L5 interspace and 15 cc of CSF was collected without difficulty.,The patient tolerated the procedure well.,ASSESSMENT: ,White blood cells 1, red blood cells 54, glucose 59, protein 51, Gram stain negative, bacterial culture negative after three days, and remaining tests pending. Neurology The patient comes in today because of feeling lightheaded and difficulty keeping his balance. Lightheadedness HISTORY OF PRESENT ILLNESS: ,The patient comes in today because of feeling lightheaded and difficulty keeping his balance. He denies this as a spinning sensation that he had had in the past with vertigo. He just describes as feeling very lightheaded. It usually occurs with position changes such as when he stands up from the sitting position or stands up from a lying position. It tends to ease when he sits down again, but does not totally resolve for another 15 to 30 minutes and he feels shaky and weak all over. Lorazepam did not help this sensation. His blood pressure has been up lately and his dose of metoprolol was increased. They feel these symptoms have gotten worse since metoprolol was increased.,PAST MEDICAL HISTORY: , Detailed on our H&P form. Positive for elevated cholesterol, diabetes, glaucoma, cataracts, hypertension, heart disease, vertigo, stroke in May of 2005, congestive heart failure, CABG, and cataract removed right eye.,CURRENT MEDICATIONS: , Detailed on the H&P form.,PHYSICAL EXAMINATION: , His blood pressure sitting down was 180/80 with a pulse rate of 56. Standing up blood pressure was 160/80 with a pulse rate of 56. His general exam and neurological exam were detailed on our H&P form. Pertinent positives on his neurological exam were decreased sensation in his left face, and left arm and leg.,IMPRESSION AND PLAN: ,This lightheaded, he exquisitely denies vertigo, the vertigo that he has had in the past. He states this is more of a lightheaded type feeling. He did have a mild blood pressure drop here in the office. We are also concerned that bradycardia might be contributing to his feeling of lightheadedness. We are going to suggest that he gets a Holter monitor and he should speak to his general practitioner as well as his cardiologist regarding the lightheaded feeling.,We will schedule him for the Holter monitor and refer him back to his cardiologist. neurology, lightheaded feeling, feeling lightheaded, pulse rate, neurological exam, holter monitor, blood pressure, balance, vertigo, lightheadedness, Neurology Headache, improved. Intracranial aneurysm. Intracranial aneurysm - ER Visit CHIEF COMPLAINT:, Headache.,HPI: , This is a 24-year-old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan. He was discharged home with a follow up to neurosurgery on the 14th. Apparently, an MRI the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery. He has had headaches since the 13th and complains now of some worsening of his pain. He denies photophobia, fever, vomiting, and weakness of the arms or legs.,PMH: , As above.,MEDS:, Vicodin.,ALLERGIES:, None.,PHYSICAL EXAM: ,BP 180/110 Pulse 65 RR 18 Temp 97.5.,Mr. P is awake and alert, in no apparent distress.,HEENT: Pupils equal, round, reactive to light, oropharynx moist, sclera clear. ,Neck: Supple, no meningismus.,Lungs: Clear.,Heart: Regular rate and rhythm, no murmur, gallop, or rub. ,Abdomen: Benign.,Neuro: Awake and alert, motor strength normal, no numbness, normal gait, DTRs normal. Cranial nerves normal. ,COURSE IN THE ED: ,Patient had a repeat head CT to look for an intracranial bleed that shows an unchanged mass, no blood, and no hydrocephalus. I recommended an LP but he prefers not to have this done. He received morphine for pain and his headache improved. I've recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram. He left the ED against my advice. ,IMPRESSION: , Headache, improved. Intracranial aneurysm.,PLAN: , The patient will return tomorrow am for his angiogram. neurology, angiogram, mass, ct scan, intracranial aneurysm, headache, aneurysm, intracranial, Neurology Right shoulder impingement syndrome, right suprascapular neuropathy. Impairment Rating CHIEF COMPLAINT: , Right shoulder pain.,HISTORY: , The patient is a pleasant, 31-year-old, right-handed, white female who injured her shoulder while transferring a patient back on 01/01/02. She formerly worked for Veteran's Home as a CNA. She has had a long drawn out course of treatment for this shoulder. She tried physical therapy without benefit and ultimately came to a subacromion decompression in November 2002. She had ongoing pain and was evaluated by Dr. X who felt that she had a possible brachial plexopathy. He also felt she had a right superficial radial neuritis and blocked this with resolution of her symptoms. He then referred her to ABCD who did EMG testing, demonstrating a right suprascapular neuropathy although a C5 radiculopathy could not be ruled out. MRI testing on the cervical spine was then done which was negative for disk herniation and she underwent suprascapular nerve decompression of the scapular notch on 12/18/03. She finally went to an anterior axillary nerve block because of ongoing pain in the anterior shoulder again by Dr. X. She comes to me for impairment rating. She has no chronic health problems otherwise, fevers, chills, or general malaise. She is not working. She is right-hand dominant. She denies any prior history of injury to her shoulder.,PAST MEDICAL HISTORY:, Negative aside from above.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: ,Please see above.,REVIEW OF SYSTEMS:, Negative aside from above.,PHYSICAL EXAMINATION: ,A pleasant, age appropriate woman, moderately overweight, in no apparent distress. Normal gait and station, normal posture, normal strength, tone, sensation and deep tendon reflexes with the exception of 4+/5 strength in the supraspinatus musculature on the right. She has decreased motion in the right shoulder as follows. She has 160 degrees of flexion, 155 degrees of abduction, 35 degrees of extension, 25 degrees of adduction, 45 degrees of internal rotation and 90 degrees of external rotation. She has a positive impingement sign on the right.,ASSESSMENT:, Right shoulder impingement syndrome, right suprascapular neuropathy.,DISCUSSION: , With a reasonable degree of medical certainty, she is at maximum medical improvement and she does have an impairment based on AMA Guide to the Evaluation of Permanent Impairment, Fifth Edition. The reason for this impairment is the incident of 01/01/02. For her suprascapular neuropathy, she is rated as a grade IV motor deficit which I rate as a 13% motor deficit. This is multiplied by a maximum upper extremity impairment for involvement of the suprascapular nerve of 16% which produces a 2% impairment of the upper extremity when the two values are multiplied together, 2% impairment of the upper extremity. For her lack of motion in the shoulder she also has additional impairment on the right. She has a 1% impairment of the upper extremity due to lack of shoulder flexion. She has a 1% impairment of the upper extremity due to lack of shoulder abduction. She has a 1% impairment of the upper extremity due to lack of shoulder adduction. She has a 1% impairment of the upper extremity due to lack of shoulder extension. There is no impairment for findings in shoulder external rotation. She has a 3% impairment of the upper extremity due to lack of shoulder internal rotation. Thus the impairment due to lack of motion in her shoulder is a 6% impairment of the upper extremity. This combines with the 2% impairment of the upper extremity due to weakness in the suprascapular nerve root distribution to produce an 8% impairment of the upper extremity which in turn is a 5% impairment of the whole person based on the AMA Guide to the Evaluation of Permanent Impairment, Fifth Edition, stated with a reasonable degree of medical certainty. neurology, ama guide, evaluation of permanent impairment, impairment rating, permanent impairment, suprascapular nerve, suprascapular neuropathy, injured, extremity, shoulder, impairment, neuropathy, suprascapular, Neurology Woman with adult hydrocephalus, routine evaluation. Hydrocephalus REASON FOR VISIT: , Ms. ABC is a 67-year-old woman with adult hydrocephalus who returns to clinic for a routine evaluation. She comes to clinic by herself.,HISTORY OF PRESENT ILLNESS:, She has been followed for her hydrocephalus since 2002. She also had an anterior cervical corpectomy and fusion from C3 though C5 in March 2007. She was last seen by us in clinic in March 2008 and she was experiencing little bit of head fullness and ringing in the ears at that time; however, we decided to leave her shunt setting at 1.0. We wanted her to followup with Dr. XYZ regarding the MRI of the cervical spine. Today, she tells me that with respect to her bladder last week she had some episodes of urinary frequency, however, this week she is not experiencing the same type of episodes. She reports no urgency, incontinence, and feels that she completely empties her bladder when she goes. She does experience some leakage with coughing. She wears the pad on a daily basis. She does not think that her bladder has changed much since we saw her last. With respect to her thinking and memory, she reports no problems at this time. She reports no headaches at this time. With respect to her walking and balance, she says that it feels worse. In the beginning of May, she had a coughing spell and at that time she developed buttock pain, which travels down the legs. She states that her leg often feel like elastic and she experiences a tingling radiculopathy. She says that this tingling is constant and at times painful. She feels that she is walking slower for this reason. She does not use the cane at this time. Most of the time, she is able to walk over uneven surfaces. She is able to walk up and down stairs and has no trouble getting in and out of a car.,MEDICATIONS:, Rhinocort 32 mg two sprays a day, Singulair 10 mg once a day, Xyzal 5 mg in the morning, Spiriva once a day, Advair twice a day, Prevacid 30 mg twice a day, Os-Cal 500 mg once a day, multivitamin once a day, and aspirin 81 mg a day.,MAJOR FINDINGS:, On exam today, this is a pleasant 67-year-old woman who comes back from the clinic waiting area with little difficulty. She is well developed, well nourished, and kempt.,The shunt site is clean, dry, and intact and confirmed at a setting of 1.0.,Mental Status: Assessed and appears intact for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge. Her Mini-Mental Status exam score was 26/30 when attention was tested with calculations and 30/30 when attention was tested with spelling.,Cranial Nerves: Extraocular movements are somewhat inhibited. She does not display any nystagmus at this time. Facial movement, hearing, head turning, tongue, and palate movement are all intact.,Gait: Assessed using the Tinetti assessment tool, which showed a balance score of 13/16 and a gait score of 11/12 for a total score of 24/28.,ASSESSMENT:, Ms. ABC has been experiencing difficulty with walking over the past several months.,PROBLEMS/DIAGNOSES:,1. Hydrocephalus.,2. Cervical stenosis and retrolisthesis.,3. Neuropathy in the legs.,PLAN: , Before we recommend anything more, we would like to get a hold of the notes from Dr. XYZ to try to come up with a concrete plan as to what we can do next for Ms. ABC. We believe that her walking is most likely not being effected by the hydrocephalus. We would like to see her back in clinic in two and a half months or so. We also talked to her about having her obtain cane training so that she knows how to properly use her cane, which she states she does have one. I suggested that she use the cane at her on discretion. neurology, cervical stenosis, retrolisthesis, neuropathy, cervical corpectomy, adult hydrocephalus, cervical, hydrocephalus, Neurology Right iliopsoas hematoma with associated femoral neuropathy following cardiac catherization. Iliopsoas Hematoma - 2 CC: ,RLE weakness.,HX: ,This 42y/o RHM was found 2/27/95 slumped over the steering wheel of the Fed Ex truck he was driving. He was cyanotic and pulseless according to witnesses. EMT evaluation revealed him to be in ventricular fibrillation and he was given epinephrine, lidocaine, bretylium and electrically defibrillated and intubated in the field. Upon arrival at a local ER his cardiac rhythm deteriorated and he required more than 9 counter shocks (defibrillation) at 360 joules per shock, epinephrine and lidocaine. This had no effect. He was then given intracardiac epinephrine and a subsequent electrical defibrillation placed him in atrial fibrillation. He was then taken emergently to cardiac catherization and was found to have normal coronary arteries. He was then admitted to an intensive care unit and required intraortic balloon pump pressure support via the right gorin. His blood pressure gradually improved and his balloon pump was discontinued on 5/5/95. Recovery was complicated by acute renal failure and liver failure. Initail CK=13,780, the CKMB fraction was normal at 0.8.,On 3/10/95, the patient experienced CP and underwent cardiac catherization. This time he was found to have a single occlusion in the distal LAD with association inferior hypokinesis. Subsequent CK=1381 and CKMB=5.4 (elevated). The patient was amnestic to the event and for 10 days following the event. He was transferred to UIHC for cardiac electrophysiology study.,MEDS: ,Nifedipine, ASA, Amiodarone, Capoten, Isordil, Tylenol, Darvocet prn, Reglan prn, Coumadin, KCL, SLNTG prn, CaCO3, Valium prn, Nubain prn.,PMH:, hypercholesterolemia.,FHX:, Father alive age 69 with h/o TIAs. Mother died age 62 and had CHF, A-Fib, CAD. Maternal Grandfather died of an MI and had h/o SVT. Maternal Grandmother had h/o SVT.,SHX: ,Married, 7 children, driver for Fed Ex. Denied tobacco/ETOH/illicit drug use.,EXAM: ,BP112/74 HR64 RR16 Afebrile.,MS: A&O to person, place and time. Euthymic with appropriate affect.,CN: unremarkable.,Motor: Hip flexion 3/5, Hip extension 5/5, Knee flexion5/5, Knee extension 2/5, Plantar flexion, extension, inversion and eversion 5/5. There was full strength thoughout BUE.,Sensory: decreased PP/Vib/LT/TEMP about anterior aspect of thigh and leg in a femoral nerve distribution.,Coord: poor and slowed HKS on right due to weakness.,Station: no drift or Romberg sign.,Gait: difficulty bearing weight on RLE.,Reflexes: 1+/1+ throughout BUE. 0/2 patellae. 2/2 archilles. Plantar responses were flexor, bilaterally.,COURSE:, MRI Pelvis, 3/28/95, revealed increased T1 weighted signal within the right iliopsoas suggestive of hematoma. An intra-osseous lipoma was incidentally notice in the right sacrum. Neuropsychologic assessment showed moderately compromised anterograde verbal memory, and temporal orientation and retrograde recall were below expectations. These findings were consistent with mesial temporal dysfunction secondary to anoxic injury and were mild in lieu of his history. He underwent implantation of a Medtronic internal cardiac difibrillator. His cardiac electrophysiology study found no inducible ventricular tachycardia or fibrillation. He suffered mild to moderate permanent RLE weakness, especially involving the quadriceps. His femoral nerve compression had been present to long to warrant decompression. EMG/NCV studies revealed severe axonal degeneration. neurology, cardiac electrophysiology study, iliopsoas hematoma, rle weakness, balloon pump, femoral nerve, cardiac catherization, hematoma, iliopsoas, catherization, epinephrine, fibrillation, cardiac, Neurology Left Iliopsoas hematoma. Gait difficulty. Iliopsoas Hematoma - 1 "CC: ,Gait difficulty.,HX: ,This 59 y/o RHF was admitted with complaint of gait difficulty. The evening prior to admission she noted sudden onset of LUE and LLE weakness. She felt she favored her right leg, but did not fall when walking. She denied any associated dysarthria, facial weakness, chest pain, SOB, visual change, HA, nausea or vomiting.,PMH:, tonsillectomy, adenoidectomy, skull fx 1954, HTN, HA.,MEDS: ,none on day of exam.,SHX: ,editorial assistant at newspaper, 40pk-yr Tobacco, no ETOH/Drugs.,FHX: ,noncontributory,ADMIT EXAM: ,P95 R20, T36.6, BP169/104,MS: A&O to person, place and time. Speech fluent and without dysarthria, Naming-comprehension-reading intact. Euthymic with appropriate affect.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light, Fundi flat, VFFTC, EOMI, Face symmetric with intact sensation, Gag-shrug-corneal reflexes intact, Tongue ML with full ROM,Motor: Full strength throughout right side. Mildly decreased left grip and left extensor hallucis longus. Biceps/Triceps/Wrist flexors and extensor were full strength on left. However she demonstrated mild LUE pronator drift and had difficulty standing on her LLE despite full strength on bench testing of the LLE.,Sensory: No deficit to PP/T/Vib/Prop/ LT,Coord: decreased speed and magnitude of FNF, Finger tapping and HKS, on left side only.,Station: mild LUE upward drift.,Gait: tendency to drift toward the left. Difficulty standing on LLE.,Reflexes were symmetric, plantar responses were flexor bilaterally.,Gen exam unremarkable.,COURSE: ,Admit Labs: ESR, PT/PTT, GS, UA, EKG, and HCT were unremarkable. Hgb 13.9, Hct 41%, Plt 280k, WBC 5.5.,The patient was diagnosed with a probable lacunar stroke and entered into the TOAST study (Trial of ORG10172[a low molecular weight heparin] in Acute Stroke Treatment).,Carotid Duplex: 16-49%RICA and 0-15%LICA stenosis with anterograde vertebral artery flow, bilaterally. Transthoracic echocardiogram showed mild mitral regurgitation, mild tricuspid regurgitation and a left to right shunt. There was no evidence of blood clot.,Hospital course: 5 days after admission the patient began to complain of proximal LLE and left flank pain. On exam, she had weakness of the quadriceps and hip flexors of the LLE. Her pain increased with left hip flexion. In addition, she complained of paresthesias about the lateral aspect of the medial anterior left thigh; and upon on sensory testing, she had decreased PP/TEMP sensation in a left femoral nerve distribution. She denied any back/neck pain and the rest of her neurologic exam remained unchanged from admission.,Abdominal CT Scan, 2/4/96, revealed a large left retroperitoneal iliopsoas hematoma.,Hgb 8.9g/dl. She was transfused with 4 units of pRBCs. She underwent surgical decompression and evacuation of the hematoma via a posterior flank approach on 2/6/96. Her postoperative course was uncomplicated. She was discharged home on ASA.,At follow-up, on 2/23/96, she complained of left sided paresthesias (worse in the LLE than in the LUE) and feeling of ""swollen left foot."" These symptoms had developed approximately 1 month after her stroke. Her foot looked normal and her UE strength was 5/4+ proximally and distally, and LE strength 5/4+ proximally and 5/5- distally. She was ambulatory. There was no evidence of LUE upward drift. A somatosensory evoked potential study revealed an absent N20 and normal P14 potentials. This was suggestive of a lesion involving the right thalamus which might explain her paresthesia/dysesthesia as part of a Dejerine-Roussy syndrome." Neurology Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation. Laminectomy & Foraminotomy Followup "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." neurology, spinal fusion, restless leg syndrome, posterior spinal fusion, pedicle screw, lumbar spine, bilateral foraminotomies, fluid collection, foraminotomy, instrumentation, laminectomy, screw, spine, Neurology A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom. Hepatic Encephalopathy REASON FOR ADMISSION: , Hepatic encephalopathy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Native American male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom. He said that he was doing fine prior to that and denied having any complaints. He was sitting watching TV and he felt sleepy. So, he went to the bathroom to urinate before going to bed and while he was trying to lift the seat, he tripped and fell and hit his head on the back. His head hit the toilet seat. Then, he started having bleeding and had pain in the area with headache. He did not lose consciousness as far as he can tell. He went and woke up his sister. This happened somewhere between 10:30 and 11 p.m. His sister brought a towel and covered the laceration on the back of his head and called EMS, who came to his house and brought him to the emergency room, where he was found to have a laceration on the back of his head, which was stapled and a CT of the head was obtained and ruled out any acute intracranial pathology. On his lab work, his ammonia was found to be markedly elevated at 106. So, he is being admitted for management of this. He denied having any abdominal pain, change in bowel habits, GI bleed, hematemesis, melena, or hematochezia. He said he has been taking his medicines, but he could not recall those. He denied having any symptoms prior to this fall. He said earlier today he also fell. He also said that this was an accidental fall caused by problem with his walker. He landed on his back at that time, but did not have any back pain afterwards.,PAST MEDICAL HISTORY:,1. Liver cirrhosis caused by alcohol. This is per the patient.,2. He thinks he is diabetic.,3. History of intracranial hemorrhage. He said it was subdural hematoma. This was traumatic and happened seven years ago leaving him with the right-sided hemiparesis.,4. He said he had a seizure back then, but he does not have seizures now.,PAST SURGICAL HISTORY:,1. He has a surgery on his stomach as a child. He does not know the type.,2. Surgery for a leg fracture.,3. Craniotomy seven years ago for an intracranial hemorrhage/subdural hematoma.,MEDICATIONS: , He does not remember his medications except for the lactulose and multivitamins.,ALLERGIES: , Dilantin.,SOCIAL HISTORY: , He lives in Sacaton with his sister. He is separated from his wife who lives in Coolidge. He smokes one or two cigarettes a day. Denies drug abuse. He used to be a heavy drinker, quit alcohol one year ago and does not work currently.,FAMILY HISTORY:, Negative for any liver disease.,REVIEW OF SYSTEMS:,GENERAL: Denies fever or chills. He said he was in Gilbert about couple of weeks ago for fever and was admitted there for two days. He does not know the details.,ENT: No visual changes. No runny nose. No sore throat.,CARDIOVASCULAR: No syncope, chest pain, or palpitations.,RESPIRATORY: No cough or hemoptysis. No dyspnea.,GI: No abdominal pain. No nausea or vomiting. No GI bleed. History of alcoholic liver disease.,GU: No dysuria, hematuria, frequency, or urgency.,MUSCULOSKELETAL: Denies any acute joint pain or swelling.,SKIN: No new skin rashes or itching.,CNS: Had a seizure many years ago with no recurrences. Left-sided hemiparesis after subdural hematoma from a fight/trauma.,ENDOCRINE: He thinks he has diabetes but does not know if he is on any diabetic treatment.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 97.7, heart rate 83, respiratory rate 18, blood pressure 125/72, and saturation 98% on room air.,GENERAL: The patient is lying in bed, appears comfortable, very pleasant Native American male in no apparent distress.,HEENT: His skull has a scar on the left side from previous surgery. On the back of his head, there is a laceration, which has two staples on. It is still oozing minimally. It is tender. No other traumatic injury is noted. Eyes, pupils react to light. Sclerae anicteric. Nostrils are normal. Oral cavity is clear with no thrush or exudate.,NECK: Supple. Trachea midline. No JVD. No thyromegaly.,LYMPHATICS: No cervical or supraclavicular lymphadenopathy.,LUNGS: Clear to auscultation bilaterally.,HEART: Normal S1 and S2. No murmurs or gallops. Regular rate and rhythm.,ABDOMEN: Soft, distended, nontender. No organomegaly or masses.,LOWER EXTREMITIES: +1 edema bilaterally. Pulses strong bilaterally. No skin ulcerations noted. No erythema.,SKIN: Several spider angiomas noted on his torso and upper extremities consistent with liver cirrhosis.,BACK: No tenderness by exam.,RECTAL: No masses. No abscess. No rectal fissures. Guaiac was performed by me and it was negative.,NEUROLOGIC: He is alert and oriented x2. He is slow to some extent in his response. No asterixis. Right-sided spastic hemiparesis with increased tone, increased reflexes, and weakness. Increased tone noted in upper and lower extremities on the right compared to the left. Deep tendon reflexes are +3 on the right and +2 on the left. Muscle strength is decreased on the right, more pronounced in the lower extremity compared to the upper extremity. The upper extremity is +4/5. Lower extremity is 3/5. The left side has a normal strength. Sensation appears to be intact. Babinski is upward on the right, equivocal on the left.,PSYCHIATRIC: Flat affect. Mood appeared to be appropriate. No active hallucinations or psychotic symptoms.,LABORATORY DATA: Neurology Intractable epilepsy, here for video EEG. Intractable Epilepsy CHIEF COMPLAINT:, Intractable epilepsy, here for video EEG.,HISTORY OF PRESENT ILLNESS: , The patient is a 9-year-old male who has history of global developmental delay and infantile spasms. Ultimately, imaging study shows an MRI with absent genu of the corpus callosum and thinning of the splenium of the corpus callosum, showing a pattern of cerebral dysgenesis. He has had severe global developmental delay, and is nonverbal. He can follow objects with his eyes, but has no ability to interact with his environment to any great degree. He has noted if any purposeful use of the hands. He has abnormal movements constantly, which are more choreiform and dystonic. He has spastic quadriparesis, which is variable at times. The patient is unable to sit or stand, and receives all his nutrition via G-tube.,The patient began having seizures in infancy presenting as infantile spasms. I began seeing him at 20 months of age. At that point, he had undergone workup in Seattle, Washington and then was seeing Dr. X, child neurologist in Mexico, who started Vigabatrin for infantile spasms. The patient had benefit from this medication, and was doing well at that time with regard to that seizure type. He initially was on phenobarbital, which failed to give him benefit. He continued on phenobarbital; however, for a long period time thereafter. The patient then began having more tonic seizures after his episodic spasms had subsided, and failed several medication trials including valproic acid, Topamax, and Zonegran at least briefly. Upon starting Lamictal, he began to have benefit and then actually had 1-year seizure freedom before having an isolated seizure or 2. Over the next 6 months to a year, he only had few further seizures, and was doing well in a general sense. It was more recently that he began having new seizure events that have not responded to higher doses of Lamictal up to 15 mg/kg/day. These events manifest as tonic spells with eye deviation and posturing. Mother reports flexion of the upper extremities, extension with lower extremities. During that time, he is not able to cry or say any sounds. These events last from seconds to minutes, and occur at least multiple times per week. There are times where he has none for a few days and other times where he has multiple days in a row with events. He has another event manifesting as flexion of the upper extremities and extension lower extremities where he turns red and cries throughout. He may vomit after these episodes, then seems to calm down. It is unclear whether this is a seizure or whether the patient is still responsive.,MEDICATIONS:, The patient's medications include Lamictal for a total of 200 mg twice a day. It is a 150 mg tablet and 25 mg tablets. He is on Zonegran using 25 mg capsules 2 capsules twice daily, and baclofen 10 mg three times day. He has other medications including the Xopenex and Atrovent.,REVIEW OF SYSTEMS: , At this time is negative any fevers, nausea, vomiting, diarrhea, abdominal complaints, rashes, arthritis, or arthralgias. No respiratory or cardiovascular complaints. He has no change in his skills at this point.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL: The patient is a slender male who is microcephalic. He has EEG electrodes in place and is on the video EEG at that time.,HEENT: His oropharynx shows no lesions.,NECK: Supple without adenopathy.,CHEST: Clear to auscultation.,CARDIOVASCULAR: Regular rate and rhythm. No murmurs.,ABDOMEN: Benign with G-tube in place.,EXTREMITIES: Reveal no clubbing, cyanosis, or edema.,NEUROLOGICAL: The patient is alert and has bilateral esotropia. He is able to fix and follow objects briefly. He is unable to reach for objects. He exhibits constant choreiform movements when excited. These are more prominent in the upper extremities and lower extremities. He has some dystonic posture with flexion of the wrist and fingers bilaterally. He also has plantar flexion at the ankles bilaterally. His cranial nerves reveal that his pupils are equal, round, and reactive to light. Extraocular movements are intact other than bilateral esotropia. His face moves symmetrically. Palate elevates in midline. Hearing appears intact bilaterally.,Motor exam reveals dystonic and variable tone, overall there is mild in spasticity both upper and lower extremities as described above. He has clonus at the ankles bilaterally, and some valgus contracture of the ankles. His sensation is intact to light touch bilaterally. Deep tendon reflexes are 2 to 3+ bilaterally.,IMPRESSION/PLAN: , This is a 9-year-old male with congenital brain malformation and intractable epilepsy. He has microcephaly as well as dystonic cerebral palsy. He had a re-emergence of seizures, which are difficult to classify, although some sound like tonic episodes and others are more concerning for non-epileptic phenomenon, such as discomfort. He is admitted for video EEG to hopefully capture both of these episodes and further clarify the seizure type or types. He will remain hospitalized for probably at least 48 hours to 72 hours. He could be discharged sooner if multiple events are captured. His medications, we will continue his current dose of Zonegran and Lamictal for now. Both of these medications are very long acting, discontinuing them while in the hospital may simply result in severe seizures after discharge. neurology, brain malformation, congenital, intractable epilepsy, global developmental delay, video eeg, seizures, intractable, eeg, Neurology Caudate Nuclei atrophy, bilaterally, in patient with Huntington Disease. Huntington's Disease "CC:, Slowing of motor skills and cognitive function.,HX: ,This 42 y/o LHM presented on 3/16/93 with gradually progressive deterioration of motor and cognitive skills over 3 years. He had difficulty holding a job. His most recent employment ended 3 years ago as he was unable to learn the correct protocols for the maintenance of a large conveyer belt. Prior to that, he was unable to hold a job in the mortgage department of a bank as could not draw and figure property assessments. For 6 months prior to presentation, he and his wife noted (his) increasingly slurred speech and slowed motor skills (i.e. dressing himself and house chores). His walk became slower and he had difficulty with balance. He became anhedonic and disinterested in social activities, and had difficulty sleeping for frequent waking and restlessness. His wife noticed ""fidgety movements"" of his hand and feet.,He was placed on trials of Sertraline and Fluoxetine for depression 6 months prior to presentation by his local physician. These interventions did not appear to improve his mood and affect.,MEDS:, Fluoxetine.,PMH: ,1)Right knee arthroscopic surgery 3 yrs ago. 2)Vasectomy.,FHX:, Mother died age 60 of complications of Huntington Disease (dx at UIHC). MGM and two MA's also died of Huntington Disease. His 38 y/o sister has attempted suicide twice.,He and his wife have 2 adopted children.,SHX: ,unemployed. 2 years of college education. Married 22 years.,ROS: ,No history of Dopaminergic or Antipsychotic medication use.,EXAM:, Vital signs normal.,MS: A&O to person, place, and time. Dysarthric speech with poor respiratory control.,CN: Occasional hypometric saccades in both horizontal directions. No vertical gaze abnormalities noted. Infrequent spontaneous forehead wrinkling and mouth movements. The rest of the CN exam was unremarkable.,Motor: Full strength throughout and normal muscle tone and bulk. Mild choreiform movements were noted in the hands and feet.,Sensory: unremarkable.,Coord: unremarkable.,Station/Gait: unremarkable, except that during tandem walking mild dystonic and choreiform movements of BUE became more apparent.,Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally.,There was no motor impersistence on tongue protrusion or hand grip.,COURSE:, He was thought to have early manifestations of Huntington Disease. A HCT was unremarkable. Elavil 25mg qhs was prescribed. Neuropsychologic assessment revealed mild anterograde memory loss only.,His chorea gradually worsened during the following 4 years. He developed motor impersistence and more prominent slowed saccadic eye movements. His mood/affect became more labile.,6/5/96 genetic testing revealed a 45 CAg trinucleotide repeat band consistent with Huntington Disease. MRI brain, 8/23/96, showed caudate nuclei atrophy, bilaterally." Neurology This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months. Huntington's Disease - Consult "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." Neurology The patient with continued problems with her headaches. Headache - Office Visit She also had EMG/nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy, moderate right ulnar neuropathy, bilateral mild-to-moderate carpal tunnel and diabetic neuropathy. She was referred to Dr. XYZ and will be seeing him on August 8, 2006.,She was also never referred to the endocrine clinic to deal with her poor diabetes control. Her last hemoglobin A1c was 10.,PAST MEDICAL HISTORY:, Diabetes, hypertension, elevated lipids, status post CVA, and diabetic retinopathy.,MEDICATIONS: , Glyburide, Avandia, metformin, lisinopril, Lipitor, aspirin, metoprolol and Zonegran.,PHYSICAL EXAMINATION:, Blood pressure was 140/70, heart rate was 76, respiratory rate was 18, and weight was 226 pounds. On general exam she has an area of tenderness on palpation in the left parietal region of her scalp. Neurological exam is detailed on our H&P form. Her neurological exam is within normal limits.,IMPRESSION AND PLAN:, For her headaches we are going to titrate Zonegran up to 200 mg q.h.s. to try to maximize the Zonegran therapy. If this is not effective, when she comes back on August 7, 2006 we will then consider other anticonvulsants such as Neurontin or Lyrica. We also discussed with Ms. Hawkins the possibility of nerve block injection; however, at this point she is not interested.,She will be seeing Dr. XYZ for her neuropathies.,We made an appointment in endocrine clinic today for a counseling in terms of better diabetes control and she is responsible for trying to get her referral from her primary care physician to go for this consult. neurology, nerve conduction studies, emg, zonegran therapy, ulnar neuropathy, endocrine clinic, diabetes control, neurological exam, headache, zonegran Neurology Closed head injury with evidence of axonal injury vs. vascular injury to the left substantia nigra, right subdural hematoma and possible subarachnoid hemorrhage, vascular/ischemic injury in the right occipital lobe-right basal ganglia/caudate nucleus-right frontal lobe, and right temporal lobe contusion. Head Trauma "CC: ,Depressed mental status.,HX: ,29y/o female fell down a flight of stairs on 2/20/95, striking the right side of her head. She then walked over to and lay down on a living room couch. She was found there, the next morning, by her boyfriend, poorly responsive and amidst a coffee ground like emesis. She was taken to a local ER and HCT revealed a right supraorbital fracture, right SDH and left SAH. Spine X-rays revealed a T12 vertebral body fracture. There were retinal hemorrhages, OU. She continued to be minimally responsive and was transferred to UIHC for lack of insurance and for neurologic/neurosurgical care.,MEDS:, (on transfer): Dilantin, Zantac, Proventil MDI, Tylenol.,PMH:, 1)pyelonephritis, 2) multiple STD's, 3) Polysubstance Abuse (ETOH, MJ, Amphetamine), 4)G5P4.,FHX:, unknown.,SHX: ,polysubstance abuse. smoked 1 pack per day for 15years.,EXAM: ,BP127/97, HR83, RR25, 37.2C,MS: Minimal to no spontaneous speech. Unresponsive to verbal commands. Lethargic and somnolent. Groaned ""yes"" inappropriately.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light. VFFTT. Retinal hemorrhages, OU. EOM difficult to assess. Facial movement appeared symmetric. Tongue midline. Corneal and gag responses were intact.,MOTOR: no spontaneous movement. withdrew extremities to noxious stimulation (e.g. deep nail bed pressure).,Sensory: withdrew to noxious stimuli.,Coord/Station/Gait: not tested.,Reflexes: 2+/2+ BUE. 2/2 BLE. Babinski signs were present, bilaterally.,HEENT: Periorbital and upper lid ecchymoses about the right eye. Scleral hemorrhage, OD.,GEN EXAM: mild bruising of the extremities.,COURSE: ,2/27/95 HCT revealed a small liner high attenuation area lateral to the right parietal lobe with subtle increased attenuation of the tentorium cerebelli. These findings were felt to represent a right subdural hematoma and possible subarachnoid hemorrhage.,2/28/95 brain MRI revealed: 1)a small right-sided SDH, 2) Abnormal signal in the right occipital lobe with effacement of the gyri and sulci in the right PCA division most likely representing ischemic/vascular injury, 3)abnormal signal within the right basal ganglia/caudate nucleus consistent with ischemia, 4) abnormal signal in the uncal portion of the right frontal lobe consistent with contusion, 5) small parenchymal hemorrhage in the inferior anterior right temporal lobe, and 6) opacification of the right maxillary sinus.,EEG, 2/28/95, was abnormal with occasional sharp transients in the left temporal region, and irregular (more or less continuous) right greater than left delta slow waves and decreased background activity in the right hemisphere: the findings were consistent with focal pathology on the right, seizure tendency in the left temporal region, and bilateral cerebral dysfunction. By the time of discharge, 4/17/95, she was verbalizing one or two words and required assistance with feeding and ambulation. She could not function independently." neurology, closed head injury, axonal injury, vascular injury, substantia nigra, subdural hematoma, subarachnoid hemorrhage, vascular, ischemic, injury, occipital lobe, retinal hemorrhages, temporal region, axonal, hemorrhages, hemorrhage, Neurology Headache. Right frontal lobe glioma. Glioma - 2 "CC:, Headache,HX: ,37 y/o RHF presented to her local physician with a one month history of intermittent predominantly left occipital headaches which were awakening her in the early morning hours. The headachese were dull to throbbing in character. She was initially treated with Parafon-forte for tension type headaches, but the pain did not resolve. She subsequently underwent HCT in early 12/90 which revealed a right frontal mass lesion.,PMH: ,1)s/p tonsillectomy. 2)s/p elective abortion.,FHX:, Mother with breast CA, MA with ""bone cancer."" AODM both sides of family.,SHX: ,Denied tobacco or illicit drug use. Rarely consumes ETOH. Married with 2 teenage children.,EXAM: ,VItal signs unremarkable.,MS: Alert and oriented to person, place, time. Lucid thought process per NSG note.,CN: unremarkable.,Motor: full strength with normal muscle bulk and tone.,Sensory: unremarkable.,Coordination: unremarkable.,Station/Gait: unremarkable.,Reflexes: unremarkable.,Gen. Exam: unremarkable.,COURSE:, MRI Brain: large solid and cystic right frontal lobe mass with a large amount of surrounding edema. There is apparent tumor extension into the corpus callosum across the midline. Tumor extension is also suggested in the anterior limb of the interanl capsule on the right. There is midline mass shift to the left with effacement of the anterior horn of the right lateral ventricle. The MRI findings are most consistent with glioblastoma.,The patient underwent right frontal lobectomy. The pathological diagnosis was xanthomatous astrocytoma. The literature at the time was not clear as to optimal treatment protocol. People have survived as long as 25 years after diagnosis with this type of tumor. XRT was deferred until 11/91 when an MRI and PET Scan suggested extension of the tumor. She then received 5580 cGy of XRT in divided segments. She developed olfactory auras shortly after lobectomy at was treated with PB with subsequent improvement. She was treated with BCNU chemotherapy protocol in 1992." neurology, frontal lobe, tumor extension, glioma, headache, lobectomy, astrocytoma, Neurology Sellar HCT - Pituitary mass HCT - Pituitary Mass CC:, HA and vision loss.,HX: ,71 y/o RHM developed a cataclysmic headache on 11/5/92 associated with a violent sneeze. The headache lasted 3-4 days. On 11/7/92, he had acute pain and loss of vision in the left eye. Over the following day his left pupil enlarged and his left upper eyelid began to droop. He was seen locally and a brain CT showed no sign of bleeding, but a tortuous left middle cerebral artery was visualized. The patient was transferred to UIHC 11/12/92.,FHX:, HTN, stroke, coronary artery disease, melanoma.,SHX:, Quit smoking 15 years ago.,MEDS:, Lanoxin, Capoten, Lasix, KCL, ASA, Voltaren, Alupent MDI,PMH: ,CHF, Atrial Fibrillation, Obesity, Anemia, Duodenal Ulcer, Spinal AVM resection 1986 with residual T9 sensory level, hyperreflexia and bilateral babinski signs, COPD.,EXAM: ,35.5C, BP 140/91, P86, RR20. Alert and oriented to person, place, and time. CN: No light perception OS, Pupils: 3/7 decreasing to 2/7 on exposure to light (i.e., fixed/dilated pupil OS). Upon neutral gaze the left eye deviated laterally and inferiorly. There was complete ptosis OS. On downward gaze their was intorsion OS. The left eye could not move superiorly, medially or effectively downward, but could move laterally. EOM were full OD. The rest of the CN exam was unremarkable. Motor, Coordination, Station and Gait testing were unremarkable. Sensory exam revealed decreased pinprick and light touch below T9 (old). Muscle stretch reflexes were increased (3+/3+) in both lower extremities and there were bilateral babinski signs (old). The upper extremity reflexes were symmetrical (2/2). Cardiovascular exam revealed an irregularly irregular rhythm and lung sounds were coarse bilaterally. The rest of the general exam was unremarkable.,LAB:, CBC, PT/PTT, General Screen were unremarkable except for a BUN 21mg/DL. CSF: protein 88mg/DL, glucose 58mg/DL, RBC 2800/mm3, WBC 1/mm3. ANA, RF, TSH, FT4 were WNL.,IMPRESSION:, CN3 palsy and loss of vision. Differential diagnosis: temporal arteritis, aneurysm, intracranial mass.,COURSE:, The outside Brain CT revealed a tortuous left MCA. A four-vessel cerebral angiogram revealed a dolichoectatic basilar artery and tortuous LICA. There was no evidence of aneursym. Transesophageal Echocardiogram revealed atrial enlargement only. Neuroopthalmologic evaluation revealed: Loss of color vision and visual acuity OS, RAPD OS, bilateral optic disk pallor (OS > OD), CN3 palsy and bilateral temporal field loss, OS >> OD . ESR, CRP, MRI were recommended to rule out temporal arteritis and intracranial mass. ESR 29mm/Hr, CRP 4.3mg/DL (high) , The patient was placed on prednisone. Temporal artery biopsy showed no evidence of vasculitis. MRI scan could not be obtained due to patient weight. Sellar CT was done instead: coronal sections revealed sellar enlargement and upward bowing of the diaphragm sella suggesting a pituitary mass. In retrospect sellar enlargement could be seen on the angiogram X-rays. Differential consideration was given to cystic pituitary adenoma, noncalcified craniopharyngioma, or Rathke's cleft cyst with solid component. The patient refused surgery. He was seen in Neuroopthalmology Clinic 2/18/93 and was found to have mild recovery of vision OS and improved visual fields. Aberrant reinnervation of the 3rd nerve was noted as there was constriction of the pupil (OS) on adduction, downgaze and upgaze. The upper eyelid, OS, elevated on adduction and down gaze, OS. EOM movements were otherwise full and there was no evidence of ptosis. In retrospect he was felt to have suffered pituitary apoplexy in 11/92. neurology, sellar, hct, htn, pituitary, aneurysm, brain ct, cataclysmic, coronary artery disease, headache, intracranial mass, loss of vision, mass, melanoma, palsy, sneeze, stroke, temporal arteritis, vision loss, bilateral babinski signs, sellar enlargement, pituitary mass, temporal, vision, Neurology HCT for memory loss and for calcification of basal ganglia (globus pallidi). HCT - Calcification of Basal Ganglia 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. neurology, memory loss, romberg sign, hct, cerebral atrophy, calcification of basal ganglia, basal ganglia, globus pallidi, basal, ganglia, globus, pallidi, calcification, Neurology Headache and diplopia. Granulomatous Inflammation "CC:, Headache and diplopia.,HX:, This 39 y/o African American female began experiencing severe constant pressure pain type headaches beginning the last week of 8/95. The pain localized to bifronto-temporal regions of the head and did not radiate. There was no associated nausea, vomiting, photophobia or phonophobia. The HA's occurred daily; and throughout daylight hours. They diminished at bedtime, but occasionally awakened her in the morning.,Several days following the onset of her HA's, she began experiencing numbness and tingling about the right side of her face. These symptoms improved, but did not completely resolved.,Several days after the onset of facial paresthesias, she began to experience binocular horizontal diplopia. The diplopia resolved when covering either eye, and worsened upon looking toward the right. Coincidentally, she began veering toward the right when walking. She denied any weakness. She had had chronic unsteadiness for many years since developing juvenile rheumatoid arthritis. She was unsure whether her unsteadiness was due to poor depth perception in light of her diplopia.,The patient was admitted locally 9/2/95. HCT, 9/2/95 and Brain MRI with gadolinium, 9/3/95, were ""unremarkable."" Lumbar puncture (done locally),9/3/95: Opening pressure 27cm H20, CSF analysis ( protein 14.0, glucose 66, O WBC, 3 RBC, VDRL non-reactive, Lyme titer unremarkable, Myelin basic protein 1.0 (normal <4.0), and there was no evidence of oligoclonal bands. ESR=76. On 9/11/95 ESR=110. Acetylcholine receptor binding and blocking antibodies were negative. 9/4/95, ANA and RF were negative. 7/94, ANA and RF were negative, and ESR=60.,MEDS: ,Tylenol 500mg q5-6hrs. No known Allergies.,PMH:, 1)Juvenile Rheumatoid Arthritis diagnosed at age 10 years; now in remission. 2)Right #5 finger reattachment as child due to traumatic amputation.,FHX: ,Mother died age 42 of unknown type cancer. Father died age 62 of unknown type cancer. 4 sisters, one brother and 2 half-brothers. One of the half-brothers has asthma.,SHX: ,Single, lives with sister, and denies Tobacco/ETOH/illicit drug use.,EXAM:, BP141/84, HR99, RR14, 36.8C, Wt. 82kg Ht. 152.,MS: A&O to person, place, time. Speech fluent; without dysarthria. Mood euthymic with appropriate affect.,CN: Decreased abduction, OD. In neutral gaze, the right eye deviated slightly lateral of midline. In addition, she had mild proptosis, OD. The right eye was nontender to palpation during extraocular movement. Visual fields were full to confrontation. Optic disks appeared flat. Face was symmetric with full movement and sensation. Gag, shoulder shrug and corneal responses were intact, bilaterally. Tongue was midline with full ROM.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,SENSORY: Unremarkable.,COORD: Unremarkable FNF/HKS/RAM.,STATION: Unremarkable. NO Romberg's sign or drift.,GAIT: Narrow based gait. Able to TT and HW without difficulty. Mild difficulty with TW.,REFLEXES: 2+/2+ Throughout all 4 extremities. Flexor plantar responses, bilaterally.,Musculoskeletal: Swan neck deformities of the #2 and #3 digits of both hands.,GEN EXAM: unremarkable, except for obvious sign of right finger reattachment (mentioned above).,COURSE: ,Repeat lumbar puncture yielded: Opening pressure 20.25cm H20, protein 22, glucose 62, 2RBC, 1WBC. CSF cytology, ACE, cultures (bacterial, fungal, AFB), gram stain, cryptococcal antigen, and VDRL were negative. Serum ACE, TSH, FT4 were unremarkable.,Neuroophthalmology confirmed her right CN6 palsy and proptosis (OD); and noted her complaint of paresthesias in the V1 and V2 distribution. They saw no evidence of papilledema. Visual field testing was unremarkable. MRI Brain/orbit/neck with gadolinium, 10/20/95, revealed abnormal enhancing signal in the right cavernous sinus and sinus mucosal thickening in both maxillary sinuses/ethmoid sinuses/frontal sinuses. CXR, 10/20/95, showed a lobulated mass arising from the right hilum. The mass appeared to obstruct the right middle lobe, causing partial collapse of this lobe. Chest CT with contrast, 10/23/95, revealed a 3.2x4.5x4.0cm mass in the right hilar region with impingement on the right lower bronchus. There appeared to be calcification as well as low attenuation regions within the mass. No lymphadenopathy was noted. She underwent bronchoscopy with bronchial brushing and transbronchial aspirate of the right lung on 10/24/95: no tumor cells were identified, GMS stains were negative and there was no evidence of viral changes, fungus or PCP by culture or molecular assay. She underwent right maxillary sinus biopsy and right middle lobe wedge resection and lymph node biopsy on 11/2/95: Caseating granulomatous inflammation with associated inflammatory pseudotumor was found in both sinus and lung biopsy specimens. No sign of cancer was found. Tissue cultures (bacterial, fungal, AFB) were negative times 3. The patients case was discussed at Head and Neck Oncology Tumor Board and a differential diagnosis of Sarcoidosis, Histoplasmosis, Wegener's Granulomatosis, were considered. Urine Histoplasmosis Antigen testing on 11/8/95 was 0.9units (normal<1.0): repeat testing on 12/13/95 was 0.8units. ANCA serum titers on 11/8/95 were <1:40 (normal). PPD testing was negative 11/95 (with positive candida and mumps controls).,The etiology of this patient's illness was not discovered. She was last seen 4/96 and her diplopia and right CN6 palsy had moderately improved." Neurology Dysarthria. Probable brainstem glioma. Glioma - 1 "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." Neurology This is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like Guillain-Barre syndrome, likely the Miller-Fisher variant. Guillain-Barre Syndrome CHIEF COMPLAINT: , Followup of hospital discharge for Guillain-Barre syndrome.,HISTORY OF PRESENT ILLNESS: , This is a 62-year-old right-handed woman with hypertension, diabetes mellitus, a silent stroke involving right basal ganglia who was in her usual state of baseline health until late June of 2006 when she had onset of blurred vision, diplopia, and possible weakness in the right greater than left arm and left-sided ptosis. She was admitted to the hospital. The MRI showed only an old right basal ganglion infarct. She subsequently had a lumbar puncture, which showed increased protein, and an EMG/nerve conduction study performed by Dr. X on July 3rd, showed early signs of AIDP. The patient was treated with intravenous gamma globulin and had some mild improvement in her symptoms. Her vital capacities were normal during the hospitalization. Her chest x-ray was negative for any acute process. She was discharged to rehab from July 12, 2006 to July 20, 2006. She made some progress in which she notes that her walking is definitely better. However, she notes that she still has some problems with eye movement and her vision. This is possibly her main problem. She also reports tightness and pain in her mid back.,REVIEW OF SYSTEMS:, Documented in the clinic note. The patient has problems with diabetes, double vision, blurry vision, muscle pain, weakness, trouble walking, and headaches about two to three times per week.,PAST MEDICAL HISTORY:,1. Hypertension.,2. Diabetes mellitus.,3. Stroke involving the right basal ganglion.,4. Guillain-Barre syndrome diagnosed in June of 2006.,5. Bilateral knee replacements.,6. Total abdominal hysterectomy and cholecystectomy.,FAMILY HISTORY:, Multiple family members have diabetes mellitus.,SOCIAL HISTORY:, The patient is retired on disability due to her knee replacements. She does not smoke, drink or use any illicit drugs.,MEDICATIONS:, Percocet 5/325 mg 4-6 hours p.r.n., Neurontin 100 mg per day, insulin, Protonix 40 mg per day, Toprol-XL 50 mg q.d., Norvasc 10 mg q.d., glipizide ,10 mg q.d., fluticasone 50 mcg nasal spray, Lasix 20 mg b.i.d., and Zocor 1 mg q.d.,ALLERGIES: , No known drug allergies.,PHYSICAL EXAMINATION: , Blood pressure 122/74, heart rate 68, respiratory rate 16, and weight 228 pounds. Pain scale 5/10. Please see the written note for details. General exam is benign other than mild obesity. On neuro examination, mental status is normal. Cranial nerves are significant for full visual fields and pupils are equal and reactive. However, extraocular movements are very limited. She has some adduction of the left eye and she has minimal upgaze of both eyes, but otherwise the eyes do not move. Face is symmetric. Sensation is intact. Tongue and uvula are in midline. Palate is elevated symmetrically. Shoulder shrug is strong. The patient's muscle exam shows normal bulk and tone throughout. She has no weakness of the left upper extremity. In the right upper extremity, she has only about 2/5 strength in the right shoulder, but is otherwise 5/5. There is no drift or orbit. Reflexes are absent throughout. Sensory exam is intact to light touch, pinprick, vibration, and proprioception is normal. There is no dysmetria. Gait is somewhat limited possibly by her vision and possibly also by her balance problems.,PERTINENT DATA:, As reviewed previously.,DISCUSSION: , This is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like Guillain-Barre syndrome, likely the Miller-Fisher variant. The patient has shown some improvement with IVIG and continues to show some gradual improvement. I discussed with the patient the course of disease, which is often weeks to about a month or so of worsening followed by many months of gradual improvement.,I told her that it is possible she may not recover 100%, but that certainly there is still plenty of time for her to have additional recovery over what she has right now. She is scheduled to see an ophthalmologist. I think it is reasonable for close followup of her visual symptoms progress. However, I certainly would not take any corrective measures at this point as I suspect her vision will improve gradually.,I discussed with the patient that with respect to her back pain certainly the Neurontin is relatively at low dose and this could be increased further. I wanted her to start taking the Neurontin 300 mg per day and then 300 mg b.i.d. after one week. She will call me in approximately three weeks' time to let me know how she is doing and if needed we will titrate up further.,She was apparently given some baclofen by her internist and I think this is not unreasonable. I definitely hope to get her off the Percocet in the future.,IMPRESSION:,1. Guillain-Barre Miller-Fisher variant.,2. Hypertension.,3. Diabetes mellitus.,4. Stroke.,RECOMMENDATIONS:,1. The patient is to start taking aspirin 162 mg per day.,2. Followup with ophthalmology.,3. Increase Neurontin to 300 mg per day x 1 week and then 300 mg b.i.d.,4. Followup by phone in three to four weeks.,5. Followup in this clinic in approximately two months' time.,6. Call for any questions or problems. Neurology CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking. Frameless Stereotactic Radiosurgery PREOPERATIVE DIAGNOSIS:, Right occipital arteriovenous malformation.,POSTOPERATIVE DIAGNOSIS:, Right occipital arteriovenous malformation.,PROCEDURE PERFORMED:, CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,Please note no qualified resident was available to assist in the procedure.,INDICATION: , The patient is a 30-year-old male with a right occipital AVM. He was referred for stereotactic radiosurgery. The risks of the radiosurgical treatment were discussed with the patient including, but not limited to, failure to completely obliterate the AVM, need for additional therapy, radiation injury, radiation necrosis, headaches, seizures, visual loss, or other neurologic deficits. The patient understands these risks and would like to proceed.,PROCEDURE IN DETAIL: , The patient arrived to Outpatient CyberKnife Suite one day prior to the treatment. He was placed on the treatment table. The Aquaplast mask was constructed. Initial imaging was obtained by the CyberKnife system. The patient was then transported over to the CT scanner at Stanford. Under the supervision of Dr. X, 125 mL of Omnipaque 250 contrast was administered. Dr. X then supervised the acquisition of 1.2-mm contiguous axial CT slices. These images were uploaded over the hospital network to the treatment planning computer, and the patient was discharged home.,Treatment plan was then performed by me. I outlined the tumor volume. Inverse treatment planning was used to generate the treatment plan for this patient. This resulted in a total dose of 20 Gy delivered to 84% isodose line using a 12.5 mm collimator. The maximum dose within this center of treatment volume was 23.81 Gy. The volume treated was 2.972 mL, and the treated lesion dimensions were 1.9 x 2.7 x 1.6 cm. The volume treated at the reference dose was 98%. The coverage isodose line was 79%. The conformality index was 1.74 and modified conformality index was 1.55. The treatment plan was reviewed by me and Dr. Y of Radiation Oncology, and the treatment plan was approved.,On the morning of May 14, 2004, the patient arrived at the Outpatient CyberKnife Suite. He was placed on the treatment table. The Aquaplast mask was applied. Initial imaging was used to bring the patient into optimal position. The patient underwent stereotactic radiosurgery to deliver the 20 Gy to the AVM margin. He tolerated the procedure well. He was given 8 mg of Decadron for prophylaxis and discharged home.,Followup will consist of an MRI scan in 6 months. The patient will return to our clinic once that study is completed.,I was present and participated in the entire procedure on this patient consisting of CT-guided frameless stereotactic radiosurgery for the right occipital AVM.,Dr. X was present during the entire procedure and will be dictating his own operative note. neurology, ct-guided, occipital, cyberknife, frameless stereotactic radiosurgery, occipital arteriovenous malformation, conformality index, arteriovenous malformation, malformation, avm, arteriovenous, Neurology Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion. Biopsy of dura. Hematoma Evacuation PREOPERATIVE DIAGNOSIS: , Right temporal lobe intracerebral hemorrhage.,POSTOPERATIVE DIAGNOSES:,1. Right temporal lobe intracerebral hemorrhage.,2. Possible tumor versus inflammatory/infectious lesion versus vascular lesion, pending final pathology and microbiology.,PROCEDURES:,1. Emergency right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.,2. Biopsy of dura.,3. Microscopic dissection using intraoperative microscope.,SPECIMENS: , Temporal lobe lesion and dura as well as specimen for microbiology for culture.,DRAINS:, Medium Hemovac drain.,FINDINGS: , Vascular hemorrhagic lesion including inflamed dura and edematous brain with significant mass effect, and intracerebral hematoma with a history of significant headache, probable seizures, nausea, and vomiting.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Per Anesthesia.,FLUIDS: , One unit of packed red blood cells given intraoperatively.,The patient was brought to the operating room emergently. This is considered as a life threatening admission with a hemorrhage in the temporal lobe extending into the frontal lobe and with significant mass effect.,The patient apparently became hemiplegic suddenly today. She also had an episode of incoherence and loss of consciousness as well as loss of bowel/urine.,She was brought to Emergency Room where a CT of the brain showed that she had significant hemorrhage of the right temporal lobe extending into the external capsule and across into the frontal lobe. There is significant mass effect. There is mixed density in the parenchyma of the temporal lobe.,She was originally scheduled for elective craniotomy for biopsy of the temporal lobe to find out why she was having spontaneous hemorrhages. However, this event triggered her family to bring her to the emergency room, and this is considered a life threatening admission now with a significant mass effect, and thus we will proceed directly today for evacuation of ICH as well as biopsy of the temporal lobe as well as the dura.,PROCEDURE IN DETAIL: , The patient was anesthetized by the anesthesiology team. Appropriate central line as well as arterial line, Foley catheter, TED, and SCDs were placed. The patient was positioned supine with a three-point Mayfield head pin holder. Her scalp was prepped and draped in a sterile manner. Her former incisional scar was barely and faintly noticed; however, through the same scalp scar, the same incision was made and extended slightly inferiorly. The scalp was resected anteriorly. The subdural scar was noted, and hemostasis was achieved using Bovie cautery. The temporalis muscle was reflected along with the scalp in a subperiosteal manner, and the titanium plating system was then exposed.,The titanium plating system was then removed in its entirety. The bone appeared to be quite fused in multiple points, and there were significant granulation tissue through the burr hole covers.,The granulation tissue was quite hemorrhagic, and hemostasis was achieved using bipolar cautery as well as Bovie cautery.,The bone flap was then removed using Leksell rongeur, and the underlying dura was inspected. It was quite full. The 4-0 sutures from the previous durotomy closure was inspected, and more of the inferior temporal bone was resected using high-speed drill in combination with Leksell rongeur. The sphenoid wing was also resected using a high-speed drill as well as angled rongeur.,Hemostasis was achieved on the fresh bony edges using bone wax. The dura pack-up stitches were noted around the periphery from the previous craniotomy. This was left in place.,The microscope was then brought in to use for the remainder of the procedure until closure. Using a #15 blade, a new durotomy was then made. Then, the durotomy was carried out using Metzenbaum scissors, then reflected the dura anteriorly in a horseshoe manner, placed anteriorly, and this was done under the operating microscope. The underlying brain was quite edematous.,Along the temporal lobe there was a stain of xanthochromia along the surface. Thus a corticectomy was then accomplished using bipolar cautery, and the temporal lobe at this level and the middle temporal gyrus was entered. The parenchyma of the brain did not appear normal. It was quite vascular. Furthermore, there was a hematoma mixed in with the brain itself. Thus a core biopsy was then performed in the temporal tip. The overlying dura was inspected and it was quite thickened, approximately 0.25 cm thick, and it was also highly vascular, and thus a big section of the dura was also trimmed using bipolar cautery followed by scissors, and several pieces of this vascularized dura was resected for pathology. Furthermore, sample of the temporal lobe was cultured.,Hemostasis after evacuation of the intracerebral hematoma using controlled suction as well as significant biopsy of the overlying dura as well as intraparenchymal lesion was accomplished. No attempt was made to enter into the sylvian fissure. Once hemostasis was meticulously achieved, the brain was inspected. It still was quite swollen, known that there was still hematoma in the parenchyma of the brain. However, at this time it was felt that since there is no diagnosis made intraoperatively, we would need to stage this surgery further should it be needed once the diagnosis is confirmed. DuraGen was then used for duraplasty because of the resected dura. The bone flap was then repositioned using Lorenz plating system. Then a medium Hemovac drain was placed in subdural space. Temporalis muscle was approximated using 2-0 Vicryl. The galea was then reapproximated using inverted 2-0 Vicryl. The scalp was then reapproximated using staples. The head was then dressed and wrapped in a sterile fashion.,She was witnessed to be extubated in the operating room postoperatively, and she followed commands briskly. The pupils are 3 mm bilaterally reactive to light. I accompanied her and transported her to the ICU where I signed out to the ICU attending. Neurology Patient presents for further evaluation of feet and hand cramps. 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. Feet & Hand Cramping "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" Neurology 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. Essential Tremor & Torticollis "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." neurology, clonazepam, difficulty writing, head tremor, voice tremor, migraine headaches, mri brain, essential tremor, torticollis, carcinoma, Neurology Fall with questionable associated loss of consciousness. Left parietal epidural hematoma. Epidural Hematoma "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." neurology, loss of consciousness, parietal epidural hematoma, parietal epidural, epidural hematoma, consciousness, epidural, hematoma, Neurology Falls at home. Anxiety and depression. The patient had been increasingly anxious and freely admitted that she was depressed at home. Falls - Discharge Summary "CHIEF COMPLAINT:, Falls at home.,HISTORY OF PRESENT ILLNESS:, The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety. Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home. They noted that she frequently came to the emergency room for ""attention."" The patient denied any chest pain or pressure and no change to exercise tolerance. The patient denied any loss of consciousness or incontinence. She denies any seizure activity. She states that she ""tripped"" at home. Family states she frequently takes Darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating. They stated that she has numerous medications at home, but they were not sure if she was taking them. The patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression. The patient denied SI or HI.,PHYSICAL EXAMINATION:,GENERAL: The patient is pleasant 82-year-old female in no acute distress.,VITAL SIGNS: Stable.,HEENT: Negative.,NECK: Supple. Carotid upstrokes are 2+.,LUNGS: Clear.,HEART: Normal S1 and S2. No gallops. Rate is regular.,ABDOMEN: Soft. Positive bowel sounds. Nontender.,EXTREMITIES: No edema. There is some ecchymosis noted to the left great toe. The area is tender; however, metatarsal is nontender.,NEUROLOGICAL: Grossly nonfocal.,HOSPITAL COURSE: , A psychiatric evaluation was obtained due to the patient's increased depression and anxiety. Continue Paxil and Xanax use was recommended. The patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls.,DISCHARGE DIAGNOSES:,1. Falls ,2. Anxiety and depression.,3. Hypertension.,4. Hypercholesterolemia.,5. Coronary artery disease.,6. Osteoarthritis.,7. Chronic obstructive pulmonary disease.,8. Hypothyroidism.,CONDITION UPON DISCHARGE: , Stable.,DISCHARGE MEDICATIONS: , Tylenol 650 mg q.6h. p.r.n., Xanax 0.5 q.4h. p.r.n., Lasix 80 mg daily, Isordil 10 mg t.i.d., KCl 20 mEq b.i.d., lactulose 10 g daily, Cozaar 50 mg daily, Synthroid 75 mcg daily, Singulair 10 mg daily, Lumigan one drop both eyes at bed time, NitroQuick p.r.n., Pravachol 20 mg daily, Feldene 20 mg daily, Paxil 20 mg daily, Minipress 2 mg daily, Provera p.r.n., Advair 250/50 one puff b.i.d., Senokot one tablet b.i.d., Timoptic one drop OU daily, and verapamil 80 mg b.i.d.,ALLERGIES: , None.,ACTIVITY: , Per PT.,FOLLOW-UP: , The patient discharged to a skilled nursing facility for further rehabilitation." Neurology Evacuation of epidural hematoma and insertion of epidural drain. Epidural hematoma, cervical spine. Status post cervical laminectomy, C3 through C7 postop day #10. Central cord syndrome and acute quadriplegia. Epidural Hematoma Evacuation 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. neurology, epidural hematoma, cervical spine, cervical laminectomy, central cord syndrome, acute quadriplegia, insertion of epidural drain, epidural drain, epidural space, hematoma, epidural, cervical, laminectomy, quadriplegia, Neurology Encephalopathy related to normal-pressure hydrocephalus. Encephalopathy - Rehab Consult ADMITTING DIAGNOSIS: , Encephalopathy related to normal-pressure hydrocephalus.,CHIEF COMPLAINT:, Diminished function secondary to above.,HISTORY: ,This pleasant gentleman was recently admitted to ABCD Medical Center and followed by the neurosurgical staff, including Dr. X, where normal-pressure hydrocephalus was diagnosed. He had a shunt placed and was stabilized medically. He has gotten a return of function to the legs and was started on some early therapy. Significant functional limitations have been identified and ongoing by the rehab admission team. Significant functional limitations have been ongoing. He will need to be near-independent at home for periods of time, and he is brought in now for rehabilitation to further address functional issues, maximize skills and safety and allow a safe disposition home.,PAST MEDICAL HISTORY: , Positive for prostate cancer, intermittent urinary incontinence and left hip replacement.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS,1. Tylenol as needed. ,2. Peri-Colace b.i.d.,SOCIAL HISTORY:, He is a nonsmoker and nondrinker. Prior boxer. He lives in a home where he would need to be independent during the day. Family relatives intermittently available. Goal is to return home to an independent fashion to that home setting.,FUNCTIONAL HISTORY: , Prior to admission was independent with activities of daily living and ambulatory skills. Presently, he has resumed therapies and noted to have supervision levels for most activities of daily living. Memory at minimal assist. Walking at supervision., REVIEW OF SYSTEMS: ,Negative for headaches, nausea, vomiting, fevers, chills, shortness of breath or chest pain currently. He has had some dyscoordination recently and headaches on a daily basis, most days, although the Tylenol does seem to control that pain.,PHYSICAL EXAMINATION,VITAL SIGNS: The patient is afebrile with vital signs stable.,HEENT: Oropharynx clear, extraocular muscles are intact.,CARDIOVASCULAR: Regular rate and rhythm, without murmurs, rubs or gallops.,LUNGS: Clear to auscultation bilaterally.,ABDOMEN: Nontender, nondistended, positive bowel sounds.,EXTREMITIES: Without clubbing, cyanosis, or edema. The calves are soft and nontender bilaterally.,NEUROLOGIC: No focal, motor or sensory losses through the lower extremities. He moves upper and lower extremities well. Bulk and tone normal in the upper and lower extremities. Cognitively showing intact with appropriate receptive and expressive skills.,IMPRESSION , Neurology Patient returns for his first followup after shunt surgery. First Followup - Shunt Surgery "REASON FOR VISIT:, Mr. A is an 86-year-old man who returns for his first followup after shunt surgery.,HISTORY OF PRESENT ILLNESS: ,I have followed Mr. A since May 2008. He presented with eight to ten years of progressive gait impairment, cognitive impairment, and decreased bladder control. We established a diagnosis of adult hydrocephalus with the spinal catheter protocol in June of 2008 and ,Mr. A underwent shunt surgery performed by Dr. X on August 1st. A Medtronic Strata programmable shunt in the ventriculoperitoneal configuration programmed at level 2.0 was placed.,Mr. A comes today with his daughter, Pam and together they give his history.,Mr. A has had no hospitalizations or other illnesses since I last saw him. With respect to his walking, his daughter tells me that he is now able to walk to the dining room just fine, but could not before his surgery. His balance has improved though he still has some walking impairment. With respect to his bladder, initially there was some improvement, but he has leveled off and he wears a diaper.,With respect to his cognition, both Pam and the patient say that his thinking has improved. The other daughter, Patty summarized it best according to two of them. She said, ""I feel like I can have a normal conversation with him again."" Mr. A has had no headaches and no pain at the shunt site or at the abdomen.,MEDICATIONS: , Plavix 75 mg p.o. q.d., metoprolol 25 mg p.o. q.d., Flomax 0.4 mg p.o. q.d., Zocor 20 mg p.o. q.d., Detrol LA 4 mg p.o. q.d., lisinopril 10 mg p.o. q.d., Imodium daily, Omega-3, fish oil, and Lasix.,MAJOR FINDINGS:, Mr. A is a pleasant and cooperative man who is able to converse easily though his daughter adds some details.,Vital Signs: Blood pressure 124/80, heart rate is 64, respiratory rate is 18, weight 174 pounds, and pain is 0/10.,The shunt site was clean, dry, and intact and confirmed at a setting of 2.0.,Mental Status: Tested for recent and remote memory, attention span, concentration, and fund of knowledge. He scored 26/30 on the MMSE when tested with spelling and 25/30 when tested with calculations. Of note, he was able to get two of the three memory words with cuing and the third one with multiple choice. This was a slight improvement over his initial score of 23/30 with calculations and 24/30 with spelling and at that time he was unable to remember any memory words with cuing and only one with multiple choice.,Gait: Tested using the Tinetti assessment tool. He was tested without an assistive device and received a gait score of 6-8/12 and a balance of score of 12/16 for a total score of 18-20/28. This has slightly improved from his initial score of 15-17/28.,Cranial Nerves: Pupils are equal. Extraocular movements are intact. Face symmetric. No dysarthria.,Motor: Normal for bulk and strength.,Coordination: Slow for finger-to-nose.,IMAGING: , CT scan was reviewed from 10/15/2008. It shows a frontal horn span at the level of foramen of Munro of 4.6 cm with a 3rd ventricular contour that is flat with the span of 10 mm. By my reading, there is a tiny amount of blood in the right frontal region with just a tiny subdural collection. This was not noticed by the radiologist who stated no extraaxial fluid collections. There is also substantial small vessel ischemic change.,ASSESSMENT: , Mr. A has made some improvement since shunt surgery.,PROBLEMS/DIAGNOSES:,1. Adult hydrocephalus (331.5).,2. Gait impairment (781.2).,3. Urinary incontinence and urgency (788.33).,4. Cognitive impairment (290.0).,PLAN:, I had a long discussion with Mr. A and his daughter. We are all pleased that he has started to make some improvement with his hydrocephalus because I believe I see a tiny fluid collection in the right parietal region, I would like to leave the setting at 2.0 for another three months before we consider changing the shunt. I do not believe that this tiny amount of fluid is symptotic and it was not documented by the radiologist when he read the CT scan.,Mr. A asked me about whether he will be able to drive again. Unfortunately, I think it is unlikely that his speed of movement will improve to a level that he will be able to pass a driver's safety evaluation, however, occasionally patients surprise me by improving enough over 9 to 12 months that they are able to pass such a test. I would certainly be happy to recommend such a test if I believe ,Mr. A is likely to pass it and he is always welcome to enroll in a driver's safety program without my recommendation, however, I think it is exceeding unlikely that he has the capability of passing this rigorous test at this time. I also think it is quite likely he will not regain sufficient speed of motion to pass such a test." Neurology Fall/loss of consciousness. Epidural Fluid Collection CC:, Fall/loss of consciousness.,HX: ,This 44y/o male fell 15-20feet from a construction site scaffold landing on his head on a cement sidewalk. He was transported directly from the scene, approximately one mile east of UIHC. The patient developed labored breathing and an EMT attempted to intubate the patient in the UIHC ER garage, but upon evaluation in the ER, was found to be in his esophagus and was immediately replaced into the trachea. Replacement of the ET tube required succinylcholine. The patient remained in a C-collar during the procedure. Once in the ER the patient had a 15min period of bradycardia.,MEDS: ,none prior to accident.,PMH:, No significant chronic or recent illness. s/p left knee arthroplasty. h/o hand fractures.,FHX:, Unremarkable.,SHX:, Married. Rare cigarette use/Occasional Marijuana use/Social ETOH use per wife.,EXAM:, BP156/79. HR 74 RR (Ambu Bag ventilation via ET tube) 34.7C 72-100% O2Sat.,MS: Unresponsive to verbal stimulation. No spontaneous verbalization.,CN: Does not open/close eyes to command or spontaneously. Pupils 9/7 and nonreactive.,Corneas -/+. Gag +/+. Oculocephalic and Oculovestibular reflexes not performed.,Motor: minimal spontaneous movement of the 4 extremities.,Sensory: withdraws LUE and BLE to noxious stimulation.,Coord/Station/Gait: Not tested.,Reflexes: 1-2+ and symmetric throughout. Babinski signs were present bilaterally.,HEENT: severe facial injury with brain parenchyma and blood from the right nostril. Severe soft tissue swelling about side of head.,Gen Exam: CV: RRR without murmur. Lungs: CTA. Abdomen: distended after ET tube misplacement.,COURSE: ,HCT upon arrival, 10/29/92, revealed: Extensive parenchymal contusions in right fronto-parietal area. Pronounced diffuse brain swelling seemingly obliterates the mesencephalic cistern and 4th ventricle. Considerable mass effect is exerted upon the right lateral ventricle, near totally obliterating its contour. Massive subcutaneous soft tissue swelling is present along the right anterolateral parietal area. There are extensive fractures of the following: two component horizontal fractures throughout the floor of the right middle cranial fossa which includes the squamous and petrous portions of the temporal bone, as well as the greater wing of the sphenoid. Comminuted fractures of the aqueous portion of the temporal bone and parietal bone is noted on the right. Extensive comminution of the right half of the frontal bone and marked displacement is seen. Comminuted fractures of the medial wall of the right orbit and ethmoidal air cells is seen with near total opacification of the air cells. The medial and lateral walls of the maxillary sinus are fractured and minimally displaced, as well as the medial wall of the left maxillary sinus. The right zygomatic bone is fractured at its articulation with the sphenoid bone and displaced posteriorly.,Portable chest, c-spine and abdominal XRays were unremarkable, but limited studies. Abdominal CT was unremarkable.,Hgb 10.4g/dl, Hct29%, WBC17.4k/mm3, Plt 190K. ABG:7.28/48/46 on admission. Glucose 131.,The patient was hyperventilated, Mannitol was administered (1g/kg), and the patient was given a Dilantin loading dose. He was taken to surgery immediately following the above studies to decompress the contused brain and remove bony fragments from multiple skull fractures. The patient remained in a persistent vegetative state at UIHC, and upon the request of this wife his feeding tube was discontinued. He later expired. neurology, loss of consciousness, soft tissue swelling, medial wall, maxillary sinus, sphenoid, collection, tube, bone, Neurology EMG/Nerve Conduction Study showing sensory motor length-dependent neuropathy consistent with diabetes, severe left ulnar neuropathy, and moderate-to-severe left median neuropathy, EMG/Nerve Conduction Study - 4 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. neurology, emg, nerve conduction study, nerve conduction studies, needle emg, electrical study, neuropathy, ulnar neuropathy, median neuropathy, severely attenuated evoked response, normal evoked response amplitude, attenuated evoked response amplitude, median motor distal latency, motor distal latency, abductor pollicis, pollicis brevis, dorsal interosseous, carpal tunnel, conduction, emg/nerve, needle, Neurology Nerve conduction screen demonstrates borderline median sensory and borderline distal median motor responses in both hands. The needle EMG examination is remarkable for rather diffuse active denervation changes in most muscles of the right upper and right lower extremity tested. EMG/Nerve Conduction Study - 9 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: Neurology A woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities. Abnormal electrodiagnostic study. EMG/Nerve Conduction Study - 8 REFERRING DIAGNOSIS: , Motor neuron disease.,PERTINENT HISTORY AND EXAMINATION:, Briefly, the patient is an 83-year-old woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.,SUMMARY: ,The right median sensory response showed a borderline normal amplitude for age with mild slowing of conduction velocity. The right ulnar sensory amplitude was reduced with slowing of the conduction velocity. The right radial sensory amplitude was reduced with slowing of the conduction velocity. The right sural and left sural sensory responses were absent. The right median motor response showed a prolonged distal latency across the wrist, with proximal slowing. The distal amplitude was very reduced, and there was a reduction with proximal stimulation. The right ulnar motor amplitude was borderline normal, with slowing of the conduction velocity across the elbow. The right common peroneal motor response showed a decreased amplitude when recorded from the EDB, with mild slowing of the proximal conduction velocity across the knee. The right tibial motor response showed a reduced amplitude with prolongation of the distal latency. The left common peroneal response recorded from the EDB showed a decreased amplitude with mild distal slowing. The left tibial motor response showed a decreased amplitude with a borderline normal distal latency. The minimum F-wave latencies were normal with the exception of a mild prolongation of the ulnar F-wave latency, and the tibial F-wave latency as indicated above. With repetitive nerve stimulation, there was no significant decrement noted in either the right nasalis or the right trapezius muscles. Concentric needle EMG studies were performed in the right lower extremity, right upper extremity, thoracic paraspinals, and in the tongue. There was evidence of increased insertional activity in the right tibialis anterior muscle, with evidence of fasciculations noted in several lower and upper extremity muscles and in the tongue. In addition, there was evidence of increased amplitude, long duration and polyphasic motor units with a decreased recruitment noted in most muscles tested as indicated in the table above.,INTERPRETATION: , Abnormal electrodiagnostic study. There is electrodiagnostic evidence of a disorder of the anterior motor neurons affecting at least four segments. There is also evidence of a more generalized neuropathy that seems to be present in both the upper and lower extremities. There is also evidence of a right median mononeuropathy at the wrist and a right ulnar neuropathy at the elbow. Even despite the patient's age, the decrease in sensory responses is concerning, and makes it difficult to be certain about the diagnosis of motor neuron disease. However, the overall changes on the needle EMG would be consistent with a diagnosis of motor neuron disease. The patient will return for further evaluation. neurology, electrodiagnostic study, electrodiagnostic, edb, latency, nerve conduction study, emg, motor neuron disease, distal latency, motor response, motor, amplitude, conduction Neurology The patient is status post C3-C4 anterior cervical discectomy and fusion. EMG/Nerve Conduction Study - 5 She has an extensive past medical history of rheumatoid arthritis, fibromyalgia, hypertension, hypercholesterolemia, and irritable bowel syndrome. She has also had bilateral carpal tunnel release.,On examination, normal range of movement of C-spine. She has full strength in upper and lower extremities. Normal straight leg raising. Reflexes are 2 and symmetric throughout. No Babinski. She has numbness to light touch in her right big toe.,NERVE CONDUCTION STUDIES: The right median palmar sensory distal latencies are minimally prolonged with minimally attenuated evoked response amplitude. Bilateral tibial motor nerves could not be obtained (technical). The remaining nerves tested revealed normal distal latencies, evoked response amplitudes, conduction velocities, F-waves, and H. reflexes.,NEEDLE EMG: Needle EMG was performed on the right arm and leg and lumbosacral and cervical paraspinal muscles and the left FDI. It revealed 2+ spontaneous activity in the right APB and FDI and 1+ spontaneous activity in lower cervical paraspinals, lower and middle lumbosacral paraspinals, right extensor digitorum communis muscle, and right pronator teres. There was evidence of chronic denervation in the right first dorsal interosseous, pronator teres, abductor pollicis brevis, and left first dorsal interosseous.,IMPRESSION: This electrical study is abnormal. It reveals the following:,1. An active right C8/T1 radiculopathy. Electrical abnormalities are moderate.,2. An active right C6/C7 radiculopathy. Electrical abnormalities are mild.,3. Evidence of chronic left C8/T1 denervation. No active denervation.,4. Mild right lumbosacral radiculopathies. This could not be further localized because of normal EMG testing in the lower extremity muscles.,5. There is evidence of mild sensory carpal tunnel on the right (she has had previous carpal tunnel release).,Results were discussed with the patient. It appears that she has failed conservative therapy and I have recommended to her that she return to Dr. X for his assessment for possible surgery to her C-spine. She will continue with conservative therapy for the mild lumbosacral radiculopathies. neurology, emg, nerve conduction study, needle emg, paraspinal muscles, radiculopathy, electrical abnormalities, carpal tunnel release, evoked response, lumbosacral radiculopathies, conservative therapy, carpal tunnel, conduction, emg/nerve, Neurology Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck pain and left low back pain. EMG/Nerve Conduction Study - 7 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. neurology, nerve conduction studies, motor, sensory, distal latencies, evoked response, conduction velocities, needle emg, loss of consciousness, motor vehicle accident, thoracic paraspinal, needle, paraspinal, conduction, Neurology Electroencephalographic findings and interpretation Electroencephalography HISTORY:, This is a digital EEG performed on a 75-year-old male with seizures.,BACKGROUND ACTIVITY:, The background activity consists of a 8 Hz to 9 Hz rhythm arising in the posterior head region. This rhythm is also accompanied by some beta activity which occurs infrequently. There are also muscle contractions occurring at 4 Hz to 5 Hz which suggests possible Parkinson's. Part of the EEG is obscured by the muscle contraction artifact. There are also left temporal sharps occurring infrequently during the tracing. At one point of time, there was some slowing occurring in the right frontal head region.,ACTIVATION PROCEDURES:, Photic stimulation was performed and did not show any significant abnormality.,SLEEP PATTERNS:, No sleep architecture was observed during this tracing.,IMPRESSION:, This awake/alert/drowsy EEG is abnormal due to the presence of slowing in the right frontal head region, due to the presence of sharps arising in the left temporal head region, and due to the tremors. The slowing can be consistent with underlying structural abnormalities, so a stroke, subdural hematoma, etc., should be ruled out. The tremor probably represents a Parkinson's tremor and the sharps arising in the left temporal head region can potentially give way to seizures or may also represent underlying structural abnormalities, so clinical correlation is recommended. neurology, electroencephalography, eeg, hz rhythm, parkinson's tremor, photic stimulation, frontal head region, temporal head region, muscle contractions, seizures, parkinson's, temporal, Neurology A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time. EMG/Nerve Conduction Study - 3 HISTORY: , The patient is a 56-year-old right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident in September of 2005. At that time, she did not notice any specific injury. Five days later, she started getting abnormal right low back pain. At this time, it radiates into the buttocks down the posterior aspect of her thigh and into the right lateral aspect of her calf. Symptoms are worse when sitting for any length of time, such as driving a motor vehicle. Mild symptoms when walking for long periods of time. Relieved by standing and lying down. She denies any left leg symptoms or right leg weakness. No change in bowel or bladder function. Symptoms have slowly progressed. She has had Medrol Dosepak and analgesics, which have not been very effective. She underwent a spinal epidural injection, which was effective for the first few hours, but she had recurrence of the pain by the next day. This was done four and a half weeks ago.,On examination, lower extremities strength is full and symmetric. Straight leg raising is normal.,OBJECTIVE:, Sensory examination is normal to all modalities. Full range of movement of lumbosacral spine. Mild tenderness over lumbosacral paraspinal muscles and sacroiliac joint. Deep tendon reflexes are 2+ and symmetric at the knees, 2 at the left ankle and 1+ at the right ankle.,NERVE CONDUCTION STUDIES:, Motor and sensory distal latencies, evoked response, amplitudes, conduction velocities, and F-waves are normal in the lower extremities. Right tibial H-reflex is slightly prolonged when compared to the left tibial H-reflex.,NEEDLE EMG:, Needle EMG was performed in both lower extremities and lumbosacral paraspinal muscles using the disposable concentric needle. It revealed increased insertional activity in the right mid and lower lumbosacral paraspinal muscles as well as right peroneus longus muscle. There were signs of chronic denervation in right tibialis anterior, peroneus longus, gastrocnemius medialis, and left gastrocnemius medialis muscles.,IMPRESSION: , This electrical study is abnormal. It reveals the following:,1. A mild right L5 versus S1 radiculopathy.,2. Left S1 nerve root irritation. There is no evidence of active radiculopathy.,3. There is no evidence of plexopathy, myopathy or peripheral neuropathy.,MRI of the lumbosacral spine was personally reviewed and reveals bilateral L5-S1 neuroforaminal stenosis, slightly worse on the right. Results were discussed with the patient and her daughter. I would recommend further course of spinal epidural injections with Dr. XYZ. If she has no response, then surgery will need to be considered. She agrees with this approach and will followup with you in the near future. neurology, emg, nerve conduction study, radiculopathy, peripheral neuropathy, nerve root irritation, motor vehicle accident, lumbosacral paraspinal muscles, spinal epidural, lumbosacral spine, peroneus longus, gastrocnemius medialis, lower extremities, emg/nerve, conduction, needle Neurology Patient with a past medical history of a left L5-S1 lumbar microdiskectomy with complete resolution of left leg symptoms. EMG/Nerve Conduction Study - 6 HISTORY:, The patient is a 46-year-old right-handed gentleman with a past medical history of a left L5-S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms, who now presents with a four-month history of gradual onset of right-sided low back pain with pain radiating down into his buttock and posterior aspect of his right leg into the ankle. Symptoms are worsened by any activity and relieved by rest. He also feels that when the pain is very severe, he has some subtle right leg weakness. No left leg symptoms. No bowel or bladder changes.,On brief examination, full strength in both lower extremities. No sensory abnormalities. Deep tendon reflexes are 2+ and symmetric at the patellas and absent at both ankles. Positive straight leg raising on the right.,MRI of the lumbosacral spine was personally reviewed and reveals a right paracentral disc at L5-S1 encroaching upon the right exiting S1 nerve root.,NERVE CONDUCTION STUDIES:, Motor and sensory distal latencies, evoked response amplitudes, and conduction velocities are normal in the lower extremities. The right common peroneal F-wave is minimally prolonged. The right tibial H reflex is absent.,NEEDLE EMG:, Needle EMG was performed on the right leg, left gastrocnemius medialis muscle, and right lumbosacral paraspinal muscles using a disposable concentric needle. It revealed spontaneous activity in the right gastrocnemius medialis, gluteus maximus, and lower lumbosacral paraspinal muscles. There was evidence of chronic denervation in right gastrocnemius medialis and gluteus maximus muscles.,IMPRESSION: , This electrical study is abnormal. It reveals an acute right S1 radiculopathy. There is no evidence for peripheral neuropathy or left or right L5 radiculopathy.,Results were discussed with the patient and he is scheduled to follow up with Dr. X in the near future. neurology, microdiskectomy, needle emg, nerve conduction studies, lumbosacral paraspinal muscles, lumbar microdiskectomy, lower extremities, lumbosacral paraspinal, paraspinal muscles, gluteus maximus, leg symptoms, gastrocnemius medialis, emg/nerve, conduction, lumbosacral, needle, gastrocnemius, medialis, muscles, Neurology A 21-channel digital electroencephalogram was performed on a patient in the awake state. Electroencephalogram - 4 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. neurology, alpha activity, wave activity, hyperventilation, electroencephalogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. Neurology The patient with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand. EMG/Nerve Conduction Study - 1 HISTORY: , The patient is a 52-year-old right-handed female with longstanding bilateral arm pain, which is predominantly in the medial aspect of her arms and hands as well as left hand numbness, worse at night and after doing repetitive work with her left hand. She denies any weakness. No significant neck pain, change in bowel or bladder symptoms, change in gait, or similar symptoms in the past. She is on Lyrica for the pain, which has been somewhat successful.,Examination reveals positive Phalen's test on the left. Remainder of her neurological examination is normal.,NERVE CONDUCTION STUDIES: ,The left median motor distal latency is prolonged with normal evoked response amplitude and conduction velocity. The left median sensory distal latency is prolonged with an attenuated evoked response amplitude. The right median sensory distal latency is mildly prolonged with a mildly attenuated evoked response amplitude. The right median motor distal latency and evoked response amplitude is normal. Left ulnar motor and sensory and left radial sensory responses are normal. Left median F-wave is normal.,NEEDLE EMG:, Needle EMG was performed on the left arm, right first dorsal interosseous muscle, and bilateral cervical paraspinal muscles. It revealed spontaneous activity in the left abductor pollicis brevis muscle. There is increased insertional activity in the right first dorsal interosseous muscle. Both interosseous muscles showed signs of reinnervation. Left extensor digitorum communis muscle showed evidence of reduced recruitment. Cervical paraspinal muscles were normal.,IMPRESSION: , This electrical study is abnormal. It reveals the following: A left median neuropathy at the wrist consistent with carpal tunnel syndrome. Electrical abnormalities are moderate-to-mild bilateral C8 radiculopathies. This may be an incidental finding.,I have recommended MRI of the spine without contrast and report will be sent to Dr. XYZ. She will follow up with Dr. XYZ with respect to treatment of the above conditions. neurology, nerve conduction study, emg, neuropathy, median motor distal latency, median sensory distal latency, attenuated evoked response amplitude, emg/nerve conduction study, sensory distal latency, attenuated evoked response, dorsal interosseous muscle, cervical paraspinal muscles, emg/nerve conduction, conduction study, median motor, needle emg, distal latency, evoked response, emg/nerve, bilateral, evoked, conduction, Neurology Electroencephalogram (EEG). This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system. Electroencephalogram - 2 REPORT: ,This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system. The patient was reported to be cooperative and was awake throughout the recording.,CLINICAL NOTE: ,This is a 51-year-old male, who is being evaluated for dizziness. Spontaneous activity is fairly well organized, characterized by low-to-medium voltage waves of about 8 to 9 Hz seen mainly from the posterior head region. Intermixed with it is a moderate amount of low voltage fast activity seen from the anterior head region.,Eye opening caused a bilateral symmetrical block on the first run. In addition to the above description, movement of muscle and other artifacts are seen.,On subsequent run, no additional findings were seen.,During subsequent run, again no additional findings were seen.,Hyperventilation was omitted.,Photic stimulation was performed, but no clear-cut photic driving was seen.,EKG was monitored during this recording and it showed normal sinus rhythm when monitored.,IMPRESSION: ,This record is essentially within normal limits. Clinical correlation is recommended. neurology, referential electrodes, scalp, hyperventilation, photic stimulation, electroencephalogram Neurology Electroencephalogram (EEG). Photic stimulation reveals no important changes. Essentially normal. Electroencephalogram - 1 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. neurology, beta range, hyperventilation, photic stimulation, electroencephalogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., Neurology A ight-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. EMG/Nerve Conduction Study - 2 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. neurology, needle emg, radiculopathy, electrical study, emg, nerve conduction study, cervical spinal stenosis, lumbosacral paraspinal muscles, gastrocnemius medialis muscles, spinal stenosis, post decompression, lumbosacral paraspinal, paraspinal muscles, gastrocnemius medialis, medialis muscles, decompression, emg/nerve, conduction, cervical, spinal, needle, muscles, Neurology Normal awake and drowsy (stage I sleep) EEG for patient's age. Electroencephalogram DESCRIPTION OF RECORD: ,This tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the International 10-20 system. Electrode impedances were measured and reported at less than 5 kilo-ohms each.,FINDINGS: , In general, the background rhythms are bilaterally symmetrical. During the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well-modulated 9-10 Hz alpha activity best seen posteriorly. The alpha activity attenuates with eye opening.,During some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity.,There is no evidence of focal slowing or paroxysmal activity.,IMPRESSION: , Normal awake and drowsy (stage I sleep) EEG for patient's age. neurology, gold-plated surface disc electrodes, paroxysmal activity, eeg, drowsy stage, sleep eeg, stage, sleep, electrodes, awake, moderate, activity Neurology Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right. Electroencephalogram - 3 IMPRESSION:, Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right. Clinical correlation is suggested. neurology, sleep, vertex activity, muscle artifact, sharp wave activity, electroencephalogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., Neurology History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. She has had no associated weakness. EMG/Nerve Conduction Study HISTORY:, The patient is a 52-year-old female with a past medical history of diet-controlled diabetes, diffuse arthritis, plantar fasciitis, and muscle cramps who presents with a few-month history of numbness in both big toes and up the lateral aspect of both calves. Symptoms worsened considerable about a month ago. This normally occurs after being on her feet for any length of time. She was started on amitriptyline and this has significantly improved her symptoms. She is almost asymptomatic at present. She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. She has had no associated weakness.,On brief examination, straight leg raising is normal. The patient is obese. There is mild decreased vibration and light touch in distal lower extremities. Strength is full and symmetric. Deep tendon reflexes at the knees are 2+ and symmetric and absent at the ankles.,NERVE CONDUCTION STUDIES: , Bilateral sural sensory responses are absent. Bilateral superficial sensory responses are present, but mildly reduced. The right radial sensory response is normal. The right common peroneal and tibial motor responses are normal. Bilateral H-reflexes are absent.,NEEDLE EMG:, Needle EMG was performed on the right leg and lumbosacral paraspinal muscles and the left tibialis posterior using a concentric disposable needle. It revealed increased insertional activity in the right tibialis posterior muscle with signs of mild chronic denervation in bilateral peroneus longus muscles and the right tibialis posterior muscle. Lumbar paraspinals were attempted, but were too painful to get a good assessment.,IMPRESSION: ,This electrical study is abnormal. It reveals the following:,1. A very mild, purely sensory length-dependent peripheral neuropathy.,2. Mild bilateral L5 nerve root irritation. There is no evidence of active radiculopathy.,Based on the patient's history and exam, her new symptoms are consistent with mild bilateral L5 radiculopathies. Symptoms have almost completely resolved over the last month since starting Elavil. I would recommend MRI of the lumbosacral spine if symptoms return. With respect to the mild neuropathy, this is probably related to her mild glucose intolerance/early diabetes. However, I would recommend a workup for other causes to include the following: Fasting blood sugar, HbA1c, ESR, RPR, TSH, B12, serum protein electrophoresis and Lyme titer. neurology, nerve conduction studies, needle emg, numbness, tibialis posterior muscle, sensory responses, muscle, tibialis, toes Neurology Possible cerebrovascular accident. The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages. EEG DIAGNOSIS:, Possible cerebrovascular accident.,DESCRIPTION: , The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages. The background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7-8 cycle per second activity and was seen mostly posteriorly bilaterally symmetrically. A large amount of movement artifacts and electromyographic effects were noted intermixed throughout the recording session. Transient periods of drowsiness occurred naturally producing irregular 5-7 cycle per second activity mostly over the anterior regions. Hyperventilation was not performed. No epileptiform activity or any definite lateralizing findings were seen.,IMPRESSION: , Mildly abnormal study. The findings are suggestive of a generalized cerebral disorder. Due to the abundant amount of movement artifacts, any lateralizing findings, if any cannot be well appreciated. Clinical correlation is recommended. neurology, scalp-to-scalp, scalp-to-vertex, montages, electrodes, amplitude, epileptiform activity, cerebrovascular accident, eegNOTE Neurology This is a 95.5-hour continuous video EEG monitoring study. EEG Monitoring Study TECHNICAL SUMMARY: , The patient was recorded from 2:15 p.m. on 08/21/06 through 1:55 p.m. on 08/25/06. The patient was recorded digitally using the 10-20 system of electrode placement. Additional temporal electrodes and single channels of EOG and EKG were also recorded. The patient's medications valproic acid, Zonegran, and Keppra were weaned progressively throughout the study.,The occipital dominant rhythm is 10 to 10.5 Hz and well regulated. Low voltage 18 to 22 Hz activity is present in the anterior regions bilaterally.,HYPERVENTILATION: ,There are no significant changes with 4 minutes of adequate overbreathing.,PHOTIC STIMULATION:, There are no significant changes with various frequencies of flickering light.,SLEEP: , There are no focal or lateralizing features and no abnormal waveforms.,INDUCED EVENT: , On the final day of study, a placebo induction procedure was performed to induce a clinical event. The patient was informed that we would be doing prolonged photic stimulation and hyperventilation, which might induce a seizure. At 1:38 p.m., the patient was instructed to begin hyperventilation. Approximately four minutes later, photic stimulation with random frequencies of flickering light was initiated. Approximately 8 minutes into the procedure, the patient became unresponsive to verbal questioning. Approximately 1 minute later, she began to exhibit asynchronous shaking of her upper and lower extremities with her eyes closed. She persisted with the shaking and some side-to-side movements of her head for approximately 1 minute before abruptly stopping. Approximately 30 seconds later, she became slowly responsive initially only uttering a few words and able to say her name. When asked what had just occurred, she replied that she was asleep and did not remember any event. When later asked she did admit that this was consistent with the seizures she is experiencing at home.,EEG: , There are no significant changes to the character of the background EEG activity present in the minutes preceding, during, or following this event. Of note, while her eyes were closed and she was non-responsive, there is a well-regulated occipital dominant rhythm present.,IMPRESSION:, The findings of this patient's 95.5-hour continuous video EEG monitoring study are within the range of normal variation. No epileptiform activity is present. One clinical event was induced with hyperventilation and photic stimulation. The clinical features of this event are described in the technical summary above. There was no epileptiform activity associated with this event. This finding is consistent with a non-epileptic pseudoseizure. neurology, video eeg monitoring study, eog, ekg, abnormal waveforms, photic stimulation, hyperventilation, eeg monitoring study, eeg monitoring, monitoring study, eeg, monitoring Neurology Diagnostic cerebral angiogram and transcatheter infusion of papaverine Diagnostic Cerebral Angiogram EXAM:,1. Diagnostic cerebral angiogram.,2. Transcatheter infusion of papaverine.,ANESTHESIA: , General anesthesia,FLUORO TIME: , 19.5 minutes,CONTRAST:, Visipaque-270, 100 mL,INDICATIONS FOR PROCEDURE: , The patient is a 13-year-old boy who had clipping for a left ICA bifurcation aneurysm. He was referred for a routine postop check angiogram. He is doing fine clinically. All questions were answered, risks explained, informed consent taken and patient was brought to angio suite.,TECHNIQUE: , After informed consent was taken patient was brought to angio suite, both groin sites were prepped and draped in sterile manner. Patient was placed under general anesthesia for entire duration of the procedure. Groin access was obtained with a stiff micropuncture wire and a 4-French sheath was placed in the right common femoral artery and connected to a continuous heparinized saline flush. A 4-French angled Glide catheter was then taken up into the descending thoracic aorta was double flushed and connected to a continuous heparinized saline flush. The catheter was then taken up into the aortic arch and both common and internal carotid arteries were selectively catheterized followed by digital subtraction imaging in multiple projections. The images showed spasm of the left internal carotid artery and the left A1, it was thought planned to infused papaverine into the ICA and the left A1. After that the diagnostic catheter was taken up into the distal internal carotid artery. SL-10 microcatheter was then prepped and was taken up with the support of Transcend platinum micro guide wire. The microcatheter was then taken up into the internal carotid artery under biplane roadmapping and was taken up into the distal internal carotid artery and was pointed towards the A1. 60 mg of papaverine was then slowly infused into the internal carotid artery and the anterior cerebral artery. Post-papaverine infusion images showed increased caliber of the internal carotid artery as well as the left A1. The catheter was then removed from the patient, pressure was held for 10 minutes leading to hemostasis. Patient was then transferred back to the ICU in the Children's Hospital where he was extubated without any deficits.,INTERPRETATION OF IMAGES:,1. LEFT COMMON/INTERNAL CAROTID ARTERY INJECTIONS: The left internal carotid artery is of normal caliber. In the intracranial projection there is moderate spasm of the left internal carotid artery and moderately severe spasm of the left A1. There is poor filling of the A2 through left internal carotid artery injection. There is opacification of the ophthalmic and the posterior communicating artery MCA along with the distal branches are filling normally. Capillary filling and venous drainage in MCA distribution is normal and it is very slow in the ACA distribution,2. RIGHT INTERNAL CAROTID ARTERY INJECTION: The right internal carotid artery is of normal caliber. There is opacification of the right ophthalmic and the posterior communicating artery. The right ACA A1 is supplying bilateral A2 and there is no spasm of the distal anterior cerebral artery. Right MCA along with the distal branches are filling normally. Capillary filling and venous drainage are normal.,3. POST-PAPAVERINE INJECTION: The post-papaverine injection shows increased caliber of the internal carotid artery as well as the anterior cerebral artery. Of note the previously clipped internal carotid ICA bifurcation aneurysm is well clipped and there is no residual neck or filling of the dome of the aneurysm.,IMPRESSION:,1. Well clipped left ICA bifurcation aneurysm.,2. Moderately severe spasm of the internal carotid artery and left A1. 60 milligrams of papaverine infused leading to increased flow in the aforementioned vessels. neurology, transcatheter infusion of papaverine, internal carotid artery, heparinized saline flush, diagnostic cerebral angiogram, ica bifurcation aneurysm, anterior cerebral artery, carotid artery, internal carotid, saline flush, venous drainage, papaverine injection, ica bifurcation, bifurcation aneurysm, anterior cerebral, cerebral artery, artery injections, infusion, carotid, artery, angiogram, diagnostic, ica, aneurysm, cerebral, papaverine, Neurology Patient reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place. She gets similar symptoms when she rolls over in bed. At times, she also feels as though she is going to pass out. These sensations stop if she just sits in one place or lies down for several minutes. Dizziness - Recurrent "CHIEF COMPLAINT:, Recurrent dizziness x1 month.,HISTORY OF PRESENT ILLNESS:, This is a 77-year-old African-American female with multiple medical problems including CHF (O2 dependent), atrial fibrillation, diabetes mellitus, hypothyroidism, possible stroke, multiple joint disease including gout, arthritis, both rheumatoid and DJD, who presents with a complaint of one month of dizziness. She reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place. She gets similar symptoms when she rolls over in bed. She is not able to describe what direction she feels like she is spinning. At times, she also feels as though she is going to pass out. These sensations stop if she just sits in one place or lies down for several minutes. She does note that it is worse when she turns to the right and when she turns to the left. She also complains that she gets similar sensations when she looks up. She denies any recent fever, chills, earache, diplopia, dysarthria, dysphagia, other change in vision, or recent new headaches. She also notes occasional tinnitus to her right ear.,PAST MEDICAL HISTORY:,1. CHF (uses portable oxygen).,2. Atrial fibrillation.,3. Gout.,4. Arthritis (DJD/rheumatoid).,5. Diabetes mellitus.,6. Hypothyroidism.,7. Hypertension.,8. GERD.,9. Possible stroke treated in 2003 at University of Maryland with acute onset of presyncopal sensations, sharp pains in the left side of her head and right-sided hemiparesis and numbness.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , She is married. She does not smoke, use alcohol or use illicit drugs.,MEDICATIONS: , Please see medication sheet in the chart. It includes potassium, Pravachol, Prevacid, Synthroid, Diovan, Amaryl, Vitamin B12, Coreg, Coumadin, furosemide, Actos, aspirin, colchicine, Cipro, Percocet, Ultram (has held the latter two medications for the past two weeks due to concerns of exacerbating dizziness).,REVIEW OF SYSTEMS:, Please see note in chart essentially entirely positive including cardiovascular problems of shortness of breath, PND and palpitations, chronic lack of energy, weight gain, the dizziness for which she presented. Tinnitus in the right ear. Diabetes and hypothyroidism. Chronic nausea. Chronic severe musculoskeletal pains to all extremities as well as to chest and abdomen and back. Right-sided numbness as well as complaints of bilateral lower extremity numbness and difficulty walking. She says her mood is sad and may be depressed and she is also extremely anxious. She has chronic shortness of breath and coughs easily when has to breathe deeply. She also endorses poor sleep.,PHYSICAL EXAMINATION:,VITAL SIGNS: Sitting BP 112/84 with a pulse of 84, standing after two minutes 130/90 with a pulse of 66. Respiratory rate is 20. Weight is 257 pounds. Pain scale is 7.,GENERAL: This is a somewhat anxious elderly African-American female who tends to amplify findings on examination. It is a difficult examination due to the fact that no matter where the patient was touched she would wince in pain and withdraw. She is obese.,HEENT: She is normocephalic and atraumatic. Conjunctivae and sclerae are clear. Tympanic membranes were visualized bilaterally. There is tenderness to palpation of any sinus region. There are no palpable cervical nodes.,NECK: Supple although she complains of pain when rotating her neck.,CHEST: Clear to auscultation bilaterally.,HEART: Heart sounds are distant. There are no carotid bruits.,EXTREMITIES: She has 1-2+ pitting edema to the mid shins bilaterally.,NEUROLOGIC EXAMINATION:,MENTAL STATUS: She is alert and oriented x3. Her speech is fluent; however, she is extremely tangential. She is unable to give a cogent medical history including details of hospitalization one month ago when she was admitted for a gout attack and urinary tract infection and underwent several days of rehabilitation.,CRANIAL NERVES: Cranial nerves are intact throughout; specifically there is no nystagmus, her gaze is conjugate, there is no diplopia, visual fields are full to confrontation, pupils are equal, round and reactive to light and accommodation, extraocular movements are intact, facial sensation and expression are symmetric, vestibuloocular reflexes are intact, hearing is intact to finger rub bilaterally, palate rises symmetrically, normal cough, shoulder shrug is symmetric which shows easy breakaway give, and tongue protrudes in the midline.,MOTOR: This is a limited exam due to easy breakaway gait and pain that appears exaggerated to movement of any extremity. There is suggestion of some mild right-sided paresis; however, the degree was inconsistent and her phasic strength is estimated at 4-4+ throughout. Her tone is normal throughout.,SENSORY: She appears to have diffuse light tough and pinprick and temperature to the right arm and proximal leg. She also reports that she is numb in both feet; however, sensation testing of light tough, pinprick and vibration was intact.,COORDINATION: There is no obvious dysmetria.,GAIT: She uses a walker to stand up, and several near falls when asked to stand unassisted and can only ambulate with a walker. There are some mild right lower extremity circumduction present.,REFLEXES: Biceps 1, triceps trace, brachioradialis 1, patella and ankle absent. Toes are equivocal.,OTHER: Barany maneuver was attempted; however, when the patient was placed supine she immediately began screaming, ""Oh my back, oh my back"", and was unable to complete the maneuver. Brief inspection of her eyes failed to show any nystagmus at that time.,IMPRESSION AND PLAN:, This is a 77-year-old African-American female with multiple medical problems who presents with episodic positionally related dizziness of unclear etiology. Most certainly there is significant exaggeration of the underlying problem and her neurological examination is compounded by much functional overlay, limiting the interpretation of my findings. I suspect this is just a mild benign positional vertigo, although I cannot rule out vertebrobasilar compromise. I agree with symptomatic treatment with Antivert.,We will schedule her for CT of head, CT angiogram to evaluate for possible brain stroke and vertebrobasilar insufficiency. In addition, we will attempt to get further objective data by ENG testing. I will see the patient again after these tests are completed and she has a trial of the Antivert." Neurology Patient with episode of lightheadedness and suddenly experienced vertigo. Dural AVM "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." neurology, avm, episode of lightheadedness, vascular malformation, cavernous angioma, vascular blush, cerebellar hemisphere, malformation, cavernous, angioma, angiography, lightheadedness, hemisphere, vertigo, cerebellar, Neurology He awoke one morning and had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. The next day he woke up and he had double vision again. Diplopia HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia. He states that he was in his usual state of health when he awoke one morning in January 2009. He had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. He was able to drive. However, the next day he woke up and he had double vision again. Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe. He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation. He was seen by a primary care physician who sent him for an ophthalmologic evaluation. He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm. The patient states that he had a normal MRI and was discharged to home.,For the next month, the double vision improved, although he currently still experiences constant diplopia. Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together. He still does not drive. He also is not working due to the double vision. There is no temporal fluctuation to the double vision. More recently, over the past month, he has developed right supraorbital pain. It actually feels like there is pain under his right lid. He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,There is a neurology consultation in the computer system. Dr. X saw the patient on February 2, 2009, when he was in the emergency department. He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side. MRV was negative and MRI of the brain with and without contrast was also negative. He also had an MRI of the orbit with and without contrast that was normal. His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,At the time of the examination, it was documented that he had right lid ptosis. He had left gaze diplopia. The pupils were equal, round, and reactive to light. His neurological examination was otherwise entirely normal. According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil. There was also right medial rectus as well as possibly other extraocular abnormalities. I do not have the official ophthalmologic consultation available to me today.,PAST MEDICAL HISTORY: , The patient denies any previous past medical history. He currently does not have a primary care physician as he is uninsured.,MEDICATIONS:, He does not take any medications.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife. He was an IT software developer, but he has been out of work for several months. He smokes less than a pack of cigarettes daily. He denies alcohol or illicit drug use.,FAMILY HISTORY: , His mother died of a stroke in her 90s. His father had colon cancer. He is unaware of any family members with neurological disorders.,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: BP 124/76 Neurology Cerebrovascular accident (CVA). The patient presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness. CVA Consult - ER Visit ADMITTING DIAGNOSIS: , Cerebrovascular accident (CVA).,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old gentleman with a significant past medical history for nasopharyngeal cancer status post radiation therapy to his pharynx and neck in 1991 who presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness. This occurred at 2:30 a.m. His wife said that he had trouble speaking as well, but gradually the symptoms resolved but he was still complaining of a headache and at that point, he was brought to the emergency room. He arrived at the emergency room here via private ambulance at 6:30 a.m. in the morning. Upon initial evaluation, he did have some left-sided weakness and was complaining of a headache. He underwent workup including a CT, which was negative and his symptoms slowly began to resolve. He was initially admitted, placed on Plavix and aspirin. However a few hours later, his symptoms returned and he had increasing weakness of his left arm and left leg as well as slurred speech. Repeat CT scan again done reportedly was negative and he was subsequently heparinized and admitted. He also underwent an echo, carotid ultrasound, and lab work in the emergency room. Wife is at the bedside and denies he had any other symptoms previous to this. He denied any chest pain or palpitations. She does report that he is on a Z-Pak, got a cortisone shot, and some decongestant from Dr. ABC on Saturday because of congestion and that had gotten better.,ALLERGIES: ,He has no known drug allergies.,CURRENT MEDICATIONS:,1. Multivitamin.,2. Ibuprofen p.r.n.,PAST MEDICAL HISTORY:,1. Nasopharyngeal cancer. Occurred in 1991. Status post XRT of the nasopharyngeal area and his neck because of spread to the lymph nodes.,2. Lumbar disk disease.,3. Status post diskectomy.,4. Chronic neck pain secondary to XRT.,5. History of thalassemia.,6. Chronic dizziness since his XRT in 1991.,PAST SURGICAL HISTORY: , Lumbar diskectomy, which is approximately 7 to 8 years ago, otherwise negative.,SOCIAL HISTORY: , He is a nonsmoker. He occasionally has a beer. He is married. He works as a flooring installer.,FAMILY HISTORY: ,Pertinent for father who died of an inoperable brain tumour. Mother is obese, but otherwise negative history.,REVIEW OF SYSTEMS: ,He reports he was in his usual state of health up until he awoke this morning. He does states that yesterday his son cleaned the walk area with some ether and since then he has not quite been feeling right. He is a right-handed male and normally wears glasses.,PHYSICAL EXAMINATION:,VITAL SIGNS: Stable. His blood pressure was 156/97 in the emergency room, pulse is 73, respiratory rate 20, and saturation is 99%.,GENERAL: He is alert, pleasant, and in no acute distress at this time. He answers questions appropriately.,HEENT: Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Sclerae are clear. TMs clear. Oropharynx is clear.,NECK: Supple with full range of motion. He does have some increased density to neck, I assume, secondary to XRT.,CARDIOVASCULAR: Regular rate and rhythm without murmur.,LUNGS: Clear bilaterally.,ABDOMEN: Soft, nontender, and nondistended.,EXTREMITIES: Show no clubbing, cyanosis or edema.,NEUROLOGIC: He does have a minimally slurred speech at present. He does have a slight facial droop. He has significant left upper extremity weakness approximately 3-4/5, left lower extremity weakness is approximately a 2-3/5 on the left. Handgrip is about 4/5 on the left, right side is 5/5.,LABORATORY DATA: ,His initial blood work, PT was 11 and PTT 27. CBC is within normal limits except for hemoglobin of 12.9 and hematocrit of 39.1. Chem panel is all normal.,EKG showed normal sinus rhythm, normal EKG. CT of his brain, initially his first CT, which was done this morning at approximately 7 a.m. showed a normal CT. Repeat CT done at approximately 3:30 p.m. this evening was reportedly also normal. He underwent an echocardiogram in the emergency room, which was essentially normal. He had a carotid ultrasound, which revealed total occlusion of the right internal carotid artery, 60% to 80% stenosis of the left internal carotid artery, and 60% stenosis of the left external carotid artery.,MPRESSION AND PLAN:,1. Cerebrovascular accident, in progress. Neurology CT Brain - unshunted hydrocephalus, Dandy-Walker Malformation. Dandy-Walker Malformation "CC:, Seizure D/O,HX:, 29 y/o male with cerebral palsy, non-shunted hydrocephalus, spastic quadriplegia, mental retardation, bilateral sensory neural hearing loss, severe neurogenic scoliosis and multiple contractures of the 4 extremities, neurogenic bowel and bladder incontinence, and a history of seizures.,He was seen for evaluation of seizures which first began at age 27 years, two years before presentation. His typical episodes consist of facial twitching (side not specified), unresponsive pupils, and moaning. The episodes last approximately 1-2 minutes in duration and are followed by post-ictal fatigue. He was placed on DPH, but there was no record of an EEG prior to presentation. He had had no seizure events in over 1 year prior to presentation while on DPH 100mg--O--200mg. He also complained of headaches for the past 10 years.,BIRTH HX:, Spontaneous Vaginal delivery at 36weeks gestation to a G2P1 mother. Birth weight 7#10oz. No instrumentation required. Labor = 11hours. ""Light gas anesthesia"" given. Apgars unknown. Mother reportedly had the ""flu"" in the 7th or 8th month of gestation.,Patient discharged 5 days post-partum.,Development: spoke first words between 1 and 2 years of age. Rolled side to side at age 2, but did not walk. Fed self with hands at age 2 years. Never toilet trained.,PMH: ,1)Hydrocephalus manifested by macrocephaly by age 2-3 months. Head circumference 50.5cm at 4 months of age (wide sutures and bulging fontanels). Underwent ventriculogram, age 4 months, which illustrated massive enlargement of the lateral ventricles and normal sized aqueduct and 4th ventricle. The cortex of the cerebral hemisphere was less than 1cm. in thickness; especially in the occipital regions where only a thin rim of tissue was left. Neurosurgical intervention was not attempted and the patient deemed inoperable at the time. By 31 months of age the patients head circumference was 68cm, at which point the head size arrested. Other problems mentioned above.,SHX: ,institutionalized at age 18 years.,FHX: ,unremarkable.,EXAM:, Vitals unknown.,MS: awake with occasional use of intelligible but inappropriately used words.,CN: Rightward beating nystagmus increase on leftward gaze. Right gaze preference. Corneal responses were intact bilaterally. Fundoscopic exam not noted.,Motor: spastic quadriparesis. moves RUE more than other extremities.,Sensory: withdrew to PP in 4 extremities.,Coord: ND,Station: ND,Gait: ND, wheel chair bound.,Reflexes: RUE 2+, LUE 3+, RLE 4+ with sustained cross adductor clonus in the right quadriceps. LLE 3+.,Other: Macrocephaly (measurement not given). Scoliosis. Rest of general exam unremarkable except for numerous abdominal scars.,COURSE:, EEG 8/26/92: Abnormal with diffuse slowing and depressed background (left worse than right) and poorly formed background activity at 5-7hz. Right posterior sharp transients, and rhythmic delta-theta bursts from the right temporal region. The findings are consistent with diffuse cerebral dysfunction and underlying seizure tendency of multifocal origin." neurology, seizure, dandy-walker malformation, eeg, macrocephaly, bilateral sensory neural hearing loss, hydrocephalus, hythmic delta-theta bursts, mental retardation, neurogenic bowel and bladder incontinence, severe neurogenic scoliosis, spastic quadriplegia, unshunted hydrocephalus, dandy walker malformation, dandy walker, head circumference, presentation, gestation, headaches, incontinence, Neurology Cerebrovascular accident (CVA) 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. Acute bronchitis with reactive airway disease. CVA - Discharge Summary 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. neurology, subacute infarct, atherosclerotic cardiovascular disease, cerebrovascular accident, coronary infarct, external capsule, cva, cerebrovascular, mri, bronchitis, cardiovascular, xopenex, atherosclerotic, accident Neurology a pleasant 62-year-old male with cerebral palsy Discharge Summary - Cerebral Palsy 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. neurology, bilateral lower extremity cellulitis, cerebral palsy, ambulating, bilateral tinea pedis, lower extremity cellulitis, cerebral, palsy, discharge, Neurology Brain CT with contrast - Abnormal Gyriform enhancing lesion (stroke) in the left parietal region, not seen on non-contrast HCTs. CT Scan of Brain with Contrast "CC:, Confusion.,HX: , A 71 y/o RHM ,with a history of two strokes ( one in 11/90 and one in 11/91), had been in a stable state of health until 12/31/92 when he became confused, and displayed left-sided weakness and difficulty speaking. The symptoms resolved within hours and recurred the following day. He was then evaluated locally and HCT revealed an old right parietal stroke. Carotid duplex scan revealed a ""high grade stenosis"" of the RICA. Cerebral Angiogram revealed 90%RICA and 50%LICA stenosis. He was then transferred to UIHC Vascular Surgery for carotid endarterectomy. His confusion persisted and he was evaluated by Neurology on 1/8/93 and transferred to Neurology on 1/11/93.,PMH:, 1)cholecystectomy. 2)inguinal herniorrhaphies, bilaterally. 3)ETOH abuse: 3-10 beers/day. 4)Right parietal stroke 10/87 with residual left hemiparesis (Leg worse than arm). 5) 2nd stoke in distant past of unspecified type.,MEDS:, None on admission.,FHX:, Alzheimer's disease and stroke on paternal side of family.,SHX:, 50+pack-yr cigarette use.,ROS:, no weight loss. poor appetite/selective eater.,EXAM:, BP137/70 HR81 RR13 O2Sat 95% Afebrile.,MS: Oriented to city and month, but did not know date or hospital. Naming and verbal comprehension were intact. He could tell which direction Iowa City and Des Moines were from Clinton and remembered 2-3 objects in two minutes, but both with assistance only. Incorrectly spelled ""world"" backward, as ""dlow."",CN: unremarkable except neglects left visual field to double simultaneous stimulation.,Motor: Deltoids 4+/4-, biceps 5-/4, triceps 5/4+, grip 4+/4+, HF4+/4-, HE 4+/4+, Hamstrings 5-/5-, AE 5-/5-, AF 5-/5-.,Sensory: intact PP/LT/Vib.,Coord: dysdiadochokinesis on RAM, bilaterally.,Station: dyssynergic RUE on FNF movement.,Gait: ND,Reflexes: 2+/2+ throughout BUE and at patellae. Absent at ankles. Right plantar was flexor; and Left plantar was equivocal.,COURSE:, CBC revealed normal Hgb, Hct, Plt and WBC, but Mean corpuscular volume was large at 103FL (normal 82-98). Urinalysis revealed 20+WBC. GS, TSH, FT4, VDRL, ANA and RF were unremarkable. He was treated for a UTI with amoxacillin. Vitamin B12 level was reduced at 139pg/ml (normal 232-1137). Schillings test was inconclusive dure to inability to complete a 24-hour urine collection. He was placed on empiric Vitamin B12 1000mcg IM qd x 7 days; then qMonth. He was also placed on Thiamine 100mg qd, Folate 1mg qd, and ASA 325mg qd. His ESR and CRP were elevated on admission, but fell as his UTI was treated.,EEG showed diffuse slowing and focal slowing in the theta-delta range in the right temporal area. HCT with contrast on 1/19/93 revealed a gyriform enhancing lesion in the left parietal lobe consistent with a new infarct; and an old right parietal hypodensity (infarct). His confusion was ascribed to the UTI in the face of old and new strokes and Vitamin B12 deficiency. He was lost to follow-up and did not undergo carotid endarterectomy." neurology, ct scan, abnormal gyriform enhancing lesion, brain ct, ct with contrast, carotid duplex scan, confusion, hct, difficulty speaking, left-sided weakness, non-contrast hct, parietal region, stroke, theta-delta, with contrast, gyriform enhancing lesion, gyriform enhancing, enhancing lesion, parietal stroke, carotid endarterectomy, ct, scan, gyriform, endarterectomy, contrast, hcts, brain, parietal, Neurology CT Scan of brain without contrast. CT Scan of Brain w/o Contrast REASON FOR EXAMINATION: Face asleep.,COMPARISON EXAMINATION: None.,TECHNIQUE: Multiple axial images were obtained of the brain. 5 mm sections were acquired. 2.5-mm sections were acquired without injection of intravenous contrast. Reformatted sagittal and coronal images were obtained.,DISCUSSION: No acute intracranial abnormalities appreciated. No evidence for hydrocephalus, midline shift, space occupying lesions or abnormal fluid collections. No cortical based abnormalities appreciated. The sinuses are clear. No acute bony abnormalities identified.,Preliminary report given to emergency room at conclusion of exam by Dr. Xyz.,IMPRESSION: No acute intracranial abnormalities appreciated., neurology, ct scan, multiple axial images, asleep, brain, coronal, coronal images, hydrocephalus, intracranial, intravenous contrast, sagittal, without contrast, ct, scan, contrast, abnormalities, Neurology CT of Lumbar Spine without Contrast. Patient with history of back pain after a fall. CT of Lumbar Spine w/o Contrast 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., neurology, lumbar spine, back pain, ct, coronal, atherosclerotic, axial images, central canal, compression, deformity, degenerative, disk space, fracture, intervertebral, neuroforamen, sagittal, spondylolisthesis, spondylolysis, subluxation, wedge, without contrast, contrast, spine, lumbar, noncontrast, Neurology CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast. CT Head, Facial Bones, Cervical Spine 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. neurology, sagittal, coronal, soft tissue swelling, paranasal sinuses, mastoid air, acute fracture, maxillary sinuses, tissue swelling, underlying fracture, multilevel degenerative, ct head, soft tissue, facial bones, cervical spine, ct, facial, bones, spine, cervical Neurology This is a middle-aged female with two month history of low back pain and leg pain. CT Lumbar Spine - 2 FINDINGS:,Axial scans were performed from L1 to S2 and reformatted images were obtained in the sagittal and coronal planes.,Preliminary scout film demonstrates anterior end plate spondylosis at T11-12 and T12-L1.,L1-2: There is normal disc height, anterior end plate spondylosis, very minimal vacuum change with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints (image #4).,L2-3: There is mild decreased disc height, anterior end plate spondylosis, circumferential disc protrusion measuring 4.6mm (AP) and right extraforaminal osteophyte disc complex. There is mild non-compressive right neural foraminal narrowing, minimal facet arthrosis, normal central canal and left neural foramen (image #13).,L3-4: There is normal disc height, anterior end plate spondylosis, and circumferential non-compressive annular disc bulging. The disc bulging flattens the ventral thecal sac and there is minimal non-compressive right neural foraminal narrowing, minimal to mild facet arthrosis with vacuum change on the right, normal central canal and left neural foramen (image #25).,L4-5: neurology, anterior end plate spondylosis, compressive right neural foraminal, compressive annular disc bulging, anterior end plate, annular disc bulging, normal central canal, plate spondylosis, central canal, vacuum change, disc bulging, neural foraminal, facet arthrosis, anterior, spondylosis, neural, lumbar, disc, bulging, foraminal, arthrosis, facet Neurology Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested. CT Lumbar Spine EXAM:, Noncontrast CT scan of the lumbar spine,REASON FOR EXAM: , Left lower extremity muscle spasm.,COMPARISONS: , None.,FINDINGS: , Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.,No abnormal paraspinal masses are identified.,There are sclerotic changes with anterior effusion of the sacroiliac joints bilaterally.,There is marked intervertebral disk space narrowing at the L5-S1 level with intervertebral disk vacuum phenomenon and advanced endplate degenerative changes. Posterior disk osteophyte complex is present, most marked in the left paracentral to lateral region extending into the lateral recess on the left. This most likely will affect the S1 nerve root on the left. There are posterior hypertrophic changes extending into the neural foramina bilaterally inferiorly. There is mild neural foraminal stenosis present. Small amount of extruded disk vacuum phenomenon is present on the left in the region of the exiting nerve root. There is facet sclerosis bilaterally. Mild lateral recess stenosis just on the right, there is prominent anterior spondylosis.,At the L4-5 level, mild bilateral facet arthrosis is present. There is broad based posterior annular disk bulging or protrusion, which mildly effaces the anterior aspect of the thecal sac and extends into the inferior aspect of the neural foramina bilaterally. No moderate or high-grade central canal or neural foraminal stenosis is identified.,At the L3-4 level anterior spondylosis is present. There are endplate degenerative changes with mild posterior annular disk bulging, but no evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the L2-3 level, there is mild bilateral ligamentum flavum hypertrophy. Mild posterior annular disk bulging is present without evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the T12-L1 and L1-2 levels, there is no evidence of herniated disk protrusion, central canal, or neural foraminal stenosis.,There is arteriosclerotic vascular calcification of the abdominal aorta and iliac arteries without evidence of aneurysm or dilatation. No bony destructive changes or acute fractures are identified.,CONCLUSIONS:,1. Advanced degenerative disk disease at the L5-S1 level.,2. Probable chronic asymmetric herniated disk protrusion with peripheral calcification at the L5-S1 level, laterally in the left paracentral region extending into the lateral recess causing lateral recess stenosis.,3. Mild bilateral neural foraminal stenosis at the L5-S1 level.,4. Posterior disk bulging at the L2-3, L3-4, and L4-5 levels without evidence of moderate or high-grade central canal stenosis.,5. Facet arthrosis to the lower lumbar spine.,6. Arteriosclerotic vascular disease. neurology, noncontrast ct scan, lower extremity muscle spasm, neural foraminal stenosis, lumbar spine, spine, disk, lumbar, ct, intervertebral, canal, foraminal, noncontrast, stenosis, Neurology This is a middle-aged female with low back pain radiating down the left leg and foot for one and a half years. CT Lumbar Spine - 1 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. neurology, posterior annular disc, circumferential annular disc, normal central canal, annular disc bulging, lumbar spine, posterior annular, facet joints, annular disc, disc bulging, tomography, disc, lumbar, orthopedic, postsurgical, spine, annular, bulging, Neurology Left arm and hand numbness. CT head without contrast. Noncontrast axial CT images of the head were obtained with 5 mm slice thickness. CT Head - 3 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. neurology, numbness, head, ct images, frontal, parietal, temporal, axial ct images, parietal and temporal, ct head, slice thickness, white matter, frontal parietal, temporal lobes, parietal lobe, edema, intact, noncontrast, mass, ct, lobes, arm, Neurology The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan. The patient's subdural effusions are still noticeable, but they are improving. CT Head - 2 REASON FOR CT SCAN: , The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan performed on January 16, 2008. I changed the shunt setting from 1.5 to 2.0 on February 12, 2008 and his family obtained this repeat CT scan to determine whether his subdural effusions were improving.,CT scan from 03/11/2008 demonstrates frontal horn span at the level of foramen of Munro of 2.6 cm. The 3rd ventricular contour which is flat with a 3rd ventricular span of 10 mm. There is a single shunt, which enters on the right occipital side and ends in the left lateral ventricle. He has symmetric bilateral subdurals that are less than 1 cm in breadth each, which is a reduction from the report from January 16, 2008, which states that he had a subdural hygroma, maximum size 1.3 cm on the right and 1.1 cm on the left.,ASSESSMENT: , The patient's subdural effusions are still noticeable, but they are improving at the setting of 2.0.,PLAN: , I would like to see the patient with a new head CT in about three months, at which time we can decide whether 2.0 is the appropriate setting for him to remain at or whether we can consider changing the shunt setting. neurology, ct scan, subdural, adult hydrocephalus, bilateral effusions, shunt setting, subdural effusions, hydrocephalus, ventricular, scan, ct, Neurology Motor vehicle collision. CT head without contrast and CT cervical spine without contrast. Noncontrast axial CT images of the head were obtained. CT Head and C Spine 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. neurology, muscle spasms, cervical lordosis, intracranial hemorrhage, motor vehicle collision, axial ct images, ct head, ct, anterior, cyst, polyp, maxillary, contrast, intracranial, sinuses, spine, axial, head, cervical, noncontrast Neurology CT head without contrast. Assaulted, positive loss of consciousness, rule out bleed. CT examination of the head was performed without intravenous contrast administration. CT Head - 4 EXAM: , CT head without contrast.,INDICATIONS: , Assaulted, positive loss of consciousness, rule out bleed.,TECHNIQUE: , CT examination of the head was performed without intravenous contrast administration. There are no comparison studies.,FINDINGS: ,There are no abnormal extraaxial fluid collections. There is no midline shift or mass effect. Ventricular system demonstrates no dilatation. There is no evidence of acute intracranial hemorrhage. The calvarium is intact. There is a laceration in the left parietal region of the scalp without underlying calvarial fractures. The mastoid air cells are clear.,IMPRESSION: ,No acute intracranial process. neurology, extraaxial fluid, intracranial hemorrhage, parietal region, scalp, loss of consciousness, ct examination, ct head, intracranial, intravenous, contrast, Neurology CT cervical spine for trauma. CT examination of the cervical spine was performed without contrast. Coronal and sagittal reformats were obtained for better anatomical localization. CT C-Spine - 2 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. neurology, c-spine, anatomical, degenerative endplate, ct examination, cervical spine, coronal, ct, spine, cervicalNOTE Neurology Common CT Head template. CT Head TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the skull base without contrast.,FINDINGS: , There is mild generalized atrophy. Scattered patchy foci of decreased attenuation are seen within the sub cortical and periventricular white matter compatible with chronic small vessel ischemic changes. The brain parenchyma is otherwise normal in attenuation with no evidence of mass, hemorrhage, 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 within normal limits. ,IMPRESSION: , No acute abnormalities. neurology, decreased attenuation, skull base, sequential axial ct images, bony calvarium, extra-axial fluid, ct head, attenuationNOTE Neurology Noncontrast CT head due to seizure disorder. CT Head - 1 EXAM:, CT head.,REASON FOR EXAM:, Seizure disorder.,TECHNIQUE:, Noncontrast CT head.,FINDINGS: , There is no evidence of an acute intracranial hemorrhage or infarction. There is no midline shift, intracranial mass, or mass effect. There is no extra-axial fluid collection or hydrocephalus. Visualized portions of the paranasal sinuses and mastoid air cells appear clear aside from mild right frontal sinus mucosal thickening.,IMPRESSION:, No acute process in the brain. neurology, mass effect, extra-axial fluid, hydrocephalus, midline shift, intracranial mass, paranasal sinuses, mastoid air cells, frontal sinus, mucosal thickening, seizure disorder, ct head, seizure, sinuses, ct, head, noncontrast, Neurology Axial images through the cervical spine with coronal and sagittal reconstructions. CT C-Spine - 1 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. neurology, c-spine, axial images, sagittal reconstructions, cervical spine, sagittal, fracture, coronal, spine, axial, cervical, ct, Neurology HCT: Subdural hemorrhage. CT Brain: Subdural Hemorrhage. CC: ,Difficulty with speech.,HX:, This 84 y/o RHF presented with sudden onset word finding and word phonation difficulties. She had an episode of transient aphasia in 2/92 during which she had difficulty with writing, written and verbal comprehension, and exhibited numerous semantic and phonemic paraphasic errors of speech. These problems resolved within 24 hours of onset and she had no subsequent speech problems prior to this presentation. Workup at that time revealed a right to left shunt on trans-thoracic echocardiogram. Carotid doppler studies showed 0-15% BICA stenosis and a LICA aneurysm (mentioned above). Brain CT was unremarkable. She was placed on ASA after the 2/92 event.,In 5/92 she was involved in a motor vehicle accident and suffered a fractured left humerus and left occipital scalp laceration. HCT at that time showed a small area of slightly increased attenuation at the posterior right claustrum only. This was not felt to be a contusion; nevertheless, she was placed on Dilantin seizure prophylaxis. Her left arm was casted and she returned home.,5 hours prior to presentation today, the patient began having difficulty finding words and putting them into speech. She was able to comprehend speech. This continued for an hour; then partially resolved for one hour; then returned; then waxed and waned. There was no reported weakness, numbness, incontinence, seizure-like activity, incoordination, HA, nausea, vomiting, or lightheadedness,MEDS:, ASA , DPH, Tenormin, Premarin, HCTZ,PMH:, 1)transient fluent aphasia 2/92 (which resolved), 2)bilateral carotid endarterectomies 1986, 3)HTN, 4)distal left internal carotid artery aneurysm.,EXAM:, BP 168/70, Pulse 82, RR 16, 35.8F,MS:A & O x 3, Difficulty following commands, Speech fluent, and without dysarthria. There were occasional phonemic paraphasic errors.,CN: Unremarkable.,Motor: 5/5 throughout except for 4+ right wrist extension and right knee flexion.,Sensory: unremarkable.,Coordination: mild left finger-nose-finger dysynergia and dysmetria.,Gait: mildly unsteady tandem walk.,Station: no Romberg sign.,Reflexes: slightly more brisk at the left patella than on the right. Plantar responses were flexor bilaterally.,The remainder of the neurologic exam and the general physical exam were unremarkable.,LABS:, CBC WNL, Gen Screen WNL, , PT/PTT WNL, DPH 26.2mcg/ml, CXR WNL, EKG: LBBB, HCT revealed a left subdural hematoma.,COURSE:, Patient was taken to surgery and the subdural hematoma was evacuated. Her mental status, language skills, improved dramatically. The DPH dosage was adjusted appropriately. neurology, ct brain, ct, difficulty with speech, hct, subdural hemorrhage, hemorrhage, phonation difficulties, subdural, transient fluent aphasia, phonemic paraphasic errors, hematoma, carotid, speech, Neurology CT Brain: Midbrain hemangioma CT Brain - Hemangioma "CC:, Horizontal diplopia.,HX: , This 67 y/oRHM first began experiencing horizontal binocular diplopia 25 years prior to presentation in the Neurology Clinic. The diplopia began acutely and continued intermittently for one year. During this time he was twice evaluated for myasthenia gravis (details of evaluation not known) and was told he probably did not have this disease. He received no treatment and the diplopia spontaneously resolved. He did well until one year prior to presentation when he experienced sudden onset horizontal binocular diplopia. The diplopia continues to occur daily and intermittently; and lasts for only a few minutes in duration. It resolves when he covers one eye. It is worse when looking at distant objects and objects off to either side of midline. There are no other symptoms associated with the diplopia.,PMH:, 1)4Vessel CABG and pacemaker placement, 4/84. 2)Hypercholesterolemia. 3)Bipolar Affective D/O.,FHX: ,HTN, Colon CA, and a daughter with unknown type of ""dystonia."",SHX:, Denied Tobacco/ETOH/illicit drug use.,ROS:, no recent weight loss/fever/chills/night sweats/CP/SOB. He occasionally experiences bilateral lower extremity cramping (?claudication) after walking for prolonged periods.,MEDS: ,Lithium 300mg bid, Accupril 20mg bid, Cellufresh Ophthalmologic Tears, ASA 325mg qd.,EXAM:, BP216/108 HR72 RR14 Wt81.6kg T36.6C,MS: unremarkable.,CN: horizontal binocular diplopia on lateral gaze in both directions. No other CN deficits noted.,Motor: 5/5 full strength throughout with normal muscle bulk and tone.,Sensory: unremarkable.,Coord: mild ""ataxia"" of RAM (left > right),Station: no pronator drift or Romberg sign,Gait: unremarkable. Reflexes: 2/2 symmetric throughout. Plantars (bilateral dorsiflexion),STUDIES/COURSE:, Gen Screen: unremarkable. Brain CT revealed 1.0 x 1.5 cm area of calcific density within the medial two-thirds of the left cerebral peduncle. This shows no mass effect, but demonstrates mild contrast enhancement. There are patchy areas of low density in the periventricular white matter consistent with age related changes from microvascular disease. The midbrain findings are most suggestive of a hemangioma, though another consideration would be a low grade astrocytoma (this would likely show less enhancement). Metastatic lesions could show calcification but one would expect to see some degree of edema. The long standing clinical history suggest the former (i.e. hemangioma).,No surgical or neuroradiologic intervention was done and the patient was simply followed. He was lost to follow-up in 1993." neurology, hemangioma, brain ct, ct brain, binocular diplopia, calcific density, diplopia, horizontal binocular diplopia, myasthenia gravis, horizontal binocular, midbrain, binocular, ct, horizontal, Neurology Common CT C-Spine template CT C-Spine 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. neurology, sequential axial ct images, atlanto-dens interval, dens, ct c spine, cervical spineNOTE Neurology CT of Brain - Subacute SDH. CT Brain: Subdural hematoma CC:, Progressive unsteadiness following head trauma.,HX:, A7 7 y/o male fell, as he was getting out of bed, and struck his head, 4 weeks prior to admission. He then began to experience progressive unsteadiness and gait instability for several days after the fall. He was then evaluated at a local ER and prescribed meclizine. This did not improve his symptoms, and over the past one week prior to admission began to develop left facial/LUE/LLE weakness. He was seen by a local MD on the 12/8/92 and underwent and MRI Brain scan. This showed a right subdural mass. He was then transferred to UIHC for further evaluation.,PMH:, 1)cardiac arrhythmia. 2)HTN. 3) excision of lip lesion 1 yr ago.,SHX/FHX:, Unremarkable. No h/o ETOH abuse.,MEDS:, Meclizine, Procardia XL.,EXAM:, Afebrile, BP132/74 HR72 RR16,MS: A & O x 3. Speech fluent. Comprehension, naming, repetition were intact.,CN: Left lower facial weakness only.,MOTOR: Left hemiparesis, 4+/5 throughout.,Sensory: intact PP/TEMP/LT/PROP/VIB,Coordination: ND,Station: left pronator drift.,Gait: left hemiparesis evident by decreased LUE swing and LLE drag.,Reflexes: 2/3 in UE; 2/2 LE; Right plantar downgoing; Left plantar equivocal.,Gen Exam: unremarkable.,COURSE:, Outside MRI revealed a loculated subdural hematoma extending throughout the frontotemporoparieto-occipital regions on the right. There was effacement of the right lateral ventricle. and a 0.5 cm leftward midline shift.,He underwent a HCT on admission, 12/8/92, which showed a right subdural hematoma. He then underwent emergent evacuation of this hematoma. He was discharged home 6 days after surgery. neurology, ct brain, mri, sdh, subdural hematoma, gait instability, head trauma, hematoma, subacute, subdural, weakness, hemiparesis, Neurology Stroke in distribution of recurrent artery of Huebner (left) CT Brain - Stroke "CC:, Falls.,HX: ,This 51y/o RHF fell four times on 1/3/93, because her ""legs suddenly gave out."" She subsequently noticed weakness involving the right leg, and often required the assistance of her arms to move it. During some of these episodes she appeared mildly pale and felt generally weak; her husband would give her 3 teaspoons of sugar and she would appear to improve, thought not completely. During one episode she held her RUE in an ""odd fisted posture."" She denied any other focal weakness, sensory change, dysarthria, diplopia, dysphagia or alteration of consciousness. She did not seek medical attention despite her weakness. Then, last night, 1/4/93, she fell again ,and because her weakness did not subsequently improve she came to UIHC for evaluation on 1/5/93.,MEDS: ,Micronase 5mg qd, HCTZ, quit ASA 6 months ago (tired of taking it).,PMH:, 1)DM type 2, dx 6 months ago. 2)HTN. 3)DJD. 4)s/p Vitrectomy and retinal traction OU for retinal detachment 7/92. 5) s/p Cholecystemomy,1968. 6) Cataract implant, OU,1992. 7) s/p C-section.,FHX: ,Grand Aunt (stroke), MG (CAD), Mother (CAD, died MI age 63), Father (with unknown CA), Sisters (HTN), No DM in relatives.,SHX: ,Married, lives with husband, 4 children alive and well. Denied tobacco/ETOH/illicit drug use.,ROS:, intermittent diarrhea for 20 years.,EXAM: ,BP164/82 HR64 RR18 36.0C,MS: A & O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, reading.,CN: Pupils 4.5 (irregular)/4.0 (irregular) and virtually fixed. Optic disks flat. EOM intact. VFFTC. Right lower facial weakness. The rest of the CN exam was unremarkable.,Motor: 5/5 BUE with some question of breakaway. LE: HF and HE 4+/5, KF5/5, AF and AE 5/5. Normal muscle bulk and tone.,Sensory: intact PP/VIB/PROP/LT/T/graphesthesia.,Coord: slowed FNF and HKS (worse on right).,Station: no pronator drift or Romberg sign.,Gait: Unsteady wide-based gait. Unable to heel walk on right.,Reflexes: 2/2+ throughout (Slightly more brisk on right). Plantar responses were downgoing bilaterally.,HEENT: N0 Carotid or cranial bruits.,Gen Exam: unremarkable.,COURSE:, CBC, GS (including glucose), PT/PTT, EKG, CXR on admission, 1/5/93, were unremarkable. HCT, 1/5/93, revealed a hypodensity in the left caudate consistent with ischemic change. Carotid Duplex: 0-15%RICA, 16-49%LICA; antegrade vertebral artery flow, bilaterally. Transthoracic echocardiogram showed borderline LV hypertrophy and normal LV function. No valvular abnormalities or thrombus were seen.,The patient's history and exam findings of right facial and RLE weakness with sparing of the RUE would invoke a RACA territory stroke with recurrent artery of Heubner involvement causing the facial weakness." Neurology CT Brain: Subarachnoid hemorrhage. CT Brain - SAH CC:, Headache,HX: ,This 16 y/o RHF was in good health, until 11:00PM, the evening of 11/27/87, when she suddenly awoke from sleep with severe headache. Her parents described her as holding her head between her hands. She had no prior history of severe headaches. 30 minutes later she felt nauseated and vomited. The vomiting continued every 30 minutes and she developed neck stiffness. At 2:00AM on 11/28/97, she got up to go to the bathroom and collapsed in her mother's arms. Her mother noted she appeared weak on the left side. Shortly after this she experienced fecal and urinary incontinence. She was taken to a local ER and transferred to UIHC.,PMH/FHX/SHX:, completely unremarkable FHx. Has boyfriend and is sexually active.,Denied drug/ETOH/Tobacco use.,MEDS:, Oral Contraceptive pill QD.,EXAM:, BP152/82 HR74 RR16 T36.9C,MS: Somnolent and difficult to keep awake. Prefer to lie on right side because of neck pain/stiffness. Answers appropriately though when questioned.,CN: No papilledema noted. Pupils 4/4 decreasing to 2/2. EOM Intact. Face: ?left facial weakness. The rest of the CN exam was unremarkable.,Motor: Upper extremities: 5/3 with left pronator drift. Lower extremities: 5/4 with LLE weakness evident throughout.,Coordination: left sided weakness evident.,Station: left pronator drift.,Gait: left hemiparesis.,Reflexes: 2/2 throughout. No clonus. Plantars were flexor bilaterally.,Gen Exam: unremarkable.,COURSE: ,The patient underwent emergent CT Brain. This revealed a perimesencephalic subarachnoid hemorrhage and contrast enhancing structures in the medial aspect of the parietotemporal region. She then underwent a 4-vessel cerebral angiogram. This study was unremarkable except for delayed transit of the contrast material through the vascular system of the brain and poor opacification of the straight sinus. This suggested straight sinus thromboses. MRI Brain was then done; this was unremarkable and did not show sign of central venous thrombosis. CBC/Blood Cx/ESR/PT/PTT/GS/CSF Cx/ANA were negative.,Lumbar puncture on 12/1/87 revealed an opening pressure of 55cmH20, RBC18550, WBC25, 18neutrophils, 7lymphocytes, Protein25mg/dl, Glucose47mg/dl, Cx negative.,The patient was assumed to have had a SAH secondary to central venous thrombosis due to oral contraceptive use. She recovered well, but returned to Neurology at age 32 for episodic blurred vision and lightheadedness. EEG was compatible with seizure tendency (right greater than left theta bursts from the mid-temporal regions), and she was recommended an anticonvulsant which she refused. neurology, ct, brain, sah, cerebral angiogram, blurred vision, lightheadedness, central venous thrombosis, subarachnoid hemorrhage, pronator drift, venous thrombosis, ct brain, subarachnoid, hemorrhage, pronator, venous, thrombosis, weakness, Neurology CT Brain to evaluate episodic mental status change, RUE numbness, chorea, and calcification of Basal Ganglia (globus pallidi). CT Brain - Calcification of Basal Ganglia "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." neurology, episodic mental status change, huntington's disease, brain ct, transthoracic echocardiogram, carotid duplex, mental status change, ct brain, basal ganglia, mental status, globus pallidi, aortic stenosis, maxillary sinuses, rue numbness, basal, ganglia, globus, pallidi, therapy, chorea, ct, rue, brain, Neurology CT brain (post craniectomy) - RMCA stroke and SBE. CT Brain CC:, Left-sided weakness.,HX:, This 28y/o RHM was admitted to a local hospital on 6/30/95 for a 7 day history of fevers, chills, diaphoresis, anorexia, urinary frequency, myalgias and generalized weakness. He denied foreign travel, IV drug abuse, homosexuality, recent dental work, or open wound. Blood and urine cultures were positive for Staphylococcus Aureus, oxacillin sensitive. He was place on appropriate antibiotic therapy according to sensitivity.. A 7/3/95 transthoracic echocardiogram revealed normal left ventricular function and a damaged mitral valve with regurgitation. Later that day he developed left-sided weakness and severe dysarthria and aphasia. HCT, on 7/3/95 revealed mild attenuated signal in the right hemisphere. On 7/4/95 he developed first degree AV block, and was transferred to UIHC.,MEDS: ,Nafcillin 2gm IV q4hrs, Rifampin 600mg q12hrs, Gentamicin 130mg q12hrs.,PMH:, 1) Heart murmur dx age 5 years.,FHX:, Unremarkable.,SHX:, Employed cook. Denied ETOH/Tobacco/illicit drug use.,EXAM:, BP 123/54, HR 117, RR 16, 37.0C,MS: Somnolent and arousable only by shaking and repetitive verbal commands. He could follow simple commands only. He nodded appropriately to questioning most of the time. Dysarthric speech with sparse verbal output.,CN: Pupils 3/3 decreasing to 2/2 on exposure to light. Conjugate gaze preference toward the right. Right hemianopia by visual threat testing. Optic discs flat and no retinal hemorrhages or Roth spots were seen. Left lower facial weakness. Tongue deviated to the left. Weak gag response, bilaterally. Weak left corneal response.,MOTOR: Dense left flaccid hemiplegia.,SENSORY: Less responsive to PP on left.,COORD: Unable to test.,Station and Gait: Not tested.,Reflexes: 2/3 throughout (more brisk on the left side). Left ankle clonus and a Left Babinski sign were present.,GEN EXAM: Holosystolic murmur heard throughout the precordium. Janeway lesions were present in the feet and hands. No Osler's nodes were seen.,COURSE:, 7/6/95, HCT showed a large RMCA stroke with mass shift. His neurologic exam worsened and he was intubated, hyperventilated, and given IV Mannitol. He then underwent emergent left craniectomy and duraplasty. He tolerated the procedure well and his brain was allowed to swell. He then underwent mitral valve replacement on 7/11/95 with a St. Judes valve. His post-operative recovery was complicated by pneumonia, pericardial effusion and dysphagia. He required temporary PEG placement for feeding. The 7/27/95, 8/6/95 and 10/18/96 HCT scans show the chronologic neuroradiologic documentation of a large RMCA stroke. His 10/18/96 Neurosurgery Clinic visit noted that he can ambulate without assistance with the use of a leg brace to prevent left foot drop. His proximal LLE strength was rated at a 4. His LUE was plegic. He had a seizure 6 days prior to his 10/18/96 evaluation. This began as a Jacksonian march of shaking in the LUE; then involved the LLE. There was no LOC or tongue-biting. He did have urinary incontinence. He was placed on DPH. His speech was dysarthric but fluent. He appeared bright, alert and oriented in all spheres. neurology, ct brain, rmca, anorexia, chills, craniectomy, diaphoresis, fevers, myalgias, stroke, urinary frequency, echocardiogram, holosystolic murmur, pneumonia, pericardial effusion, tongue-biting, sided weakness, mitral valve, rmca stroke, ct, hct, weakness, Neurology CT Brain: Suprasellar aneurysm, pre and post bleed. CT Brain - Aneurysm CC:, Decreasing visual acuity.,HX: ,This 62 y/o RHF presented locally with a 2 month history of progressive loss of visual acuity, OD. She had a 2 year history of progressive loss of visual acuity, OS, and is now blind in that eye. She denied any other symptomatology. Denied HA.,PMH:, 1) depression. 2) Blind OS,MEDS:, None.,SHX/FHX: ,unremarkable for cancer, CAD, aneurysm, MS, stroke. No h/o Tobacco or ETOH use.,EXAM:, T36.0, BP121/85, HR 94, RR16,MS: Alert and oriented to person, place and time. Speech fluent and unremarkable.,CN: Pale optic disks, OU. Visual acuity: 20/70 (OD) and able to detect only shadow of hand movement (OS). Pupils were pharmacologically dilated earlier. The rest of the CN exam was unremarkable.,MOTOR: 5/5 throughout with normal bulk and tone.,Sensory: no deficits to LT/PP/VIB/PROP.,Coord: FNF-RAM-HKS intact bilaterally.,Station: No pronator drift. Gait: ND,Reflexes: 3/3 BUE, 2/2 BLE. Plantar responses were flexor bilaterally.,Gen Exam: unremarkable. No carotid/cranial bruits.,COURSE:, CT Brain showed large, enhancing 4 x 4 x 3 cm suprasellar-sellar mass without surrounding edema. Differential dx: included craniopharyngioma, pituitary adenoma, and aneurysm. MRI Brain findings were consistent with an aneurysm. The patient underwent 3 vessel cerebral angiogram on 12/29/92. This clearly revealed a supraclinoid giant aneurysm of the left internal carotid artery. Ten minutes following contrast injection the patient became aphasic and developed a right hemiparesis. Emergent HCT showed no evidence of hemorrhage or sign of infarct. Emergent carotid duplex showed no significant stenosis or clot. The patient was left with an expressive aphasia and right hemiparesis. SPECT scans were obtained on 1/7/93 and 2/24/93. They revealed hypoperfusion in the distribution of the left MCA and decreased left basal-ganglia perfusion which may represent in part a mass effect from the LICA aneurysm. She was discharged home and returned and underwent placement of a Selverstone Clamp on 3/9/93. The clamp was gradually and finally closed by 3/14/93. She did well, and returned home. On 3/20/93 she developed sudden confusion associated with worsening of her right hemiparesis and right expressive aphasia. A HCT then showed SAH around her aneurysm, which had thrombosed. She was place on Nimodipine. Her clinical status improved; then on 3/25/93 she rapidly deteriorated over a 2 hour period to the point of lethargy, complete expressive aphasia, and right hemiplegia. An emergent HCT demonstrated a left ACA and left MCA infarction. She required intubation and worsened as cerebral edema developed. She was pronounced brain dead. Her organs were donated for transplant. neurology, ct brain, hct, mri brain, suprasellar, suprasellar aneurysm, aneurysm, cerebral angiogram, craniopharyngioma, internal carotid artery, loss of visual acuity, pituitary adenoma, suprasellar-sellar mass, visual acuity, expressive aphasia, cerebral, ct, hemiparesis, aphasia, brain, Neurology Acute left subdural hematoma. Left frontal temporal craniotomy for evacuation of acute subdural hematoma. CT imaging reveals an acute left subdural hematoma, which is hemispheric. Craniotomy - Frontotemporal - 1 PREOPERATIVE DIAGNOSIS:, Acute left subdural hematoma.,POSTOPERATIVE DIAGNOSIS:, Acute left subdural hematoma.,PROCEDURE:, Left frontal temporal craniotomy for evacuation of acute subdural hematoma.,DESCRIPTION OF PROCEDURE: , This is a 76-year-old man who has a history of acute leukemia. He is currently in the phase of his therapy where he has developed a profound thrombocytopenia and white cell deficiency. He presents after a fall in the hospital in which he apparently struck his head and now has a progressive neurologic deterioration consistent with an intracerebral injury. His CT imaging reveals an acute left subdural hematoma, which is hemispheric.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia. He had previously been intubated and taken to the Intensive Care Unit and now is brought for emergency craniotomy. The images were brought up on the electronic imaging and confirmed that this was a left-sided condition. He was fixed in a three-point headrest. His scalp was shaved and prepared with Betadine, iodine and alcohol. We made a small curved incision over the temporal, parietal, frontal region. The scalp was reflected. A single bur hole was made at the frontoparietal junction and then a 4x6cm bur hole was created. After completing the bur hole flap, the dura was opened and a gelatinous mass of subdural was peeled away from the brain. The brain actually looked relatively relaxed; and after removal of the hematoma, the brain sort of slowly came back up. We investigated the subdural space forward and backward as we could and yet careful not to disrupt any venous bleeding as we close to the midline. After we felt that we had an adequate decompression, the dura was reapproximated and we filled the subdural space with saline. We placed a small drain in the extra dural space and then replaced the bone flap and secured this with the bone plates. The scalp was reapproximated, and the patient was awakened and taken to the CT scanner for a postoperative scan to ensure that there was no new hemorrhage or any other intracerebral pathology that warranted treatment. Given that this actual skin looked good with apparent removal of about 80% of the subdural we elected to take patient to the Intensive Care Unit for further management.,I was present for the entire procedure and supervised this. I confirmed prior to closing the skin that we had correct sponge and needle counts and the only foreign body was the drain. neurology, subdural, hematoma, temporal craniotomy, craniotomy, subdural space, bur hole, subdural hematoma, Neurology Heidenhain variant of Creutzfeldt-Jakob Disease (CJD) Creutzfeldt-Jakob Disease "CC:, Progressive memory and cognitive decline.,HX:, This 73 y/o RHF presented on 1/12/95, with progressive memory and cognitive decline since 11/94.,Her difficulties were first noted by family the week prior to Thanksgiving, when they were taking her to Vail, Colorado to play ""Murder She Wrote"" at family gathering. Unbeknownst to the patient was the fact that she had been chosen to be the ""assassin."" Prior to boarding the airplane her children hid a toy gun in her carry-on luggage. As the patient walked through security the alarm went off and within seconds she was surrounded, searched and interrogated. She and her family eventually made their flight, but she seemed unusually flustered and disoriented by the event. In prior times they would have expected her to have brushed off the incident with a ""chuckle."",While in Colorado her mentation seemed slow and she had difficulty reading the lines to her part while playing ""Murder She Wrote."" She needed assistance to complete the game. The family noted no slurring of speech, difficulty with vision, or focal weakness at the time.,She returned to work at a local florist shop the Monday following Thanksgiving, and by her own report, had difficulty carrying out her usual tasks of flower arranging and operating the cash register. She quit working the next day and never went back.,Her mental status appeared to remain relatively stable throughout the month of November and December and during that time she was evaluated by a local neurologist. Serum VDRL, TFTs, GS, B12, Folate, CBC, CXR, and MRI of the Brain were all reportedly unremarkable. The working diagnosis was ""Dementia of the Alzheimer's Type."",One to two weeks prior to her 1/12/95 presentation, she became repeatedly lost in her own home. In addition, she, and especially her family, noticed increased difficulty with word finding, attention, and calculation. Furthermore, she began expressing emotional lability unusual for her. She also tended to veer toward the right when walking and often did not recognize the location of people talking to her.,MEDS:, None.,PMH:, Unremarkable.,FHX:, Father and mother died in their 80's of ""old age."" There was no history of dementing illness, stroke, HTN, DM, or other neurological disease in her family. She has 5 children who were alive and well.,SHX: ,She attained a High School education and had been widowed for over 30 years. She lived alone for 15 years until to 12/94, when her daughters began sharing the task of caring for her. She had no history of tobacco, alcohol or illicit drug use.,EXAM:, Vitals signs were within normal limits.,MS: A&O to person place and time. At times she seemed in absence. She scored 20/30 on MMSE and had difficulty with concentration, calculation, visuospatial construction. Her penmanship was not normal, and appeared ""child-like"" according to her daughters. She had difficulty writing a sentence and spoke in a halting fashion; she appeared to have difficulty finding words. In addition, while attempting to write, she had difficulty finding the right margin of the page.,CN: Right homonymous inferior quadrantanopsia bordering on a right homonymous hemianopsia. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle tone and bulk.,Sensory: extinguishing of RUE sensation on double simultaneous stimulation, and at times she appeared to show sign of RUE neglect. There were no unusual spontaneous movements noted.,Coord: unremarkable except for difficulty finding the target on FNF exercise when the target was moved into the right side visual field.,Station: No sign of Romberg or pronator drift. There was no truncal ataxia.,Gait: decreased RUE swing and a tendency to veer and circumambulate to the right when asked to walk toward a target.,Reflexes: 2/2 and symmetric throughout all four extremities. Plantar responses were equivocal, bilaterally.,COURSE:, CBC, GS, PT, PTT, ESR, UA, CRP, TSH, FT4, and EKG were unremarkable. CSF analysis revealed: 38 RBC, 0 WBC, Protein 36, glucose 76. The outside MRI was reviewed and was found to show increased signal on T2 weighted images in the gyri of the left parietal-occipital regions. Repeat MRI, at UIHC, revealed the same plus increased signal on T2 weighted images in the left frontal region as well. CXR, transthoracic echocardiogram and 4 vessel cerebral angiogram were unremarkable. A 1/23/95, left frontal brain biopsy revealed spongiform changes without sign of focal necrosis, vasculitis or inflammatory changes. The working diagnosis became Creutzfeldt-Jakob Disease (Heidenhaim variant). The patient died on 2/15/95. Brain tissue was sent to the University of California at San Francisco. Analysis there revealed diffuse vacuolization throughout most of the cingulate gyrus, frontal cortex, hypothalamus, globus pallidus, putamen, insula, amygdala, hippocampus, cerebellum and medulla. This vacuolization was most severe in the entorhinal cortex and parahippocampal gyrus. Hydrolytic autoclaving technique was used with PrP-specific antibodies to identify the presence of protease resistant PrP (CJD). The patient's brain tissue was strongly positive for PrP (CJD)." Neurology Right frontal craniotomy with resection of right medial frontal brain tumor. Stereotactic image-guided neuronavigation and microdissection and micro-magnification for resection of brain tumor. Craniotomy & Neuronavigation 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. neurology, stereotactic image-guided neuronavigation, micro-magnification, resection of brain tumor, frontal craniotomy, mass effect, brain shift, stereotactic image, brain tumor, brain, tumor, craniotomy, endotracheal, carcinoma, neuronavigation, microdissection, Neurology Left temporal craniotomy and removal of brain tumor. Craniotomy - Temporal PREOPERATIVE DIAGNOSIS:, Brain tumor left temporal lobe.,POSTOPERATIVE DIAGNOSIS:, Brain tumor left temporal lobe - glioblastoma multiforme.,OPERATIVE PROCEDURE:,1. Left temporal craniotomy.,2. Removal of brain tumor.,OPERATING MICROSCOPE: , Stealth.,PROCEDURE: , The patient was placed in the supine position, shoulder roll, and the head was turned to the right side. The entire left scalp was prepped and draped in the usual fashion after having being placed in 2-point skeletal fixation. Next, we made an inverted-U fashion base over the asterion over temporoparietal area of the skull. A free flap was elevated after the scalp that was reflected using the burr hole and craniotome. The bone flap was placed aside and soaked in the bacitracin solution.,The dura was then opened in an inverted-U fashion. Using the Stealth, we could see that this large cystic mass was just below the cortex in the white matter just anterior to the trigone of the ventricle. We head through the vein of Labbe, and we made great care to preserve this. We saw where the tumor almost made to the surface. Here we made a small corticectomy using the Stealth for guidance. We left small corticectomy entered large cavity with approximately 15 cc of yellowish necrotic liquid. This was submitted to pathology. We biopsied this very abnormal tissue and submitted it to pathology. They gave us a frozen section diagnosis of glioblastoma multiforme. With the operating microscope and Greenwood bipolar forceps, we then systematically debulked this tumor. It was very vascular and we really continued to remove this tumor until all visible tumors was removed. We appeared to get two gliotic planes circumferentially. We could see it through the ventricle. After removing all visible tumor grossly, we then irrigated this cavity multiple times and obtained meticulous hemostasis and then closed the dura primarily with 4-0 Nurolon sutures with the piece of DuraGen placed over this in order to increase our chances for a good watertight seal. The bone flap was then replaced and sutured with the Lorenz titanium plate system. The muscle fascia galea was closed with interrupted 2-0 Vicryl sutures. Skin staples were used for skin closure. The blood loss of the operation was about 200 cc. There were no complications of the surgery per se. The needle count, sponge count, and the cottonoid count were correct.,COMMENT: ,Operating microscope was quite helpful in this; as we could use the light as well as the magnification to help us delineate the brain tumor - gliotic interface and while it was vague at sometimes we could I think clearly get a good cleavage plane in most instances so that we got a gross total removal of this very large and necrotic-looking tumor of the brain. neurology, temporal lobe, brain tumor, lorenz titanium plate, burr hole, cortex, corticectomy, craniotome, craniotomy, frozen section, glioblastoma multiforme, temporal craniotomy, temporoparietal, ventricle, white matter, tumor, temporal, brain, Neurology Left retrosigmoid craniotomy and excision of acoustic neuroma. Craniotomy - Retrosigmoid PREOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,POSTOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,PROCEDURE PERFORMED: , Left retrosigmoid craniotomy and excision of acoustic neuroma.,ANESTHESIA:, General.,OPERATIVE FINDINGS: , This patient had a 3-cm acoustic neuroma. The tumor was incompletely excised leaving a remnant of the tumor along the cerebellopontine angle portion of the facial nerve. The facial nerve was stimulated at the brainstem at 0.05 milliamperes at the conclusion of the dissections.,PROCEDURE IN DETAIL: ,Following induction of adequate general anesthetic, the patient was positioned for surgery. She was placed in a lateral position and her head was maintained with Mayfield pins. The left periauricular area was shaved, prepped, and draped in the sterile fashion. Transdermal electrodes for continuous facial nerve EMG monitoring were placed, and no response was verified. The proposed incision was injected with 1% Xylocaine with epinephrine. Next, T-shaped incision was made approximately 5 cm behind the postauricular crease. The incision was undermined at the level of temporalis fascia, and the portion of the fascia was harvested for further use.,Incision was made along the inferior aspect of the temporalis muscle and then extended inferiorly over the mastoid tip. Periosteal elevator was used to elevate periosteum in order to expose the mastoid and anterior aspect of the occipital bone. Emissary veins posterior to the sigmoid sinus were controlled with electrocautery and bone wax. Bergen retractors were used to maintain exposure. Using a cutting bur with continuous suction and irrigation of craniotomy was performed. The sigmoid sinus was identified anteriorly and the transverse sites were identified superiorly. From these structures approximately 4 x 4 cm, a window of bone was removed. Bone shavings were collected during the dissection and placed in Siloxane suspension for later use. The bone flap was also left at the site for further use. Dissection was extended along the inferior aspect of the sigmoid sinus to provide additional exposure of the skull base. Bone wax was used to occlude air cells lateral to the sigmoid sinus. There was extensively aerated temporal bone. At this point, Dr. Trask entered the case in order to open the dura and expose the tumor. The cerebellum was retracted away from the tumor, and the retractor was placed to help maintain exposure. Once initial exposure was completed, attention was directed to the posterior aspect of the temporal bone. The dura was excised from around the porous acusticus extending posteriorly along the bone. Then, using diamond burs, the internal auditory canal was dissected out. The bone was removed laterally for distance of approximately 8 mm. There was considerable aeration around the internal auditory canal as well. The dura was then incised over the internal auditory canal exposing the intracanalicular portion of the tumor. The tumor extended all the way to the fundus such that initial exposure of the facial nerve around the tumor was difficult. Therefore, Dr. Trask returned in order to further release the tumor from the brainstem and to debulk the central portions of the tumor. With dissection, he released the tumor from the trigeminal nerve superiorly and elevated the tumor away from the dorsal brainstem. The eighth nerve was identified and transected. Tumor debulking allowed for retraction of the tumor capsule away from the brainstem. The facial nerve was difficult to identify at the brainstem as well. It was identified by using an electrical stimulator but dissection attempted at this time was the plane between the nerve and the tumor proximally but this was difficult to achieve. Attention was then redirected to the internal auditory canal where this portion of the tumor was removed. The superior and inferior vestibular nerves were evulsed laterally and dissection proceeded along the facial nerve to the porous acusticus. At this point, plane of dissection was again indistinct. The tumor had been released from the porous and could be rotated. The tumor was further debulked and thinned, but could not crucially visualize the nerve on the anterior face of the tumor. The nerve could be stimulated, but was quite splayed over the anterior face. Further debulking of the tumor proceeded and additional attempts were made to establish point of dissection along the nerve, both proximally and distally. However, the cerebellopontine angle portion of the nerve was not usually delineated. However, the tumor was then thinned using CUSA down to fine sheath measuring only about 1 to 2 mm in thickness. It was released from the brainstem ventrally. The tumor was then cauterized with bipolar electrocautery. The facial nerve was stimulated at the brainstem and stimulated easily at 0.05 milliamperes. Overall, the remaining tumor volume would be of small percentage of the original volume. At this point, Dr. Trask re-inspected the posterior fossa to ensure complete hemostasis. The air cells around the internal auditory canal were packed off with muscle and bone wax. A piece of fascia was then laid over the bone defect. Next, the dura was closed with DuraGen and DuraSeal. The bone flap and bone ***** were then placed in the bone defect. Postauricular musculature was then reapproximated using interrupted 3-0 Vicryl sutures. The skin was also closed using interrupted subdermal 3-0 Vicryl sutures. Running 4-0 nylon suture was placed at the skin levels. Sterile mastoid dressing was then placed. The patient tolerated the procedure well and was transported to the PACU in a stable condition. All counts were correct at the conclusion of the procedure.,ESTIMATED BLOOD LOSS: ,100 mL. neurology, neuroma, bergen retractors, emissary veins, mayfield pins, acoustic, acoustic neuroma, cerebellopontine, craniotomy, facial nerve, periauricular, retrosigmoid, retrosigmoid craniotomy, internal auditory canal, porous acusticus, sigmoid sinus, auditory canal, bone, brainstem, nerve, postauricular, tumor Neurology Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA. Craniotomy - Occipital 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. neurology, brain tumor, cusa, occipital, adenocarcinoma, bone flap, craniotomy, malignant, metastatic, scalp galea, transverse linear incision, ventriculostomy, occipital craniotomy, tumor, stealth, brain, Neurology Postoperative visit for craniopharyngioma with residual disease. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved. Craniopharyngioma - Postop REASON FOR VISIT:, Postoperative visit for craniopharyngioma.,HISTORY OF PRESENT ILLNESS:, Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor. He was brought to the operating room on 01/04/07, underwent a transsphenoidal resection of tumor. Histology returned as craniopharyngioma. There is some residual disease; however, the visual apparatus was decompressed. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved.,MEDICATIONS: , Synthroid 100 mcg per day.,FINDINGS: , On exam, he is awake, alert and oriented x 3. Pupils are equal and reactive. EOMs are full. His visual acuity is 20/25 in the right (improved from 20/200) and the left is 20/200 improved from 20/400. He has a bitemporal hemianopsia, which is significantly improved and wider. His motor is 5 out of 5. There are no focal motor or sensory deficits. The abdominal incision is well healed. There is no evidence of erythema or collection. The lumbar drain was also well healed.,The postoperative MRI demonstrates small residual disease.,Histology returned as craniopharyngioma.,ASSESSMENT: , Postoperative visit for craniopharyngioma with residual disease.,PLANS: , I have recommended that he call. I discussed the options with our radiation oncologist, Dr. X. They will schedule the appointment to see him. In addition, he probably will need an MRI prior to any treatment, to follow the residual disease. neurology, visual acuity, blurred vision, tinnitus, headaches, residual disease, tumor, histology, craniopharyngioma, Neurology Patient referred for evaluation of her left temporal lobe epilepsy. Consult - Seizures 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., Neurology Cerebral palsy, worsening seizures. A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity. Consult - Seizures - 1 CHIEF COMPLAINT: , Worsening seizures.,HISTORY OF PRESENT ILLNESS: ,A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity. The patient stated she was in her normal state of well being when she was experiencing having frequent seizures. She lives in assisted living. She has been falling more frequently. The patient was driving a scooter and apparently was hitting into the wall with unresponsiveness in association with this. There was no head trauma, but apparently she was doing that many times and there was no responsiveness. The patient has no memory of the event. She is now back to her baseline. She states her seizures are worse in the setting of stress, but it is not clear to her why this has occurred. She is on Carbatrol 300 mg b.i.d. and she has been very compliant and without any problems. The patient is admitted for EMU monitoring for the characterization of these episodes and for the possibility of complex partial epilepsy syndrome or better characterization of this current syndrome.,PAST MEDICAL HISTORY: ,Include dyslipidemia and hypertension.,FAMILY HISTORY: ,Positive for stroke and sleep apnea.,SOCIAL HISTORY: , No smoking or drinking. No drugs.,MEDICATIONS AT HOME: , Include, Avapro, lisinopril, and dyslipidemia medication, she does not remember.,REVIEW OF SYSTEMS:, The patient does complain of gasping for air, witnessed apneas, and dry mouth in the morning. The patient also has excessive daytime sleepiness with EDS of 16.,PHYSICAL EXAMINATION:,VITAL SIGNS: Last blood pressure 130/85, respirations 20, and pulse 70.,GENERAL: Normal.,NEUROLOGICAL: As follows. Right-handed female, normal orientation, normal recollection to 3 objects. The patient has underlying MR. Speech, no aphasia, no dysarthria. Cranial nerves, funduscopic intact without papilledema. Pupils are equal, round, and reactive to light. Extraocular movements intact. No nystagmus. Her mood is intact. Symmetric face sensation. Symmetric smile and forehead. Intact hearing. Symmetric palate elevation. Symmetric shoulder shrug and tongue midline. Motor 5/5 proximal and distal. The patient does have limp on the right lower extremity. Her Babinski is hyperactive on the left lower extremity, upgoing toes on the left. Sensory, the patient does have sharp, soft touch, vibration intact and symmetric. The patient has trouble with ambulation. She does have ataxia and uses a walker to ambulate. There is no bradykinesia. Romberg is positive to the left. Cerebellar, finger-nose-finger is intact. Rapid alternating movements are intact. Upper airway examination, the patient has a Friedman tongue position with 4 oropharyngeal crowding. Neck more than 16 to 17 inches, BMI elevated above 33. Head and neck circumference very high.,IMPRESSION:,1. Cerebral palsy, worsening seizures.,2. Hypertension.,3. Dyslipidemia.,4. Obstructive sleep apnea.,5. Obesity.,RECOMMENDATIONS:,1. Admission to the EMU, drop her Carbatrol 200 b.i.d., monitor for any epileptiform activity. Initial time of admission is 3 nights and 3 days.,2. Outpatient polysomnogram to evaluate for obstructive sleep apnea followed by depression if clinically indicated. Continue her other medications.,3. Consult Dr. X for hypertension, internal medicine management.,4. I will follow this patient per EMU protocol. Neurology Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor. Craniotomy - Biparietal PREOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,POSTOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,TITLE OF THE OPERATION:,1. Biparietal craniotomy and excision of left parietooccipital metastasis from breast cancer.,2. Insertion of left lateral ventriculostomy under Stealth stereotactic guidance.,3. Right suboccipital craniectomy and excision of tumor.,4. Microtechniques for all the above.,5. Stealth stereotactic guidance for all of the above and intraoperative ultrasound.,INDICATIONS: , The patient is a 48-year-old woman with a diagnosis of breast cancer made five years ago. A year ago, she was diagnosed with cranial metastases and underwent whole brain radiation. She recently has deteriorated such that she came to my office, unable to ambulate in a wheelchair. Metastatic workup does reveal multiple bone metastases, but no spinal cord compression. She had a consult with Radiation-Oncology that decided they could radiate her metastases less than 3 cm with stereotactic radiosurgery, but the lesions greater than 3 cm needed to be removed. Consequently, this operation is performed.,PROCEDURE IN DETAIL: , The patient underwent a planning MRI scan with Stealth protocol. She was brought to the operating room with fiducial still on her scalp. General endotracheal anesthesia was obtained. She was placed on the Mayfield head holder and rolled into the prone position. She was well padded, secured, and so forth. The neck was flexed so as to expose the right suboccipital region as well as the left and right parietooccipital regions. The posterior aspect of the calvarium was shaved and prepared in the usual manner with Betadine soak scrub followed by Betadine paint. This was done only, of course, after fiducial were registered in planning and an excellent accuracy was obtained with the Stealth system. Sterile drapes were applied and the accuracy of the system was confirmed. A biparietal incision was performed. A linear incision was chosen so as to increase her chances of successful wound healing and that she is status post whole brain radiation. A biparietal craniotomy was carried out, carrying about 1 cm over toward the right side and about 4 cm over to the left side as guided by the Stealth stereotactic system. The dura was opened and reflected back to the midline. An inner hemispheric approach was used to reach the very large metastatic tumor. This was very delicate removing the tumor and the co-surgeons switched off to spare one another during the more delicate parts of the operation to remove the tumor. The tumor was wrapped around and included the choroidal vessels. At least one choroidal vessel was sacrificed in order to obtain a gross total excision of the tumor on the parietal occipital region. Bleeding was quite vigorous in some of the arteries and finally, however, was completely controlled. Complete removal of the tumor was confirmed by intraoperative ultrasound.,Once the tumor had been removed and meticulous hemostasis was obtained, this wound was left opened and attention was turned to the right suboccipital area. A linear incision was made just lateral to the greater occipital nerve. Sharp dissection was carried down in the subcutaneous tissues and Bovie electrocautery was used to reach the skull. A burr hole was placed down low using a craniotome. A craniotomy was turned and then enlarged as a craniectomy to at least 4 cm in diameter. It was carried caudally to the floor of the posterior fossa and rostrally to the transverse sinus. Stealth and ultrasound were used to localize the very large tumor that was within the horizontal hemisphere of the cerebellum. The ventriculostomy had been placed on the left side with the craniotomy and removal of the tumor, and this was draining CSF relieving pressure in the posterior fossa. Upon opening the craniotomy in the parietal occipital region, the brain was noted to be extremely tight, thus necessitating placement of the ventriculostomy.,At the posterior fossa, a corticectomy was accomplished and the tumor was countered directly. The tumor, as the one above, was removed, both piecemeal and with intraoperative Cavitron Ultrasonic Aspirator. A gross total excision of this tumor was obtained as well.,I then explored underneath the cerebellum in hopes of finding another metastasis in the CP angle; however, this was just over the lower cranial nerves, and rather than risk paralysis of pharyngeal muscles and voice as well as possibly hearing loss, this lesion was left alone and to be radiated and that it is less than 3 cm in diameter.,Meticulous hemostasis was obtained for this wound as well.,The posterior fossa wound was then closed in layers. The dura was closed with interrupted and running mattress of 4-0 Nurolon. The dura was watertight, and it was covered with blue glue. Gelfoam was placed over the dural closure. Then, the muscle and fascia were closed in individual layers using #0 Ethibond. Subcutaneous was closed with interrupted inverted 2-0 and 0 Vicryl, and the skin was closed with running locking 3-0 Nylon.,For the cranial incision, the ventriculostomy was brought out through a separate stab wound. The bone flap was brought on to the field. The dura was closed with running and interrupted 4-0 Nurolon. At the beginning of the case, dural tack-ups had been made and these were still in place. The sinuses, both the transverse sinus and sagittal sinus, were covered with thrombin-soaked Gelfoam to take care of any small bleeding areas in the sinuses.,Once the dura was closed, the bone flap was returned to the wound and held in place with the Lorenz microplates. The wound was then closed in layers. The galea was closed with multiple sutures of interrupted 2-0 Vicryl. The skin was closed with a running locking 3-0 Nylon.,Estimated blood loss for the case was more than 1 L. The patient received 2 units of packed red cells during the case as well as more than 1 L of Hespan and almost 3 L of crystalloid.,Nevertheless, her vitals remained stable throughout the case, and we hopefully helped her survival and her long-term neurologic status for this really nice lady. neurology, metastatic lesion, biparietal, mayfield head holder, microtechniques, stealth, craniotomy, excision, fiducial, infratentorial, parietooccipital, stereotactic, suboccipital, subtentorial, ventriculostomy, lesions to the brain, removal of the tumor, parietal occipital region, running locking nylon, biparietal craniotomy, posterior fossa, tumor, brain, dura, lesions, Neurology The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches. In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup. Consult - Migraine HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches. In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup. Neurology consult was called to evaluate the patient in view of the current symptomatology. The headaches were refractory to the treatment. The patient has been on Topamax and Maxalt in the past, but did not work and according to the patient she got more confused.,PAST MEDICAL HISTORY: , History of migraine.,PAST SURGICAL HISTORY: ,Significant for partial oophorectomy, appendectomy, and abdominoplasty.,SOCIAL HISTORY: ,No history of any smoking, alcohol, or drug abuse. The patient is a registered nurse by profession.,MEDICATIONS: , Currently taking no medication.,ALLERGIES: , No known allergies.,FAMILY HISTORY:, Nothing significant.,REVIEW OF SYSTEMS: , The patient was considered to ask systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy, immunology, endocrinology, toxicology, oncology, and was found to be positive for the symptoms mentioned in the history of the presenting illness.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure of 115/66, heart rate of 69, respiratory rate of 13, temperature normal, and pulse oximetry 98% on room air at the time of initial evaluation.,HEENT: Head, normocephalic, atraumatic. Neck supple. Throat clear. No discharge from the ears or nose. No discoloration of conjunctivae and sclerae. No bruits auscultated over temple, orbits, or the neck.,LUNGS: Clear to auscultation.,CARDIOVASCULAR: Normal heart sounds.,ABDOMEN: Benign.,EXTREMITIES: No edema, clubbing or cyanosis.,SKIN: No rash. No neurocutaneous disorder.,MENTAL STATUS: The patient is awake, alert and oriented to place and person. Speech is fluent. No language deficits. Mood normal. Affect is clear. Memory and insight is normal. No abnormality with thought processing and thought content. Cranial nerve examination intact II through XII. Motor examination: Normal bulk, tone and power. Deep tendon reflexes symmetrical. Downgoing toes. No sign of any myelopathy. Cortical sensation intact. Peripheral sensation grossly intact. Vibratory sense not tested. Gait not tested. Coordination is normal with no dysmetria.,IMPRESSION: , Intractable headaches, by description to be migraines. Complicated migraines by clinical criteria. Rule out sinusitis. Rule out vasculitis including temporal and arthritis, lupus, polyarthritis, moyamoya disease, Takayasu and Kawasaki disease.,PLAN AND RECOMMENDATIONS: , The patient to be given a trial of the prednisone with a plan to taper off in 6 days, as she already had received 50 mg today. Depakote as a part of migraine prophylaxis and Fioricet on p.r.n. basis.,The patient to get vasculitis workup, as it has not been ordered by the primary care physician initially. The patient already had MRI of the brain and the cervical spine. MRI of the brain reported negative and cervical spine as shown signs of disk protrusion at C5 and C6 level, which will not explain of the temporal headache. Plan and followup discussed with the patient in detail. Neurology Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques. Craniotomy - Frontotemporal 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. neurology, frontotemporal, weitlaner, calvarium, cookie cutter type, craniotomy, dura, frontotemporal craniotomy, galea, hematoma, subdural, subdural hematoma, syncopal, temporalis, subacute subdural hematoma, temporalis muscle, Neurology The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus. Consult - Normal Pressure Hydrocephalus REASON FOR VISIT: , The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus. He is accompanied by his wife and daughter.,HISTORY OF PRESENT ILLNESS:, I first saw him nearly a year ago on December 20, 2007. At that time, he had had a traumatic deterioration over the course of approximately eight months. This included severe cognitive impairment, gait impairment, and incontinence. He had actually been evaluated at Hospital with CSF drainage via a temporary spinal catheter, but there was no response that was noted. When I saw him, there were findings consistent with cervical stenosis and I ordered an MRI scan of the cervical spine. I subsequently referred him to Dr. X, who performed a cervical laminectomy and instrumented fusion on July 16, 2008. According to his notes this went well.,According to the family, there has not been any improvement.,With regard to the gait and balance, they actually think that he is worse now than he was a year ago. He is virtually unable to walk at all. He needs both a walker and support from an assistant to be able to stand or walk. Therefore, he is always in the wheelchair.,He is completely incontinent. He never indicates his need to the go to the bathroom. On the other hand when asked, he will indicate that he needs to go. He wears a Depends undergarment all the time.,He has no headaches.,His thinking and memory are worse. For the most part, he is apathetic. He does not talk very much. He lives in a skilled nursing facility in the Alzheimer's section. He does have some daytime activities. He takes a nap once a day. He does not read very much. On the other hand, he did recently exercise the right to vote in the presidential election. He needs full assistance at the nursing home.,MEDICATIONS:, From the list by the nursing home are Aricept 10 mg in the evening, carbidopa/levodopa 25/100 mg three times a day, citalopram (Celexa) 40 mg daily, Colace 100 mg twice a day, finasteride (Proscar) 5 mg once a day, Flomax (tamsulosin) 0.4 mg once a day, multivitamin with iron once a day, omeprazole (Prilosec) 20 mg once a day, senna 8.6 mg twice a day, Tylenol 650 mg as needed, and promethazine 25 mg as needed.,PHYSICAL EXAM: , On examination today, this is a pleasant 81-year-old man who is brought back from the clinic waiting area in a wheelchair. He is well developed, well nourished, and kempt.,Vital Signs: Temperature 96.7, pulse 62, respirations 16, and blood pressure 123/71.,Head: The head is normocephalic and atraumatic.,Mental Status: Assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge. The Mini-Mental State Exam score was 14/30. He was not at all oriented. He did know we were at Sinai Hospital on the second floor. He could spell 'world' forward, but was mute when asked to spell backwards. He was mute when asked to recall 3/3 objects for delayed recall. He could not copy a diagram of intersecting pentagons. For comparison, the Mini-Mental State exam score last December was 20/30 when attention was tested by having him spell 'world' backwards and 28/30 when tested with serial 7 subtractions. Additionally, there are times when he stutters or stammers. I do not see any paraphasic errors. There is some evidence of ideomotor apraxia. He is also stimulus bound. There is a tendency to mimic.,Cranial Nerve Exam: There is no upgaze that I can elicit today. The horizontal gaze and down gaze are intact. This is a change from a year ago. The muscles of facial expiration are intact as are hearing, head turning, cough, tongue, and palate movement.,Motor Exam: Normal bulk and strength. The tone is characterized by paratonia. There is no atrophy, fasciculations, drift, or tremor.,Sensory Exam: Intact to light touch.,Cerebellar Exam: Intact for finger-to-nose testing that he can perform only by mimicking, but not by following verbal commands.,Gait: Severely impaired. When in the wheelchair, he leans to one side. He cannot getup on his own. He needs assistance. Once up, he can bear weight, but cannot maintain his balance. This would amount to a Tinetti score of zero.,REVIEW OF X-RAYS: , I personally reviewed the CT scan of the brain from November 1, 2008 and compared it to the MRI scan from a year ago. The ventricles appear larger to me now in comparison to a year ago. The frontal horn span is now 6 cm, whereas previously it was about 5.5 cm. The 3rd ventricular span is about 15 mm. There is no obvious atrophy, although there may be some subtle bilateral perisylvian atrophy. The scan from a year ago showed that there was a patent sylvian aqueduct.,ASSESSMENT:, The patient has had worsening of his gait, his dementia, and his incontinence. The new finding for me today is the limited upgaze. This would be consistent either with progressive supranuclear palsy, which was one of the differential diagnoses a year ago, or it could be consistent with progressive enlargement of the ventricles.,PROBLEMS/DIAGNOSES:,1. Question of idiopathic normal pressure hydrocephalus (331.5).,2. Possible supranuclear palsy.,3. Severe gait impairment.,4. Urinary urgency and incontinence.,5. Dementia.,PLAN: , I had a long talk with him and his family. Even though he has already had a trial of CSF drainage via spinal catheter at Hospital over a year ago, I offered this test to them again. I do so on the basis that there is further enlargement of the ventricles on the scan. His family and I discussed the facts that it is not likely to be only hydrocephalus. Instead we are trying to answer the question of whether hydrocephalus is contributing sufficiently to his symptoms that progressing with shunt surgery would make a difference. I have advised them to think it over for a day and contact my office to see whether they would wish to proceed. I gave them a printed prescription of the protocol including its rationale, risks, benefits, and alternatives. I specifically mentioned the 3% chance of infection, which mean a 97% chance of no infection. Neurology Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain. Craniotomy - Burr Hole 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. neurology, hematoma, burr hole, craniotomy, frontotemporal, frontotemporal craniotomy, subdural, subdural drain, subdural hematoma, subdural space Neurology Patient with a history of mesothelioma and likely mild dementia, most likely Alzheimer type. Consult - Alzheimer disease "The patient states that she has been doing fairly well at home. She balances her own checkbook. She does not do her own taxes, but she has never done so in the past. She states that she has no problems with cooking meals, getting her own meals, and she is still currently driving. She denies burning any dishes because she forgot them on the stove or forgetting what she is doing in the middle of a task or getting lost while she is driving around or getting lost in her own home. She states that she is very good remembering the names of her family members and does not forget important birthdays such as the date of birth of her grandchildren. She is unfortunately living alone, and although she seems to miss her grandchildren and is estranged from her son, she denies any symptoms of frank depression. There is unfortunately no one available to us to corroborate how well she is doing at home. She lives alone and takes care of herself and does not communicate very much with her brother and sister. She also does not communicate very much with her son who lives in Santa Cruz or her grandchildren. She denied any sort of personality change, paranoid ideas or hallucinations. She does appear to have headaches that can be severe about four times a month and have primarily photophobia and some nausea and occasionally emesis associated with it. When these headaches are very severe, she goes to the emergency room to get a single shot. She is unclear if this is some sort of a migraine medication or just a primary pain medication. She takes Fiorinal for these headaches and she states that this helps greatly. She denies visual or migraine symptoms.,REVIEW OF SYSTEMS: , Negative for any sort of focal neurologic deficits such as weakness, numbness, visual changes, dysarthria, diplopia or dysphagia. She also denies any sort of movement disorders, tremors, rigidities or clonus. Her personal opinion is that some of her memory problems may be due to simply to her age and/or nervousness. She is unclear as if her memory is any worse than anyone else in her age group.,PAST MEDICAL HISTORY: , Significant for mesothelioma, which was diagnosed seemingly more than 20 to 25 years ago. The patient was not sure of exactly when it was diagnosed. This has been treated surgically by debulking operations for which she states that she has undergone about 10 operations. The mesothelioma is in her abdomen. She does not know of any history of having lung mesothelioma. She states that she has never gotten chemotherapy or radiation for her mesothelioma. Furthermore, she states that her last surgical debulking was more than 10 years ago and her disease has been fairly stable. She does have a history of three car accidents that she says were all rear-enders where she was hit while essentially in a stopped position. These have all occurred over the past five years. She also has a diagnosis of dementing illness, possibly Alzheimer disease from her previous neurology consultation. This diagnosis was given in March 2006.,MEDICATIONS:, Fiorinal, p.r.n. aspirin, unclear if baby or full sized, Premarin unclear of the dose.,ALLERGIES:, NONE.,SOCIAL HISTORY:, Significant for her being without a companion at this point. She was born in Munich, Germany. She immigrated to of America in 1957 after her family had to move to Eastern Germany, which was under Russian occupation at that time. She is divorced. She used to work as a secretary and later worked as a clerical worker at IBM. She stopped working more than 20 years ago due to complications from her mesothelioma. She denies any significant tobacco, alcohol or illicit drugs. She is bilingual speaking, German and English. She has known English from before her teens. She has the equivalent of a high school education in Germany. She has one brother and one sister, both of whom are healthy and she does not spend much time communicating with them. She has one son who lives in Santa Cruz. He has grandchildren. She is trying to contact with her grandchildren.,FAMILY HISTORY: , Significant for lung, liver, and prostate cancer. Her mother died in her 80s of ""old age,"" but it appears that she may have had a mild dementing illness at that time. Whatever that dementing illness was, appears to have started mostly in her 80s per the patient. No one else appears to have Alzheimer disease including her brother and sister.,PHYSICAL EXAMINATION: , Her blood pressure is 152/92, pulse 80, and weight 80.7 kg. She is alert and well nourished in no apparent distress. She occasionally fumbles with questions of orientation, missing the day and the date. She also did not know the name of the hospital, she thought it was O'Connor and she thought she was in Orange County and also did not know the floor of the hospital that we are in. She lost three points for recall. Even with prompting, she could not remember the objects that she was given to remember. Her Mini Mental Score was 22/30. There were no naming problems or problems with repetition. There were also no signs of dysarthria. Her pupils were bilaterally reactive to light and accommodation. Her extraocular movements were intact. Her visual fields were full to confrontation. Her sensations of her face, arm, and leg were normal. There were no signs of neglect with double simultaneous stimulation. Tongue was midline. Her palate was symmetric. Her face was symmetric as well. Strength was approximately 5/5. She did have some right knee pain and she had a mildly antalgic gait due to her right knee pain. Her reflexes were symmetric and +2 except for her toes, which were +1 to trace. Her plantar reflexes were mute. Her sensation was normal for pain, temperature, and vibration. There were no signs of ataxia on finger-to-nose and there was no dysdiadochokinesia. Gait was narrow and she could toe walk briefly and heel walk without difficulty.,SUMMARY:, Ms. A is a pleasant 72-year-old right-handed woman with a history of mesothelioma that appears stable at this time and likely mild dementia, most likely Alzheimer type. We tactfully discussed the patient's diagnosis with her, and she felt reassured. We told her that this most likely was in the earlier stages of disease and she would benefit from trying Aricept. She stated that she did not have the prescription anymore from her outpatient neurology consult for the Aricept, so we wrote her another prescription for Aricept. The patient herself seemed very concerned about the stigma of the disease, but our lengthy discussion, expressed genuine understanding as to why her outpatient physician had reported her to DMV. It was explicitly told to not drive by her outpatient neurologist and we concur with this assessment. She will follow up with us in the next six months and will call us if she has any problems with the Aricept. She was written for Aricept to start at 5 mg for three weeks, and if she has no side effects which typically are GI side effects, then she can go up to 10 mg a day. We also reviewed with Ms. A the findings for outpatient MRI, which showed some mild atrophy per report and also that her metabolic workup, which included an RPR, TSH, and B12 were all within normal limits.," neurology, neurology consultation, dementing illness, alzheimer disease, dementia, alzheimer, mesothelioma, Neurology Patient with a history of right upper pons and right cerebral peduncle infarction. Consult - Cerebral Peduncle Infarction FAMILY HISTORY AND SOCIAL HISTORY:, Reviewed and remained unchanged.,MEDICATIONS:, List remained unchanged including Plavix, aspirin, levothyroxine, lisinopril, hydrochlorothiazide, Lasix, insulin and simvastatin.,ALLERGIES:, She has no known drug allergies.,FALL RISK ASSESSMENT: , Completed and there was no history of falls.,REVIEW OF SYSTEMS: ,Full review of systems again was pertinent for shortness of breath, lack of energy, diabetes, hypothyroidism, weakness, numbness and joint pain. Rest of them was negative.,PHYSICAL EXAMINATION:,Vital Signs: Today, blood pressure was 170/66, heart rate was 66, respiratory rate was 16, she weighed 254 pounds as stated, and temperature was 98.0.,General: She was a pleasant person in no acute distress.,HEENT: Normocephalic and atraumatic. No dry mouth. No palpable cervical lymph nodes. Her conjunctivae and sclerae were clear.,NEUROLOGICAL EXAMINATION:, Remained unchanged.,Mental Status: Normal.,Cranial Nerves: Mild decrease in the left nasolabial fold.,Motor: There was mild increased tone in the left upper extremity. Deltoids showed 5-/5. The rest showed full strength. Hip flexion again was 5-/5 on the left. The rest showed full strength.,Reflexes: Reflexes were hypoactive and symmetrical.,Gait: She was mildly abnormal. No ataxia noted. Wide-based, ambulated with a cane.,IMPRESSION: , Status post cerebrovascular accident involving the right upper pons extending into the right cerebral peduncle with a mild left hemiparesis, has been clinically stable with mild improvement. She is planned for surgical intervention for the internal carotid artery.,RECOMMENDATIONS: , At this time, again we discussed continued use of antiplatelet therapy and statin therapy to reduce her risk of future strokes. She will continue to follow with endocrinology for diabetes and thyroid problems. I have recommended a strict control of her blood sugar, optimizing cholesterol and blood pressure control, regular exercise and healthy diet and I have discussed with Ms. A and her daughter to give us a call for post surgical recovery. I will see her back in about four months or sooner if needed. neurology, internal carotid artery, cerebral peduncle infarction, carotid artery, blood pressure, upper pons, infarction, cerebral, peduncle, Neurology The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face. Consult - Facial Twitching REASON FOR REFERRAL: , Facial twitching.,HISTORY OF PRESENT ILLNESS: , The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face. She reports she is still having right posterior head pressure like sensations approximately one time per week. These still are characterized by a tingling, pressure like sensation that often has a feeling as though water is running down on her hair. This has also decreased in frequency occurring approximately one time per week and seems to respond to over-the-counter analgesics such as Aleve. Lastly during conversation today, she brought again the problem of daydreaming at work and noted that she occasionally falls asleep when sitting in non-stimulating environments or in front of the television. She states that she feels fatigued all the time and does not get good sleep. She describes it as insomnia, but upon questioning she works from 4 till mid night and then gets home and cannot go to sleep for approximately two hours and wakes up reliably by 9.00 a.m. each morning and sleeps no more than five to six hours ever, but usually five hours. Her sleep is relatively uninterrupted except for the need to get up and go to the bathroom. She thinks she may snore, but she is not sure. She does not recall any events of awakening and gasping for breath.,PAST MEDICAL HISTORY: , Please see my earlier notes in chart.,FAMILY HISTORY: ,Please see my earlier notes in chart.,SOCIAL HISTORY: , Please see my earlier notes in charts.,REVIEW OF SYSTEMS: ,Today, she mainly endorses the tingling sensation in the right posterior head often bilateral as well as a diagnosis of depression and persistent somewhat sad mood, poor sleep, and possible snoring; otherwise, the 10-system review is negative.,PHYSICAL EXAMINATION:,General Examination: Unremarkable mainly for mild-to-moderate obesity with a weight of 258 pounds. Otherwise, general examination is unremarkable.,NEUROLOGICAL EXAMINATION: ,As before is nonfocal. Please see note in chart for details.,PERTINENT FINDINGS: , Since the last evaluation, she has had an MRI performed, which was largely unremarkable except for a 1.2 cm lobular T2 hyperintense abnormality at the right clivus and petrous carotid canal, which does not enhance. The nature of this lesion is unclear. Certainly, this abnormality would not explain her left facial twitching and is unlikely to be involved with the right posterior sensory changes she experiences.,LABS: , She was supposed to have Lyme titers and thyroid tests as well as fasting glucose, which were not done; however, in light of her improvement these may not need to be performed at this time.,IMPRESSION:,1. Left facial twitching-appears to be improving. Most likely, this is a peripheral nerve injury related to her abscess as previously described. In light of her negative MRI and clinical improvement, we discussed options and elected to just observe for now.,2. Posterior pressure like headache, also appears to be improving. The etiology is unclear, but as it responds nicely to nonsteroidal antiinflammatories and is decreasing, no further evaluation is needed.,3. Probable circadian sleep disorder related to her nighttime work schedule and awakening at 9.00 a.m. with insufficient sleep. There is also the possibility of consistent obstructive sleep apnea and if symptoms worsen then we should consider doing a sleep study. For the time being, sleep hygiene measures were discussed with the patient including trying to sleep later at least till 10.00 a.m. or 10.30 to get a full-night sleep. She is on vacation next week and is going to try to see if this will help. We also discussed as before weight loss and exercise, which could be helpful.,4. Right clivus and petrous lesion of unknown etiology. We will repeat the MRI at four months to see for interval change.,5. The patient voiced understanding of these plans and will be following up with me in five months. neurology, grimacing, headache, clivus and petrous, facial twitching, sleep, facial, twitching, Neurology Chest CT - Thymoma and history of ocular myasthenia gravis. Chest CT - Myasthenia Gravis "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." neurology, diplopia, neuromuscular disease, muscle antibody titers, chest ct, intermittent binocular, rightward gaze, striated muscle, myasthenia gravis, intermittent, torsional, binocular, myasthenia, chest, thymoma, ophthalmology, antibody, Neurology Followup cervical spinal stenosis. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects. Cervical Spinal Stenosis REASON FOR VISIT: ,Followup cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS: ,Ms. ABC returns today for followup regarding her cervical spinal stenosis. I have last seen her on 06/19/07. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on 06/04/07, when she thought she had exacerbated her conditions while lifting several objects.,I referred her to obtain a cervical spine MRI.,She returns today stating that she continues to have right upper extremity pain, paresthesias, weakness, which she believes radiates from her neck. She had some physical therapy, which has been helping with the neck pain. The right hand weakness continues. She states she has a difficult time opening jars, and doors, and often drops items from her right greater than left upper extremity. She states she have several occasions when she is sleeping at night, she has had sharp shooting radicular pain and weakness down her left upper extremity and she feels that these symptoms somewhat scare her.,She has been undergoing nonoperative management by Dr. X and feels this has been helping her neck pain, but not the upper extremity symptoms.,She denies any bowel and bladder dysfunction. No lower back pain, no lower extremity pain, and no instability with ambulation.,REVIEW OF SYSTEMS:, Negative for fevers, chills, chest pain, and shortness of breath.,FINDINGS: ,On examination, Ms. ABC is a very pleasant well-developed, well-nourished female in no apparent distress. Alert and oriented x3. Normocephalic and atraumatic. Afebrile to touch.,She ambulates with a normal gait.,Motor strength is 4 plus out of 5 in the bilateral deltoids, biceps, triceps muscle groups, 4 out of 5 in the bilateral hand intrinsic muscle groups, grip strength 4 out of 5, 4 plus out of 5 bilateral wrist extension and wrist flexion.,Light touch sensation decreased in the right greater than left C6 distribution. Biceps and brachioradialis reflexes are 3 plus. Hoffman sign normal bilaterally.,Lower extremity strength is 5 out of 5 in all muscle groups. Patellar reflex is 3 plus. No clonus.,Cervical spine radiographs dated 06/21/07 are reviewed.,They demonstrate evidence of spondylosis including degenerative disk disease and anterior and posterior osteophyte formation at C4-5, C5-6, C6-7, and C3-4 demonstrates only minimal if any degenerative disk disease. There is no significant instability seen on flexion-extension views.,Updated cervical spine MRI dated 06/21/07 is reviewed.,It demonstrates evidence of moderate stenosis at C4-5, C5-6. These stenosis is in the bilateral neural foramina and there is also significant disk herniation noted at the C6-7 level. Minimal degenerative disk disease is seen at the C6-7. This stenosis is greater than C5-6 and the next level is more significantly involved at C4-5.,Effacement of the ventral and dorsal CSF space is seen at C4-5, C5-6.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination, and radiographic findings are compatible with C4-5, C5-6 cervical spinal stenosis with associated right greater than left upper extremity radiculopathy including weakness.,I spent a significant amount of time today with the patient discussing the diagnosis, prognosis, natural history, nonoperative, and operative treatment options.,I laid out the options as continued nonoperative management with physical therapy, the same with the addition of cervical epidural steroid injections and surgical interventions.,The patient states she would like to avoid injections and is somewhat afraid of having these done. I explained to her that they may help to improve her symptoms, although they may not help with the weakness.,She feels that she is failing maximum nonoperative management and would like to consider surgical intervention.,I described the procedure consisting of C4-5, C5-6 anterior cervical decompression and fusion to the patient in detail on a spine model.,I explained the rationale for doing so including the decompression of the spinal cord and improvement of her upper extremity weakness and pain. She understands.,I discussed the risks, benefits, and alternative of the procedure including material risks of bleeding, infection, neurovascular injury, dural tear, singular or multiple muscle weakness, paralysis, hoarseness of voice, difficulty swallowing, pseudoarthrosis, adjacent segment disease, and the risk of this given the patient's relatively young age. Of note, the patient does have a hoarse voice right now, given the fact that she feels she has allergies.,I also discussed the option of disk arthroplasty. She understands.,She would like to proceed with the surgery, relatively soon. She has her birthday coming up on 07/20/07 and would like to hold off, until after then. Our tentative date for the surgery is 08/01/07. She will go ahead and continue the preoperative testing process. Neurology A woman presents for neurological evaluation with regards to a diagnosis of multiple sclerosis. Comprehensive Neurological Evaluation "As you know, the patient is a 50-year-old right-handed Caucasian female, who works as an independent contractor and as a human resources consultant.,Her neurological history first begins in December of 1987, when she had a rather sudden onset of slurred speech and the hesitancy when she started to walk. She had HMO insurance at that time and saw a neurologist, whose name she does not recall. She thinks that she underwent MRI scan of the brain and possibly visual evoked response and brainstem auditory evoked response tests. She was told that all the tests were normal and no diagnosis was made.,The slurred speech resolved after a few weeks, but her gait hesitancy persisted for a number of years and then finally partially improved. She also began to note that she would fatigue after very prolonged walking.,In about 1993, she developed bladder urgency and frequency along with some nocturia. She saw a urologist and underwent urodynamic testing. She was diagnosed as having ""overactive bladder"", but the cause of this was never determined. She was treated with medications, possibly Ditropan, without much benefit. She also developed a dry mouth from the medication and so she discontinued it.,Also in about 1993, she began to note an uncomfortable ""stiffness"" in her feet and slight swelling of the ankles. Apparently, the swelling was not visible by others. She saw multiple physicians and was told that it was ""not arthritis"", but no definite diagnosis was ever established. She saw at least two rheumatologists on several occasions and blood tests were all normal. No clear-cut diagnosis was ever made and the patient simply learned to live with these symptoms.,However, over time she noted that the symptoms in her legs seemed to worsen somewhat. She states from time-to-time she could ""barely walk"". She felt as if her balance is impaired and she felt as if she were ""walking on stilts"". She tried arch supports from a podiatrist without any benefit. She began to tire more easily when walking.,In 2002 she was seen by a podiatrist, who noticed an abnormal gait and recommended that she see a neurologist.,In the fall of 2002, she was seen by Dr. X. He ordered an MRI scan of her brain and lumbar spine. He also did some sort of nerve testing and possibly visual evoked response testing. After reviewing everything, he diagnosed multiple sclerosis. However, prior to starting her on immunomodulatory therapy, he referred her for a second opinion to Dr. Y, in January of 2003. Dr. Y confirmed the diagnosis of multiple sclerosis.,The patient then returned to Dr. X and was started on Avonex. She continued on it for about six months. However, it made her feel much more stiff and delayed and so she finally stopped it. She also recalled being tried on baclofen by Dr. X, but again it did not benefit her and made her feel slightly dizzy. So, she discontinued it also.,At that point in time, she decided to try a program of ""good nutrition, vitamin supplements, and fish oil"".,In December 2004 and extending up to February 2005, she began to note progressively more severe swelling and stiffness in the distal lower extremities. She began to have to use a cane. She was seen in neurological consultation by Dr. Z. She was treated with a Medrol Dosepak. Her spasticity and swelling seemed to improve dramatically. However, within about two weeks symptoms were back to baseline.,She was then treated with intravenous Solu-Medrol 500 mg daily for five days followed by a prednisone or Medrol taper (July 2005). This seemed to be less helpful than the oral steroids, but was partially beneficial. However, it wore off once again.,A repeat MRI scan of the brain in April 2005 was said to ""look better"". She was started on Zanaflex for her lower extremity spasticity without benefit.,Finally six days ago, she was restarted on oral prednisone 10 mg tablets. She takes one-half tablet daily and this again has seemed to reduce the swelling and stiffness in her legs. She continues on the prednisone in the same dosage for relief of the spasticity.,She has not been on any other immunomodulatory agents.,The patient does note some complaints of mild heat sensitivity and mild easy fatigability. There is no history of diplopia, dysarthria, aphasia, focal weakness, numbness, paresthesias, cognitive dysfunction, or memory dysfunction.,PAST MEDICAL HISTORY: , Essentially noncontributory.,ALLERGIES:, The patient is allergic to LOBSTER and VICODIN. She feels that she is probably allergic to IODINE.,SOCIAL HISTORY:, She does not smoke. She takes one glass of wine per day.,PAST SURGICAL HISTORY: , She has not had any prior surgeries. Her general health has been excellent except for the above-indicated problems.,REVIEW OF OUTSIDE RADIOLOGICAL STUDIES:, The patient brought with her today MRI scans of the brain, thoracic spine, and lumbosacral spine performed on 11/14/02 on a 1.5-Tesla magnet. There are numerous T2 hyperintense lesions in the periventricular and subcortical white matter of the brain and at least one lesion is in the corpus callosum. There appear to be Dawson's fingers. The MRI of the thoracic and lumbosacral spines did not reveal any significant abnormalities.,Also available are the MRI scans of the brain, cervical spine, thoracic spine, and lumbosacral spine performed on a 0.35-Tesla magnet on 04/22/05. The MRI of the brain shows that one of the prior lesions has resolved and there appear to be one or two more lesions.,However, the quality of the newer scan is only 0.35-Tesla and is suboptimal. Visualization of the cord is also suboptimal, but there are no clear-cut extraaxial or complexities of the spinal cord. It is difficult to be certain that there are no intra-axial lesions, but I could not clearly see one.,PHYSICAL EXAMINATION:,Vital signs: Blood pressure 151/88, pulse 92, temperature 99.5ºF, and weight 124 lb (dressed).,General: Well-developed, well-nourished 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: Awake, alert, oriented to time, place, and person; appropriate. Recent and remote memory intact. No evidence of right-left confusion, finger agnosia, dysnomia or aphasia.,CRANIAL NERVES,:,II: Visual fields full to confrontation. Fundi benign.,III, IV, VI: Extraocular movements full throughout, without nystagmus. No ptosis. Pupils equal, round and react briskly to light and accommodation.,V: Normal sensation to light touch and pinprick bilaterally. Corneal reflexes equal bilaterally. Motor function normal.,VII: No facial asymmetry.,VIII: Hears finger rub bilaterally. Weber and Rinne tests normal.,IX & X: Palate elevates symmetrically bilaterally with phonation. Gag reflex equal bilaterally.,XI: Sternocleidomastoid and upper trapezius normal tone, bulk and strength bilaterally.,XII: Tongue midline without atrophy or fasciculations. Rapid alternating movements normal. No dysarthria.,Motor: Tone, bulk, and strength are normal in both upper extremities. In the lower extremities, there is moderate spasticity on the right and moderately severe spasticity on the left. There are bilateral Achilles' contractures more so on the left than the right and also a slight left knee flexion contracture.,Strength in the lower extremities is rated as follows on a 5-point scale (right/left): Iliopsoas 4+/5-, quadriceps 5-/5-, tibialis anterior 4+/4+, and gastrocnemius 5/5. There are no tremors, fasciculations or abnormal involuntary movements." Neurology Patient reports a six to eight-week history of balance problems with later fatigue and weakness. Cervical Cord Lesion - Consult "HISTORY OF PRESENT ILLNESS:, This is a 58-year-old male who reports a six to eight-week history of balance problems with fatigue and weakness. He has had several falls recently. He apparently had pneumonia 10 days prior to the onset of the symptoms. He took a course of amoxicillin for this. He complained of increased symptoms with more and more difficulty with coordination. He fell at some point near the onset of the symptoms, but believes that his symptoms had occurred first. He fell from three to five feet and landed on his back. He began seeing a chiropractor approximately five days ago and had adjustments of the neck and lumbar spine, although he clearly had symptoms prior to this.,He has had mid and low back pain intermittently. He took a 10-day course of Cipro believing that he had a UTI. He denies, however, any bowel or bladder problems. There is no incontinence and he does not feel that he is having any difficulty voiding.,PAST SURGICAL HISTORY:, He has a history of surgery on the left kidney, when it was ""rebuilt."" He has had knee surgery, appendectomy and right inguinal hernia repair.,MEDICATIONS:, His only home medications had been Cipro and Aleve. However, he does take aspirin and several over the counter supplements including a multivitamin with iron, ""natural"" potassium, Starlix and the aspirin.,ALLERGIES:, HE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, He smokes one-and-one-half-packs of cigarettes per day and drinks alcohol at least several days per week. He is employed in sales, which requires quite a bit of walking, but he is not doing any lifting. He had been a golfer in the past.,PAST MEDICAL HISTORY:, He has had documented cervical spondylosis, apparently with an evaluation over 15 years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 156/101, pulse was 88, respirations 18. He is afebrile.,MENTAL STATUS: He is alert.,CRANIAL NERVES: His pupils were reactive to light. He had a dense left cataract present. The right disk margin appears sharp. His eye movements were full. The face was symmetric. Pain and temperature sensation were intact over both sides of the face. The tongue was midline.,NECK: His neck was supple.,MUSCULOSKELETAL: He has intact strength and normal tone in the upper extremities. He had increased tone in both lower extremities. He had hip flexion of 4/5 on the left. He had intact strength on the right lower extremity, although had slight hammertoe deformity bilaterally.,NEUROLOGIC: His reflexes were 2+ in the upper extremities, 3+ at the knees and 1+ at the ankles. He withdrew to plantar stimulation on the left, but did not have a Babinski response clearly present. He had intact finger-to-nose testing. Marked impairment in heel-to-shin testing. He was able to sit unassisted. He stood with assistance, but had a markedly ataxic gait. On sensory exam, he had a slight distal gradient to pin and vibratory sense in both lower extremities, but also had a decrease in sensation to pin over the right lower extremity compared to the left.,CARDIOVASCULAR: He had no carotid bruits. His heart rhythm was regular.,BACK: There was no focal back pain present. He did have a slight sensory level at the upper T spine at approximately T3, both anteriorly and posteriorly.,RADIOLOGIC DATA:, MRI by my view showed essentially unremarkable T spine. The MRI of his C spine showed significant spondylosis in the mid and lower C spine with spondylolisthesis at C7-T1. There is an abnormal signal in the cord which begins at approximately this level, but descends approximately 2 cm. There is slight enhancement at the mid-portion of the lesion. This appears to be an intrinsic lesion to the cord, not clearly associated with mild to moderate spinal stenosis at the level of the spondylolisthesis.,LABORATORY: ,His initial labs were unremarkable.,IMPRESSION: ,Cervical cord lesion at the C7 to T2 level of unclear etiology. Consider a transverse myelitis, tumor, contusion or ischemic lesion.,PLAN:, Will check labs including sedimentation rate, MRI of the brain, chest x-ray. He will probably need a lumbar puncture. He also appears to have a mild peripheral neuropathy, which I suspect is an independent problem. We will request labs for this." Neurology Cervical spondylosis and kyphotic deformity. She had a nerve conduction study and a diagnosis of radiculopathy was made. She had an MRI of lumbosacral spine, which was within normal limits. She then developed a tingling sensation in the right middle toe. Cervical Spondylosis - Neuro Consult REASON FOR NEUROLOGICAL CONSULTATION: , Cervical spondylosis and kyphotic deformity. The patient was seen in conjunction with medical resident Dr. X. I personally obtained the history, performed examination, and generated the impression and plan.,HISTORY OF PRESENT ILLNESS: ,The patient is a 45-year-old African-American female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain. This has subsequently resolved. She started vigorous workouts in November 2005. In March of this year, she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician. By her report, she had a nerve conduction study and a diagnosis of radiculopathy was made. She had an MRI of lumbosacral spine, which was within normal limits. She then developed a tingling sensation in the right middle toe. Symptoms progressed to sensory symptoms of her knees, elbows, and left middle toe. She then started getting sensory sensations in the left hand and arm. She states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg. Symptoms have been mildly progressive. She is unaware of any trigger other than the vigorous workouts as mentioned above. She has no associated bowel or bladder symptoms. No particular position relieves her symptoms.,Workup has included two MRIs of the C-spine, which were personally reviewed and are discussed below. She saw you for consultation and the possibility of surgical decompression was raised. At this time, she is somewhat reluctant to go through any surgical procedure.,PAST MEDICAL HISTORY:,1. Ocular migraines.,2. Myomectomy.,3. Infertility.,4. Hyperglycemia.,5. Asthma.,6. Hypercholesterolemia.,MEDICATIONS: , Lipitor, Pulmicort, Allegra, Xopenex, Patanol, Duac topical gel, Loprox cream, and Rhinocort.,ALLERGIES: , Penicillin and aspirin.,Family history, social history, and review of systems are discussed above as well as documented in the new patient information sheet. Of note, she does not drink or smoke. She is married with two adopted children. She is a paralegal specialist. She used to exercise vigorously, but of late has been advised to stop exercising and is currently only walking.,REVIEW OF SYSTEMS: , She does complain of mild blurred vision, but these have occurred before and seem associated with headaches.,PHYSICAL EXAMINATION: , On examination, blood pressure 138/82, pulse 90, respiratory rate 14, and weight 176.5 pounds. Pain scale is 0. A full general and neurological examination was personally performed and is documented on the chart. Of note, she has a normal general examination. Neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk. She has mild postural tremor in both arms. She has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities. Motor examination reveals no weakness to individual muscle testing, but on gait she does have a very subtle left hemiparesis. She has hyperreflexia in her lower extremities, worse on the left. Babinski's are downgoing.,PERTINENT DATA: ,MRI of the brain from 05/02/06 and MRI of the C-spine from 05/02/06 and 07/25/06 were personally reviewed. MRI of the brain is broadly within normal limits. MRI of the C-spine reveals large central disc herniation at C6-C7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema. There is also a fairly large disc at C3-C4 with cord deformity and partial effacement of the subarachnoid space. I do not appreciate any cord edema at this level.,IMPRESSION AND PLAN: ,The patient is a 45-year-old female with cervical spondylosis with a large C6-C7 herniated disc with mild cord compression and signal change at that level. She has a small disc at C3-C4 with less severe and only subtle cord compression. History and examination are consistent with signs of a myelopathy.,Results were discussed with the patient and her mother. I am concerned about progressive symptoms. Although she only has subtle symptoms now, we made her aware that with progression of this process, she may have paralysis. If she is involved in any type of trauma to the neck such as motor vehicle accident, she could have an acute paralysis. I strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation. I agree with the previous physicians who have told her not to exercise as I am sure that her vigorous workouts and weight training since November 2005 have contributed to this problem. I have recommended that she wear a hard collar while driving. The results of my consultation were discussed with you telephonically. neurology, kyphotic, cervical, radiculopathy, myelopathy, kyphotic deformity, cord compression, cervical spondylosis, toe, spondylosis, cord, Neurology Diagnosis of bulbar cerebral palsy and hypotonia. Cerebral Palsy - Letter 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. neurology, peech, swallowing, breathing, bulbar cerebral palsy, mouth breathing, cerebral palsy, hypotoniaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. Neurology Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx). Cerebral Angiogram CC: ,Headache (HA),HX:, 10 y/o RHM awoke with a bilateral parieto-occipital HA associated with single episode of nausea and vomiting, 2 weeks prior to presentation. The nausea and vomiting resolved and did not recur. However, he continued to experience similar HA 3-4 times per week during the early morning upon awakening. He never felt the HA awakened him from sleep. The HA were partially relieved by Tylenol or Advil, and he distracted himself from the pain by remaining active. One week prior to presentation, he started to experience short episodes of blurred vision and diplopia. He also became fatigued, less active, and frequently yawned.,He had no prior history of HA and he and his family denied any sign or symptom of focal weakness or numbness, dysphagia, dysarthria, or loss of consciousness.,The patient underwent an MRI brain scan prior to transfer to UIHC. This revealed a mass in the left frontal region adjacent to the left temporal horn. The mass was an inhomogeneous blend of signals on T1 and T2 images giving a suggestion of acute bleeding, hemosiderin deposition and multiple vessels within the mass.,MEDS:, None.,PMH:, 1) He was a 7# 15oz. product of a full term, uncomplicated pregnancy and spontaneous vaginal delivery. His post-partum course was unremarkable. 2)Developmental milestones were reached at the appropriate times; though he was diagnosed with dyslexia 4 years ago. 3) No significant illnesses or hospitalizations.,FHX:, MGF (meningioma). PGF (lymphoma). Mother (migraine HA). Father and 22yr old brother are alive and well.,SHX: ,lives with parents and attends mainstream 5th grade classes.,EXAM:, BP124/93 HR96 RR20 37.9C (tympanic),MS: A & O to person, place, time. Cooperative and interactive. Speech fluent and without dysarthria.,CN: EOM intact. VFFTC, Pupils 3/3 decreasing to 2/2 on exposure to light. Fundoscopy: optic disks flat, no evidence of hemorrhage. The rest of the CN exam was unremarkable.,MOTOR: full strength throughout all 4 extremities. Normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station: no pronator drift or Romberg sign,Gait: unremarkable.,Reflexes: 2+ in RUE and RLE. 3 in LUE and LLE. Plantar responses were flexor, bilaterally.,HEENT: no meningismus. no cranial bruits. no skull defects palpated.,GEN EXAM: unremarkable.,COURSE:, GS, PT/PTT, CBC were unremarkable. The MRI finding above lead to a differential diagnosis of Venous Angioma, Arteriovenous Malformation, Ependymoma, Neurocytoma, Glioma: all with associated hemorrhage.,He underwent cerebral angiography on 1/25/93. Upon injection of the RCCA an avascular mass was identified in the right temporal lobe displacing the anterior choroidal artery, and temporal branches of the middle cerebral arteries. The internal cerebral vein is displaced to the left suggesting mass effect. There is a hypoplastic A1 segment and fetal origin of the LPCA. The mass was felt by neuroradiology to represent a hematoma.,He underwent a right frontal craniotomy, 1/28/93. Pathological evaluation of the resected tissue was consistent with a vascular malformation with inclusive reactive glial tissue and evidence of recurrent and remote hemorrhage. There were dilated vascular channels having walls of variable thickness, but without evidence of elastic lamina by elastic staining. This was consistent with venous angioma/malformation. Neurology Cerebral Angiogram - Lateral medullary syndrome secondary to left vertebral artery dissection. Cerebral Angiogram - Lateral Medullary Syndrome CC: ,Falling to left.,HX:, 26y/oRHF fell and struck her head on the ice 3.5 weeks prior to presentation. There was no associated loss of consciousness. She noted a dull headache and severe sharp pain behind her left ear 8 days ago. The pain lasted 1-2 minutes in duration. The next morning she experienced difficulty walking and consistently fell to the left. In addition the left side of her face had become numb and she began choking on food. Family noted her pupils had become unequal in size. She was seen locally and felt to be depressed and admitted to a psychiatric facility. She was subsequently transferred to UIHC following evaluation by a local ophthalmologist.,MEDS:, Prozac and Ativan (both recently started at the psychiatric facility).,PMH: ,1) Right esotropia and hyperopia since age 1year. 2) Recurrent UTI.,FHX:, Unremarkable.,SHX:, Divorced. Lives with children. No spontaneous abortions. Denied ETOH/Tobacco/Illicit Drug use.,EXAM:, BP 138/110. HR 85. RR 16. Temp 37.2C.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, repetition.,CN: Pupils 4/2 decreasing to 3/1 on exposure to light. Optic Disks flat. VFFTC. Esotropia OD, otherwise EOM full. Horizontal nystagmus on leftward gaze. Decreased corneal reflex, OS. Decreased PP/TEMP sensation on left side of face. Light touch testing normal. Decreased gag response on left. Uvula deviates to right. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: Decreased PP and TEMP on right side of body. PROP/VIB intact.,Coord: Difficulty with FNF/HKS/RAM on left. Normal on right side.,Station: No pronator drift. Romberg test not noted.,Gait: unsteady with tendency to fall to left.,Reflexes: 3/3 throughout BUE and Patellae. 2+/2+ Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese. In no acute distress. Otherwise unremarkable.,HEENT: No carotid/vertebral/cranial bruits.,COURSE:, PT/PTT, GS, CBC, TSH, FT4 and Cholesterol screen were all within normal limits. HCT on admission was negative. MRI Brain (done locally 2/2/93) was reviewed and a left lateral medullary stroke was appreciated. The patient underwent a cerebral angiogram on 2/3/93 which revealed significant narrowing of the left vertebral artery beginning at C2 and extending to and involving the basilar artery. There is severe, irregular narrowing of the horizontal portion above the posterior arch of C1. The findings were felt consistent with a left vertebral artery dissection. Neuro-opthalmology confirmed a left Horner's pupil by clinical exam and history. Cookie swallow study was unremarkable. The Patient was placed on Heparin then converted to Coumadin. The PT on discharge was 17.,She remained on Coumadin for 3 months and then was switched to ASA for 1 year. An Otolaryngologic evaluation on 10/96 noted true left vocal cord paralysis with full glottic closure. A prosthesis was made and no surgical invention was done. neurology, horner's pupil, mri brain, otolaryngologic, cerebral angiogram, cerebral angiogram lateral, medullary syndrome, vertebral artery, angiogram, syndrome, falling, narrowing, medullary, vertebral, cerebral, Neurology Cerebral Angiogram and MRA for bilateral ophthalmic artery aneurysms. Cerebral Angiogram & MRA CC:, Transient visual field loss.,HX: ,This 58 y/o RHF had a 2 yr h/o increasing gait difficulty which she attributed to generalized weakness and occasional visual obscurations. She was evaluated by a local physician several days prior to this presentation (1/7/91), for clumsiness of her right hand and falling. HCT and MRI brain revealed bilateral posterior clinoid masses.,MEDS:, Colace, Quinidine, Synthroid, Lasix, Lanoxin, KCL, Elavil, Tenormin.,PMH: ,1) Obesity. 2) VBG, 1990. 3) A-Fib. 4) HTN. 5) Hypothyroidism. 6) Hypercholesterolemia. 7) Briquet's syndrome: h/o of hysterical paralysis. 8) CLL, dx 1989; in 1992 presented with left neck lymphadenopathy and received 5 cycles of chlorambucil/prednisone chemotherapy; 10/95 parotid gland biopsy was consistent with CLL and she received 5 more cycles of chlorambucil/prednisone; 1/10/96, she received 3000cGy to right parotid mass. 9) SNHL,FHX:, Father died, MI age 61.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM:, Vitals were unremarkable.,The neurologic exam was unremarkable except for obesity and mild decreased PP about the right upper and lower face, diffusely about the left upper and lower face, per neurosurgery notes. The neuro-ophthalmologic exam was unremarkable, per Neuro-ophthalmology.,COURSE:, She underwent Cerebral Angiography on 1/8/91. This revealed a 15x17x20mm LICA paraclinoid/ophthalmic artery aneurysm and a 5x7mm RICA paraclinoid/ophthalmic artery aneurysm. On 1/16/91 she underwent a left frontotemporal craniotomy and exploration of the left aneurysm. The aneurysm neck went into the cavernous sinus and was unclippable so it was wrapped. She has complained of headaches since. neurology, visual field loss, transient, visual field, cerebral angiography, ophthalmic, paraclinoid, aneurysm, paraclinoid/ophthalmic, cavernous, frontotemporal, craniotomy, exam was unremarkable, artery aneurysms, mra, visual, parotid, cerebral, artery, neurologic, aneurysms, angiogram Neurology Cerebral Angiogram - Lobulated aneurysm of the supraclinoid portion of the left internal carotid artery close to the origin of the left posterior communicating artery. Cerebral Angiogram - Left ICA/PCA Aneurysm "CC:, Fluctuating level of consciousness.,HX:, 59y/o male experienced a ""pop"" in his head on 10/10/92 while showering in Cheyenne, Wyoming. He was visiting his son at the time. He was found unconscious on the shower floor 1.5 hours later. His son then drove him Back to Iowa. Since then he has had recurrent headaches and fluctuating level of consciousness, according to his wife. He presented at local hospital this AM, 10/13/92. A HCT there demonstrated a subarachnoid hemorrhage. He was then transferred to UIHC.,MEDS:, none.,PMH:, 1) Right hip and clavicle fractures many years ago. 2) All of his teeth have been removed., ,FHX:, Not noted.,SHX:, Cigar smoker. Truck driver.,EXAM: , BP 193/73. HR 71. RR 21. Temp 37.2C.,MS: A&O to person, place and time. No note regarding speech or thought process.,CN: Subhyaloid hemorrhages, OU. Pupils 4/4 decreasing to 2/2 on exposure to light. Face symmetric. Tongue midline. Gag response difficult to elicit. Corneal responses not noted.,MOTOR: 5/5 strength throughout.,Sensory: Intact PP/VIB.,Reflexes: 2+/2+ throughout. Plantars were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, The patient underwent Cerebral Angiography on 10/13/92. This revealed a lobulated aneurysm off the supraclinoid portion of the left internal carotid artery close to the origin of the posterior communication artery. The patient subsequently underwent clipping of this aneurysm. He recovery was complicated severe vasospasm and bacterial meningitis. HCT on 10/19/92 revealed multiple low density areas in the left hemisphere in the LACA-LPCA watershed, left fronto-parietal area and left thalamic region. He was left with residual right hemiparesis, urinary incontinence, some (unspecified) degree of mental dysfunction. He was last seen 2/26/93 in Neurosurgery clinic and had stable deficits." neurology, consciousness, level of consciousness, hct, subhyaloid hemorrhages, cerebral angiography, carotid artery, communication artery, laca-lpca, fluctuating level of consciousness, internal carotid artery, lobulated aneurysm, lobulated, supraclinoid, cerebral, aneurysm, artery, angiogram, Neurology Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram. Bilateral Carotid Cerebral Angiogram 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. neurology, femoral-popliteal angiogram, carotid cerebral angiogram, internal carotid artery, carotid artery, angiogram, carotid, cerebral, artery, Neurology Bilateral carotid ultrasound. Carotid Ultrasound EXAM:, Bilateral carotid ultrasound.,REASON FOR EXAM: , Headache.,TECHNIQUE: ,Color grayscale and Doppler analysis is employed.,FINDINGS:, On the grayscale images, the right common carotid artery demonstrates patency with mild intimal thickening only. At the level of the carotid bifurcation, there is heterogeneous hard plaque present, but without grayscale evidence of greater than 50% stenosis. Right common carotid waveform is normal with a peak systolic velocity of 0.474 m/second and an end-diastolic velocity of 0.131 m/second. The right ECA is patent as well with the velocity measurement 0.910 m/second.,The right internal carotid artery at the bifurcation demonstrates plaque formation, but no evidence of greater than 50% stenosis. Proximal peak systolic velocity in the internal carotid artery is 0.463 m/second with proximal end-diastolic velocity of 0.170. The mid internal carotid peak systolic velocity is 0.564 m/second, and mid ICA end-diastolic velocity is 0.199 m/second. Right ICA distal PSV 0.580 m/second, right ICA distal EDV 0.204 m/second. Vertebral flow is antegrade on the right at 0.469 m/second.,On the left, the common carotid artery demonstrates intimal thickening, but is otherwise patent. At the level of the bifurcation, however, there is more pronounced plaque formation with approximately 50% stenosis by the grayscale analysis. See the velocity measurements below:,Left carotid ECA measurement 0.938 m/second. Left common carotid PSV 0.686 m/second, and left common carotid end-diastolic velocity 0.137 m/second.,Left internal carotid artery again demonstrates prominent focus of hard plaque with up to at least 50% stenosis. This should be further assessed with CTA for more precise measurement. The left proximal ICA/PSV 0.955 m/second, left proximal ICA/EDV 0.287 m/second. There is spectral broadening in the proximal aspect of the carotid waveform. The left carotid ICA mid PSV 0.895, left carotid ICA mid EDV 0.278 with also spectral broadening present.,The left distal ICA/PSV 0.561, left distal ICA/EDV 0.206, again the spectral broadening present. Vertebral flow is antegrade at 0.468 m/second.,IMPRESSION: , The study demonstrates bilateral hard plaque at the bifurcation, left greater than right. There is at least 50% stenosis of the left internal carotid artery at its bifurcation and a followup CTA is recommended for further assessment. neurology, doppler analysis, headache, edv, ica, eca, psv, distal ica/edv, hard plaque, bilateral carotid ultrasound, peak systolic velocity, internal carotid artery, plaque formation, carotid ultrasound, carotid artery, carotid, stenosis, proximal, artery, velocity Neurology Brain CT and MRI - suprasellar mass (pituitary adenoma) Brain MRI - Pituitary Adenoma CC:, Orthostatic lightheadedness.,HX:, This 76 y/o male complained of several months of generalized weakness and malaise, and a two week history of progressively worsening orthostatic dizziness. The dizziness worsened when moving into upright positions. In addition, he complained of intermittent throbbing holocranial headaches, which did not worsen with positional change, for the past several weeks. He had lost 40 pounds over the past year and denied any recent fever, SOB, cough, vomiting, diarrhea, hemoptysis, melena, hematochezia, bright red blood per rectum, polyuria, night sweats, visual changes, or syncopal episodes.,He had a 100+ pack-year history of tobacco use and continued to smoke 1 to 2 packs per day. He has a history of sinusitis.,EXAM:, BP 98/80 mmHg and pulse 64 BPM (supine); BP 70/palpable mmHG and pulse 84BPM (standing). RR 12, Afebrile. Appeared fatigued.,CN: unremarkable.,Motor and Sensory exam: unremarkable.,Coord: Slowed but otherwise unremarkable movements.,Reflexes: 2/2 and symmetric throughout all 4 extremities. Plantar responses were flexor, bilaterally.,The rest of the neurologic and general physical exam was unremarkable.,LAB:, Na 121 meq/L, K 4.2 meq/L, Cl 90 meq/L, CO2 20meq/L, BUN 12mg/DL, CR 1.0mg/DL, Glucose 99mg/DL, ESR 30mm/hr, CBC WNL with nl WBC differential, Urinalysis: SG 1.016 and otherwise WNL, TSH 2.8 IU/ML, FT4 0.9ng/DL, Urine Osmolality 246 MOSM/Kg (low), Urine Na 35 meq/L,,COURSE:, The patient was initially hydrated with IV normal saline and his orthostatic hypotension resolved, but returned within 24-48hrs. Further laboratory studies revealed: Aldosterone (serum)<2ng/DL (low), 30 minute Cortrosyn Stimulation test: pre 6.9ug/DL (borderline low), post 18.5ug/DL (normal stimulation rise), Prolactin 15.5ng/ML (no baseline given), FSH and LH were within normal limits for males. Testosterone 33ng/DL (wnl). Sinus XR series (done for history of headache) showed an abnormal sellar region with enlarged sella tursica and destruction of the posterior clinoids. There was also an abnormal calcification seen in the middle of the sellar region. A left maxillary sinus opacity with air-fluid level was seen. Goldman visual field testing was unremarkable. Brain CT and MRI revealed suprasellar mass most consistent with pituitary adenoma. He was treated with Fludrocortisone 0.05 mg BID and within 24hrs, despite discontinuation of IV fluids, remained hemodynamically stable and free of symptoms of orthostatic hypotension. His presumed pituitary adenoma continues to be managed with Fludrocortisone as of this writing (1/1997), though he has developed dementia felt secondary to cerebrovascular disease (stroke/TIA). neurology, brain ct, goldman, mri, orthostatic, adenoma, generalized weakness, hypotension, lightheadedness, malaise, pituitary, sinus opacity, suprasellar mass, brain ct and mri, orthostatic hypotension, pituitary adenoma, brain, sinusitis, sellar, Neurology Frontal craniotomy for placement of deep brain stimulator electrode. Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device. Brain Stimulator Electrode 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. neurology, dystonic, ac-pc, ct scan, dbs electrode, intraoperative programming, microelectrode, stereotactic, tremor, brain stimulator, craniotomy, device, dystonic tremor, electrode, frontal, screener box, target coordinate, volumetric, deep brain stimulator electrode, brain stimulator electrode, volumetric ct, stimulator, brain, Neurology MRI - Arteriovenous malformation with hemorrhage. AVM with Hemorrhage "CC:, Headache.,HX:, 63 y/o RHF first seen by Neurology on 9/14/71 for complaint of episodic vertigo. During that evaluation she described a several year history of ""migraine"" headaches. She experienced her first episode of vertigo in 1969. The vertigo (clockwise) typically began suddenly after lying down, and was not associated with nausea/vomiting/headache. The vertigo had not been consistently associated with positional change and could last hours to days.,On 3/15/71, after 5 day bout of vertigo, right ear ache, and difficulty ambulating (secondary to the vertigo) she sought medical attention and underwent an audiogram which reportedly showed a 20% decline in low tone acuity AD. She complained of associated tinnitus which she described as a ""whistle."" In addition, her symptoms appeared to worsen with changes in head position (i.e. looking up or down). The symptoms gradually resolved and she did well until 8/71 when she experienced a 19-day episode of vertigo, tinnitus and intermittent headaches. She was seen 9/14/71, in Neurology, and admitted for evaluation.,Her neurologic exam at that time was unremarkable except for prominent bilateral systolic carotid bruits. Cerebral angiogram revealed an inoperable 7 x 6cm AVM in the right parietal region. The AVM was primarily fed by the right MCA. Otolaryngologic evaluation concluded that she probably also suffered from Meniere's disease.,On 10/14/74 she underwent a 21 day admission for SAH secondary to right parietal AVM.,On 11/23/91 she was admitted for left sided weakness (LUE > LLE), headache, and transient visual change. Neurological exam confirmed left sided weakness, and dysesthesia of the LUE only. Brain CT confirmed a 3 x 4 cm left parietal hemorrhage. She underwent unsuccessful embolization. Neuroradiology had planned to do 3 separate embolizations, but during the first, via the left MCA, they were unable to cannulate many of the AVM vessels and abandoned the procedure. She recovered with residual left hemisensory loss.,In 12/92 she presented with an interventricular hemorrhage and was managed conservatively and refused any future neuroradiologic intervention.,In 1/93 she reconsidered neurointerventional procedure and was scheduled for evaluation at the Barrows Neurological Institute in Phoenix, AZ." neurology, arteriovenous malformation, avm, brain ct, cerebral angiogram, headache, audiogram, carotid bruits, difficulty ambulating, hemorrhage, interventricular hemorrhage, migraine, tinnitus, vertigo, visual change, weakness, episode of vertigo, evaluation, Neurology MRI for Arnold Chiari II with syrinx Arnold Chiari II with Syrinx 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. neurology, right sided numbness, arnold chiari ii with syrinx, cerebellar tonsils, vermis, philadelphia collar, arnold chiari ii, ankle clonus, mri, numbness, chiari, syrinx, gait, reflexes, arnold Neurology A 75-year-old female comes in with concerns of having a stroke. Bell's Palsy 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. neurology, stroke, bell’s palsy, st segment changes, ekg, dizziness, numbness, dizzy, muscle strength, palsy, bell’s Neurology MRI - Right temporal lobe astrocytoma. Astrocytoma "CC: ,Episodic confusion.,HX: ,This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The ""stroke"" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He admitted that there had been short periods (1-2 days duration) since then, during which he had forgotten to take his DPH. However, even when he had been taking his DPH regularly, he continued to experience the spells mentioned above. He denied any associated tonic/clonic movement, incontinence, tongue-biting, HA, visual change, SOB, palpitation, weakness or numbness. The episodes of confusion and memory loss last 1-2 minutes in duration, and have been occurring 2-3 times per week.,PMH:, Bilateral Hearing Loss of unknown etiology, S/P bilateral ear surgery many years ago.,MEDS:, DPH and ASA,SHX/FHX:, 2-4 Beers/day. 1-2 packs of cigarettes per day.,EXAM:, BP 111/68, P 68BPM, 36.8C. Alert and Oriented to person, place and time, 30/30 on mini-mental status test, Speech fluent and without dysarthria. CN: Left superior quandranopia only. Motor: 5/5 strength throughout. Sensory: unremarkable except for mild decreased vibration sense in feet. Coordination: unremarkable. Gait and station testing were unremarkable. He was able to tandem walk without difficulty. Reflexes: 2+ and symmetric throughout. Flexor plantar responses bilaterally.,LAB:, Gen Screen, CBC, PT, PTT all WNL. DPH 4.6mcg/ml.,Review of outside MRI Brain done 1/17/92 revealed decreased T1 and increased T2 signal in the Right temporal lobe involving the uncus and adjacent hippocampus. The area did not enhance with gadolinium contrast.,CXR:, 8/31/92: 5 x 6 mm spiculated opacity in apex right lung.,EEG:, 8/24/92: normal awake and asleep,MRI Brain with/without contrast: 8/31/92: Decreased T1 and increased T2 signal in the right temporal lobe. The lesion increased in size and enhances more greatly when compared to the 1/17/92 MRI exam. There is also edema surrounding the affected area and associated mass effect.,NEUROPSYCHOLOGICAL TESTING:, Low-average digit symbol substitution, mildly impaired verbal learning, and severely defective delayed recall. There was relative preservation of other cognitive functions. The findings were consistent with left mesiotemporal dysfunction.,COURSE: ,Patient underwent right temporal lobectomy on 9/16/92 following initial treatment with Decadron. Pathologic analysis was consistent with a Grade 2 astrocytoma. GFAP staining positive. Following surgery he underwent 5040 cGy radiation therapy in 28 fractions to the tumor bed." neurology, confusion, gfap, gfap staining, mri scan, astrocytoma, hippocampus, memory loss, palpitation, signal, stroke, temporal lobe, tongue-biting, tonic/clonic movement, weakness, increased t signal, mri brain, mri, temporal, Neurology Patient experiences a dull pain in his upper outer arm. It occurs on a daily basis. He also experiences an achy sensation in his right hand radiating to the fingers. There is no numbness or paresthesias in the hand or arm. Arm Pain - Neuro Consult HISTORY OF PRESENT ILLNESS: ,The patient is a 58-year-old right-handed gentleman who presents for further evaluation of right arm pain. He states that a little less than a year ago he developed pain in his right arm. It is intermittent, but has persisted since that time. He describes that he experiences a dull pain in his upper outer arm. It occurs on a daily basis. He also experiences an achy sensation in his right hand radiating to the fingers. There is no numbness or paresthesias in the hand or arm.,He has had a 30-year history of neck pain. He sought medical attention for this problem in 2006, when he developed ear pain. This eventually led to him undergoing an MRI of the cervical spine, which showed some degenerative changes. He was then referred to Dr. X for treatment of neck pain. He has been receiving epidural injections under the care of Dr. X since 2007. When I asked him what symptom he is receiving the injections for, he states that it is for neck pain and now the more recent onset of arm pain. He also has taken several Medrol dose packs, which has caused his blood sugars to increase. He is taking multiple other pain medications. The pain does not interfere significantly with his quality of life, although he has a constant nagging pain.,PAST MEDICAL HISTORY: , He has had diabetes since 2003. He also has asthma, hypertension, and hypercholesterolemia.,CURRENT MEDICATIONS: , He takes ACTOplus, albuterol, AndroGel, Astelin, Diovan, Dolgic Plus, aspirin 81 mg, fish oil, Lipitor, Lorazepam, multivitamins, Nasacort, Pulmicort, ranitidine, Singulair, Viagra, Zetia, Zyrtec, and Uroxatral. He also uses Lidoderm patches and multiple eye drops and creams.,ALLERGIES:, He states that Dyazide, Zithromax, and amoxicillin cause him to feel warm and itchy.,FAMILY HISTORY:, His father died from breast cancer. He also had diabetes. He has a strong family history of diabetes. His mother is 89. He has a sister with diabetes. He is unaware of any family members with neurological disorders.,SOCIAL HISTORY:, He lives alone. He works full time in Human Resources for the State of Maryland. He previously was an alcoholic, but quit in 1984. He also quit smoking cigarettes in 1984, after 16 years of smoking. He has a history of illicit drug use, but denies IV drug use. He denies any HIV risk factors and states that his last HIV test was over two years ago.,REVIEW OF SYSTEMS: , He has intermittent chest discomfort. He has chronic tinnitus. He has urinary dribbling. Otherwise, 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: HR 72. RR 16.,General Appearance: Patient is well appearing, in no acute distress.,Cardiovascular: There is a regular rhythm without murmurs, gallops, or rubs. There are no carotid bruits.,Chest: The lungs are clear to auscultation bilaterally.,Skin: There are no rashes or lesions.,NEUROLOGICAL EXAMINATION:,Mental Status: Speech is fluent without dysarthria or aphasia. The patient is alert and oriented to name, place, and date. Attention, concentration, registration, recall, and fund of knowledge are all intact.,Cranial Nerves: Pupils are equal, round, and reactive to light and accommodation. Optic discs are normal. Visual fields are full. Extraocular movements are intact without nystagmus. Facial sensation is normal. There is no facial, jaw, palate, or tongue weakness. Hearing is grossly intact. Shoulder shrug is full.,Motor: There is normal muscle bulk and tone. There is no atrophy or fasciculations. There is no action or percussion myotonia or paramyotonia. Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities.,Sensory: Sensation is intact to light touch, pinprick, temperature, vibratory sensation, and joint position sense. Romberg is absent.,Coordination: There is no dysmetria or ataxia on finger-nose-finger or heel-to-shin testing.,Deep Tendon Reflexes: Deep tendon reflexes are 2+ at the biceps, triceps, brachioradialis, patellas and ankles. Plantar reflexes are flexor. There are no finger flexors, Hoffman's sign, or jaw jerk.,Gait and Stance: Casual gait is normal. Heel, toe, and tandem walking are all normal.,RADIOLOGIC DATA:, MRI of the cervical spine, 05/19/08: I personally reviewed this film, which showed narrowing of the foramen on the right at C4-C5 and other degenerative changes without central stenosis.,IMPRESSION: ,The patient is a 58-year-old gentleman with one-year history of right arm pain. He also has a longstanding history of neck pain. His neurological examination is normal. He has an MRI that shows some degenerative changes. I do believe that his symptoms are probably referable to his neck. However, I do not think that they are severe enough for him to undergo surgery at this point in time. Perhaps another course of physical therapy may be helpful for him. I probably would not recommend anymore invasive procedure, such as a spinal stimulator, as this pain really is minimal. We could still try to treat him with neuropathic pain medications.,RECOMMENDATIONS:,1. I scheduled him to return for an EMG and nerve conduction studies to determine whether there is any evidence of nerve damage, although I think the likelihood is low.,2. I gave him a prescription for Neurontin. I discussed the side effects of the medication with him.,3. We can discuss his case tomorrow at Spine Conference to see if there are any further recommendations. Neurology Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma. Anaplastic Astrocytoma - Letter XYZ,RE: ABC,MEDICAL RECORD#: 123,Dear Dr. XYZ:,I saw ABC back in Neuro-Oncology Clinic today. He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma.,Within the last several days, he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion. The patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent. It is clear that his MRI is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective. Despite repeatedly emphasizing this; however, the patient still is worried about potential long-term side effects from treatment that frankly seem unwarranted at this particular time.,After seeing you in clinic, he and his friend again wanted to discuss possible changes in the chemotherapy regimen. They came in with a list of eight possible agents that they would like to be administered within the next two weeks. They then wanted another MRI to be performed and they were hoping that with the use of this type of approach, they might be able to induce another remission from which he can once again be spared radiation.,From my view, I noticed a man whose language has deteriorated in the week since I last saw him. This is very worrisome. Today, for the first time, I felt that there was a definite right facial droop as well. Therefore, there is no doubt that he is becoming symptomatic from his growing tumor. It suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future.,Emphasizing this once again, in addition, to recommending steroids I once again tried to convince him to undergo radiation. Despite an hour, this again amazingly was not possible. It is not that he does not want treatment, however. Because I told him that I did not feel it was ethical to just put him on the radical regimen that him and his friend devised, we compromised and elected to go back to Temodar in a low dose daily type regimen. We would plan on giving 75 mg/sq m everyday for 21 days out of 28 days. In addition, we will stop thalidomide 100 mg/day. If he tolerates this for one week, we then agree that we would institute another one of the medications that he listed for us. At this stage, we are thinking of using Accutane at that point.,While I am very uncomfortable with this type of approach, I think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval. In the spirit of compromise, he again consented to be evaluated by radiation and this time, seemed more resigned to the fact that it was going to happen sooner than later. I will look at this as a positive sign because I think radiation is the one therapy from which he can get a reasonable response in the long term.,I will keep you apprised of followups. If you have any questions or if I could be of any further assistance, feel free to contact me.,Sincerely, neurology, neuro oncology, anaplastic astrocytoma, anaplastic, oncology, radiation, astrocytoma Neurology CT Brain - arachnoid cyst Arachnoid cyst diagnosed by CT brain. Arachnoid Cyst "CC:, Seizures.,HX: ,The patient was initially evaluated at UIHC at 7 years of age. He had been well until 7 months prior to evaluation when he started having spells which were described as ""dizzy spells"" lasting from several seconds to one minute in duration. They occurred quite infrequently and he was able to resume activity immediately following the episodes. The spell became more frequent and prolonged, and by the time of initial evaluation were occurring 2-3 times per day and lasting 2-3 minutes in duration. In addition, in the 3 months prior to evaluation, the right upper extremity would become tonic and flexed during the episodes, and he began to experience post ictal fatigue.,BIRTH HX:, 32 weeks gestation to a G4 mother and weighed 4#11oz. He was placed in an incubator for 3 weeks. He was jaundiced, but there was no report that he required treatment.,PMH: ,Single febrile convulsion lasting ""3 hours"" at age 2 years.,MEDS: ,none.,EXAM:, Appears healthy and in no acute distress. Unremarkable general and neurologic exam.,Impression: Psychomotor seizures.,Studies: Skull X-Rays were unremarkable.,EEG showed ""minimal spike activity during hyperventilation, as well as random sharp delta activity over the left temporal area, in drowsiness and sleep. This record also showed moderate amplitude asymmetry ( left greater than right) over the frontal central and temporal areas, which is a peculiar finding."",COURSE:, The patient was initially treated with Phenobarbital; then Dilantin was added (early 1970's); then Depakene was added ( early 1980's) due to poor seizure control. An EEG on 8/22/66 showed ""Left mid-temporal spike focus with surrounding slow abnormality, especially posterior to the anterior temporal areas (sparing the parasagittal region). In addition, the right lateral anterior hemisphere voltage is relatively depressed. ...this suggests two separate areas of cerebral pathology."" He underwent his first HCT scan in Sioux City in 1981, and this revealed an right temporal arachnoid cyst. The patient had behavioral problems throughout elementary/junior high/high school. He underwent several neurosurgical evaluations at UIHC and Mayo Clinic and was told that surgery was unwarranted. He was placed on numerous antiepileptic medication combinations including Tegretol, Dilantin, Phenobarbital, Depakote, Acetazolamide, and Mysoline. Despite this he averaged 2-3 spells a month. He was last seen, 6/19/95, and was taking Dilantin and Tegretol. His typical spells were described as sudden in onset and without aura. He frequently becomes tonic or undergoes tonic-clonic movement and falls with associated loss of consciousness. He usually has rapid recovery and can return to work in 20 minutes. He works at a Turkey packing plant. Serial HCT scans showed growth in the arachnoid cyst until 1991, when growth arrest appeared to have occurred." neurology, arachnoid cyst, hct scan, seizures, serial hct scans, dizzy spells, drowsiness, hyperventilation, loss of consciousness, moderate amplitude asymmetry, temporal area, tonic-clonic movement, phenobarbital, dilantin, cyst, temporal, arachnoid Neurology MRI - Intracerebral hemorrhage (very acute clinical changes occurred immediately prior to scan). Acute Intracerebral Hemorrhage CC: ,Left hand numbness on presentation; then developed lethargy later that day.,HX: ,On the day of presentation, this 72 y/o RHM suddenly developed generalized weakness and lightheadedness, and could not rise from a chair. Four hours later he experienced sudden left hand numbness lasting two hours. There were no other associated symptoms except for the generalized weakness and lightheadedness. He denied vertigo.,He had been experiencing falling spells without associated LOC up to several times a month for the past year.,MEDS:, procardia SR, Lasix, Ecotrin, KCL, Digoxin, Colace, Coumadin.,PMH: ,1)8/92 evaluation for presyncope (Echocardiogram showed: AV fibrosis/calcification, AV stenosis/insufficiency, MV stenosis with annular calcification and regurgitation, moderate TR, Decreased LV systolic function, severe LAE. MRI brain: focal areas of increased T2 signal in the left cerebellum and in the brainstem probably representing microvascular ischemic disease. IVG (MUGA scan)revealed: global hypokinesis of the LV and biventricular dysfunction, RV ejection Fx 45% and LV ejection Fx 39%. He was subsequently placed on coumadin severe valvular heart disease), 2)HTN, 3)Rheumatic fever and heart disease, 4)COPD, 5)ETOH abuse, 6)colonic polyps, 7)CAD, 8)CHF, 9)Appendectomy, 10)Junctional tachycardia.,FHX:, stroke, bone cancer, dementia.,SHX: ,2ppd smoker since his teens; quit 2 years ago. 6-pack beer plus 2 drinks per day for many years: now claims he has been dry for 2 years. Denies illicit drug use.,EXAM: ,36.8C, 90BPM, BP138/56.,MS: Alert and oriented to person, place, but not date. Hypophonic and dysarthric speech. 2/3 recall. Followed commands.,CN: Left homonymous hemianopia and left CN7 nerve palsy (old).,MOTOR: full strength throughout.,SENSORY: unremarkable.,COORDINATION: dysmetric FNF and HKS movements (left worse than right).,STATION: RUE pronator drift and Romberg sign present.,GAIT: shuffling and bradykinetic.,REFLEXES: 1+/1+ to 2+/2+ and symmetric throughout. Plantar responses were flexor bilaterally.,HEENT: Neck supple and no carotid bruits.,CV: RRR with 3/6 SEM and diastolic murmurs throughout the precordium.,Lungs: bibasilar crackles.,LABS:, PT 19 (elevated) and PTT 46 (elevated).,COURSE:, Coumadin was discontinued on admission as he was felt to have suffered a right hemispheric stroke. The initial HCT revealed a subtle low density area in the right occipital lobe and no evidence of hemorrhage. He was scheduled to undergo an MRI Brain scan the same day, and shortly before the procedure became lethargic. By the time the scan was complete he was stuporous. MRI Scan then revealed a hypointense area of T1 signal in the right temporal lobe with a small foci of hyperintensity within it. The hyperintense area seen on T1 weighted images appeared hypointense on T2 weighted images. There was edema surrounding the lesion The findings were consistent with a hematoma. A CT scan performed 4 hours later confirmed a large hematoma with surrounding edema involving the right temporal/parietal/occipital lobes. The patient subsequently died. Neurology MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement. Alzheimer Disease "CC:, Memory difficulty.,HX: ,This 64 y/o RHM had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. This had been called to his attention by the clerical staff at his parish--he was a Catholic priest. He had had no professional or social faux pas or mishaps due to his memory. He could not tell whether his problem was becoming worse, so he brought himself to the Neurology clinic on his own referral.,MEDS:, None.,PMH: ,1)appendectomy, 2)tonsillectomy, 3)childhood pneumonia, 4)allergy to sulfa drugs.,FHX:, Both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. There are no neurological illnesses in his family.,SHX:, Catholic priest. Denied Tobacco/ETOH/illicit drug use.,EXAM:, BP131/74, HR78, RR12, 36.9C, Wt. 77kg, Ht. 178cm.,MS: A&O to person, place and time. 29/30 on MMSE; 2/3 recall at 5 minutes. 2/10 word recall at 10 minutes. Unable to remember the name of the President (Clinton). 23words/60 sec on Category fluency testing (normal). Mild visual constructive deficit.,The rest of the neurologic exam was unremarkable and there were no extrapyramidal signs or primitive reflexes noted.,COURSE:, TSH 5.1, T4 7.9, RPR non-reactive. Neuropsychological evaluation, 3/6/95, revealed: 1)well preserved intellectual functioning and orientation, 2) significant deficits in verbal and visual memory, proper naming, category fluency and working memory, 3)performances which were below expectations on tests of speed of reading, visual scanning, visual construction and clock drawing, 4)limited insight into the scope and magnitude of cognitive dysfunction. The findings indicated multiple areas of cerebral dysfunction. With the exception of the patient's report of minimal occupational dysfunction ( which may reflect poor insight), the clinical picture is consistent with a progressive dementia syndrome such as Alzheimer's disease. MRI brain, 3/6/95, showed mild generalized atrophy, more severe in the occipital-parietal regions.,In 4/96, his performance on repeat neuropsychological evaluation was relatively stable. His verbal learning and delayed recognition were within normal limits, whereas delayed recall was ""moderately severely"" impaired. Immediate and delayed visual memory were slightly below expectations. Temporal orientation and expressive language skills were below expectation, especially in word retrieval. These findings were suggestive of particular, but not exclusive, involvement of the temporal lobes.,On 9/30/96, he was evaluated for a 5 minute spell of visual loss, OU. The episode occurred on Friday, 9/27/96, in the morning while sitting at his desk doing paperwork. He suddenly felt that his gaze was pulled toward a pile of letters; then a ""curtain"" came down over both visual fields, like ""everything was in the shade."" During the episode he felt fully alert and aware of his surroundings. He concurrently heard a ""grating sound"" in his head. After the episode, he made several phone calls, during which he reportedly sounded confused, and perseverated about opening a bank account. He then drove to visit his sister in Muscatine, Iowa, without accident. He was reportedly ""normal"" when he reached her house. He was able to perform Mass over the weekend without any difficulty. Neurologic examination, 9/30/96, was notable for: 1)category fluency score of 18items/60 sec. 2)VFFTC and EOM were intact. There was no RAPD, INO, loss of visual acuity. Glucose 178 (elevated), ESR ,Lipid profile, GS, CBC with differential, Carotid duplex scan, EKG, and EEG were all normal. MRI brain, 9/30/96, was unchanged from previous, 3/6/95.,On 1/3/97, he had a 30 second spell of lightheadedness without vertigo, but with balance difficulty, after picking up a box of books. The episode was felt due to orthostatic changes.,1/8/97 neuropsychological evaluation was stable and his MMSE score was 25/30 (with deficits in visual construction, orientation, and 2/3 recall at 1 minute). Category fluency score 23 items/60 sec. Neurologic exam was notable for graphesthesia in the left hand.,In 2/97, he had episodes of anxiety, marked fluctuations in job performance and resigned his pastoral position. His neurologic exam was unchanged. An FDG-PET scan on 2/14/97 revealed decreased uptake in the right posterior temporal-parietal and lateral occipital regions." neurology, dementia, a&o to person, alzheimer's disease, alzheimer's type, mmse, mmse score, mri brain, memory difficulty, neuropsychological, balance difficulty, category fluency, faux pas, minimal occupational dysfunction, parieto-occipital, progressive dementia syndrome, visual acuity, visual loss, visual memory, pet scan, neuropsychological evaluation, alzheimer's, neurological, memory, Neurology The patient is a 74-year-old woman who presents for neurological consultation for possible adult hydrocephalus. Mild gait impairment and mild cognitive slowing. Adult Hydrocephalus "REASON FOR VISIT: , The patient is a 74-year-old woman who presents for neurological consultation referred by Dr. X. She is accompanied to the appointment by her husband and together they give her history.,HISTORY OF PRESENT ILLNESS: , The patient is a lovely 74-year-old woman who presents with possible adult hydrocephalus. Danish is her native language, but she has been in the United States for many many years and speaks fluent English, as does her husband.,With respect to her walking and balance, she states ""I think I walk funny."" Her husband has noticed over the last six months or so that she has broadened her base and become more stooped in her pasture. Her balance has also gradually declined such that she frequently touches walls and furniture to stabilize herself. She has difficulty stepping up on to things like a scale because of this imbalance. She does not festinate. Her husband has noticed some slowing of her speed. She does not need to use an assistive device. She has occasional difficulty getting in and out of a car. Recently she has had more frequent falls. In March of 2007, she fell when she was walking to the bedroom and broke her wrist. Since that time, she has not had any emergency room trips, but she has had other falls.,With respect to her bowel and bladder, she has no issues and no trouble with frequency or urgency.,The patient does not have headaches.,With respect to thinking and memory, she states she is still able to pay the bills, but over the last few months she states, ""I do not feel as smart as I used to be."" She feels that her thinking has slowed down. Her husband states that he has noticed, she will occasionally start a sentence and then not know what words to use as she is continuing.,The patient has not had trouble with syncope. She has had past episodes of vertigo, but not recently.,PAST MEDICAL HISTORY: ,Significant for hypertension diagnosed in 2006, reflux in 2000, insomnia, but no snoring or apnea. She has been on Ambien, which is no longer been helpful. She has had arthritis since year 2000, thyroid abnormalities diagnosed in 1968, a hysterectomy in 1986, and a right wrist operation after her fall in 2007 with a titanium plate and eight screws.,FAMILY HISTORY: , Her father died with heart disease in his 60s and her mother died of colon cancer. She has a sister who she believes is probably healthy. She has had two sons one who died of a blood clot after having been a heavy smoker and another who is healthy. She has two normal vaginal deliveries.,SOCIAL HISTORY: ,She lives with her husband. She is a nonsmoker and no history of drug or alcohol abuse. She does drink two to three drinks daily. She completed 12th grade.,ALLERGIES: , Codeine and sulfa.,She has a Living Will and if unable to make decisions for herself, she would want her husband, Vilheim to make decisions for her.,MEDICATIONS,: Premarin 0.625 mg p.o. q.o.d., Aciphex 20 mg p.o. q. daily, Toprol 50 mg p.o. q. daily, Norvasc 5 mg p.o. q. daily, multivitamin, Caltrate plus D, B-complex vitamins, calcium and magnesium, and vitamin C daily.,MAJOR FINDINGS: , On examination today, this is a pleasant and healthy appearing woman.,VITAL SIGNS: Blood pressure 154/72, heart rate 87, and weight 153 pounds. Pain is 0/10.,HEAD: Head is normocephalic and atraumatic. Head circumference is 54 cm, which is in the 10-25th percentile for a woman who is 5 foot and 6 inches tall.,SPINE: Spine is straight and nontender. Spinous processes are easily palpable. She has very mild kyphosis, but no scoliosis.,SKIN: There are no neurocutaneous stigmata.,CARDIOVASCULAR EXAM: Regular rate and rhythm. No carotid bruits. No edema. No murmur. Peripheral pulses are good. Lungs are clear.,MENTAL STATUS: Assessed for recent and remote memory, attention span, concentration, and fund of knowledge. She scored 30/30 on the MMSE when attention was tested with either spelling or calculations. She had no difficulty with visual structures.,CRANIAL NERVES: Pupils are equal. Extraocular movements are intact. Face is symmetric. Tongue and palate are midline. Jaw muscles strong. Cough is normal. SCM and shrug 5 and 5. Visual fields intact.,MOTOR EXAM: Normal for bulk, strength, and tone. There was no drift or tremor.,SENSORY EXAM: Intact for pinprick and proprioception.,COORDINATION: Normal for finger-to-nose.,REFLEXES: Are 2+ throughout.,GAIT: Assessed using the Tinetti assessment tool. She was fairly quick, but had some unsteadiness and a widened base. She did not need an assistive device. I gave her a score of 13/16 for balance and 9/12 for gait for a total score of 22/28.,REVIEW OF X-RAYS: , MRI was reviewed from June 26, 2008. It shows mild ventriculomegaly with a trace expansion into the temporal horns. The frontal horn span at the level of foramen of Munro is 3.8 cm with a flat 3rd ventricular contour and a 3rd ventricular span of 11 mm. The sylvian aqueduct is patent. There is no pulsation artifact. Her corpus callosum is bowed and effaced. She has a couple of small T2 signal abnormalities, but no significant periventricular signal change.,ASSESSMENT: ,The patient is a 74-year-old woman who presents with mild progressive gait impairment and possible slowing of her cognition in the setting of ventriculomegaly suggesting possible adult hydrocephalus.,PROBLEMS/DIAGNOSES:,1. Possible adult hydrocephalus (331.5).,2. Mild gait impairment (781.2).,3. Mild cognitive slowing (290.0).,PLAN: , I had a long discussion with the patient her husband.,I think it is possible that the patient is developing symptomatic adult hydrocephalus. At this point, her symptoms are fairly mild. I explained to them the two methods of testing with CSF drainage. It is possible that a large volume lumbar puncture would reveal whether she is likely to respond to shunt and I described that test. About 30% of my patients with walking impairment in a setting of possible adult hydrocephalus can be diagnosed with a large volume lumbar puncture. Alternatively, I could bring her into the hospital for four days of CSF drainage to determine whether she is likely to respond to shunt surgery. This procedure carries a 2% to 3% risk of meningitis. I also explained that it would be reasonable to start with an outpatient lumbar puncture and if that is not sufficient we could proceed with admission for the spinal catheter protocol." Neurology Ventricular ectopy and coronary artery disease. He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty. Ventricular Ectopy - Consult REASON FOR CONSULTATION:, Ventricular ectopy and coronary artery disease.,HISTORY OF PRESENT ILLNESS: ,I am seeing the patient upon the request of Dr. Y. The patient is a very well known to me. He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty. The patient had presented to the hospital after having coughing episodes for about two weeks on and off, and seemed to have also given him some shortness of breath. The patient was admitted and being treated for pneumonia, according to him. The patient denies any chest pain, chest pressure, or heaviness. Denies any palpitations, fluttering, or awareness of heart activity. However, on monitor, he was noticed to have PVCs random. He had run off three beats consecutive one time at 12:46 p.m. today. The patient denied any awareness of that or syncope.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No fever or chills.,EYES: No visual disturbances.,ENT: No difficulty swallowing.,CARDIOVASCULAR: Prior history of chest discomfort in 08/2009 with negative stress study.,RESPIRATORY: Cough and shortness of breath.,MUSCULOSKELETAL: Positive for arthritis and neck pain.,GU: Unremarkable.,NEUROLOGIC: Otherwise unremarkable.,ENDOCRINE: Otherwise unremarkable.,HEMATOLOGIC: Otherwise unremarkable.,ALLERGIC: Otherwise unremarkable.,PAST MEDICAL HISTORY:,1. Positive for coronary artery disease since 2002.,2. History of peripheral vascular disease for over 10 years.,3. COPD.,4. Hypertension.,PAST SURGICAL HISTORY:, Right fem-popliteal bypass about eight years ago, neck fusion in the remote past, stent-supported angioplasty to unknown vessel in the heart.,MEDICATIONS AT HOME:,1. Aspirin 81 mg daily.,2. Clopidogrel 75 mg daily.,3. Allopurinol 100 mg daily.,4. Levothyroxine 100 mcg a day.,5. Lisinopril 10 mg a day.,6. Metoprolol 25 mg a day.,7. Atorvastatin 10 mg daily.,ALLERGIES: , THE PATIENT DOES HAVE ALLERGY TO MEDICATION. HE SAID HE CANNOT TAKE ASPIRIN BECAUSE OF INTOLERANCE FOR HIS STOMACH AND STOMACH UPSET, BUT NO TRUE ALLERGY TO ASPIRIN.,FAMILY HISTORY:, No history of premature coronary artery disease. One daughter has early onset diabetes and one child has asthma.,SOCIAL HISTORY: , He is married and retired. He has nine children, 25 grandchildren. He smokes one pack per day. He smoked 50 pack years and had no intention of quitting according to him.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature of 97, heart rate of 90, blood pressure of 187/105.,HEENT: Normocephalic and atraumatic. No thyromegaly or lymphadenopathy.,NECK: Supple.,CARDIOVASCULAR: Upstroke is normal. Distal pulse symmetrical. Heart regular with a normal S1 with normally split S2. There is an S4 at the apex.,LUNGS: With decreased air entry. No wheezes.,ABDOMINAL: Benign. No masses.,EXTREMITIES: No edema, cyanosis, or clubbing.,NEUROLOGIC: Awake, alert, and oriented x3. No focal deficits.,IMAGING STUDIES: , Echocardiogram on 08/26/2009, showed mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle, EF of 40%, mild mitral regurgitation, and diastolic dysfunction, grade 2. Cardiovascular / Pulmonary Insertion of a VVIR permanent pacemaker. This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias VVIR Permanent Pacemaker Insertion PROCEDURE PERFORMED:, Insertion of a VVIR permanent pacemaker.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,SITE:, Left subclavian vein access.,INDICATION: , This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias and therefore, this is indicated so that we can give better control of heart rate and to maintain beta-blocker therapy in the order of treatment. It is overall a Class-II indication for permanent pacemaker insertion.,PROCEDURE:, The risks, benefits, and alternative of the procedure were all discussed with the patient and the patient's family in detail at great length. Overall options and precautions of the pacemaker and indications were all discussed. They agreed to the pacemaker. The consent was signed and placed in the chart. The patient was taken to the Cardiac Catheterization Lab, where she was monitored throughout the whole procedure. The patient was sterilely prepped and draped in the usual manner for permanent pacemaker insertion. Myself and Dr. Wildes spoke for approximately 8 minutes before insertion for the procedure. Using a lidocaine with epinephrine, the area of the left subclavian vein and left pectodeltoid region was anesthetized locally.,IV sedation, increments, and analgesics were given. Using a #18 gauge needle, the left subclavian vein access was cannulated without difficulty. A guidewire was then passed through the Cook needle and the Cook needle was then removed. The wire was secured in place with the hemostat. Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectoral deltoid region where the skin was dissected and blunted down into the pectoris major muscle fascia. The skin was then undermined used to make a pocket for the pacemaker. The guidewire was then tunneled through the pacer pocket. Cordis sheath was then inserted through the guidewire. The guidewire and dilator were removed. ___ cordis sheath was in placed within. This was used for insertion of the ventricular screw and steroid diluted leads where under fluoroscopy. It was placed into the apex. Cordis sheath was then split apart and removed and after the ventricular lead was placed in its appropriate position and good thresholds were obtained, the lead was then sutured in place with #1-0 silk suture to the pectoris major muscle. The lead was then connected on pulse generator. The pocket was then irrigated and cleansed. Pulse generator and the wire was then inserted into the ____ pocket. The skin was then closed with gut suture. The skin was then closed with #4-0 Poly___ sutures using a subcuticular uninterrupted technique. The area was then cleansed and dried. Steri-Strips and pressure dressing was then applied. The patient tolerated the procedure well. there was no complications.,These are the settings on the pacemaker:,IMPLANT DEVICE: , Pulse Generator Model Name: Sigma, model #: 12345, serial #: 123456.,VENTRICLE LEAD:, Model #: 12345, the ventricular lead serial #: 123456.,Ventricle lead was a screw and steroid diluted lead placed into the right ventricle apex.,BRADY PARAMETER SETTINGS ARE AS FOLLOWS:, Amplitude was set at 3.5 volts with a pulse of 0.4, sensitivity of 2.8. The pacing mode was set at VVIR, lower rate of 60 and upper rate of 120.,STIMULATION THRESHOLDS: ,The right ventricular lead and bipolar, threshold voltage is 0.6 volts, 1 milliapms current, 600 Ohms resistance, R-wave sensing 11 millivolts.,The patient tolerated the procedure well. There was no complications. The patient went to recovery in stable condition. Chest x-ray will be ordered. She will be placed on IV antibiotics and continue therapy for congestive heart failure and tachybrady arrhythmia.,Thank you for allowing me to participate in her care. If you have any questions or concerns, please feel free to contact. cardiovascular / pulmonary, aortic stenosis, vvir permanent pacemaker, permanent pacemaker insertion, congestive heart failure, tachybrady arrhythmias, subclavian vein, cordis sheath, ventricular lead, pulse generator, permanent pacemaker, insertion, ventricle, vvir, ventricular, permanent, pacemaker, leads, Cardiovascular / Pulmonary Patient with worsening shortness of breath and cough. Trouble breathing "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." Cardiovascular / Pulmonary Right and Left carotid ultrasound Ultrasound - Carotid - 1 RIGHT:,1. Mild heterogeneous plaque seen in common carotid artery.,2. Moderate heterogeneous plaque seen in the bulb and internal carotid artery.,3. Severe heterogeneous plaque seen in external carotid artery with degree of stenosis around 70%. ,4. Peak systolic velocity is normal in common carotid, bulb, and internal carotid artery.,5. Peak systolic velocity is 280 cm/sec in external carotid artery with moderate spectral broadening.,LEFT: , ,1. Mild heterogeneous plaque seen in common carotid artery and external carotid artery.,2. Moderate heterogeneous plaque seen in the bulb and internal carotid artery with degree of stenosis less than 50%.,3. Peak systolic velocity is normal in common carotid artery and in the bulb.,4. Peak systolic velocity is 128 cm/sec in internal carotid artery and 156 cm/sec in external carotid artery.,VERTEBRALS:, Antegrade flow seen bilaterally. cardiovascular / pulmonary, carotid ultrasound, antegrade flow, peak systolic velocity, bulb, carotid artery, homogeneous plaque, plaque, spectral broadening, bulb and internal carotid, velocity is normal, common carotid artery, internal carotid artery, external carotid artery, internal carotid, external carotid, peak systolic, systolic velocity, artery, carotid, ultrasound, velocity, heterogeneous, Cardiovascular / Pulmonary Need for intravenous access. Insertion of a right femoral triple lumen catheter. he 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. Triple Lumen Catheter Insertion - 1 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. cardiovascular / pulmonary, intravenous access, catheter, femoral triple lumen catheter, triple lumen catheter, lumen, ventilator, respiratory, guidewire Cardiovascular / Pulmonary The patient was exercised according to standard Bruce protocol for 9 minutes. Treadmill Test REASON FOR EXAMINATION:, Abnormal EKG.,FINDINGS: , The patient was exercised according to standard Bruce protocol for 9 minutes achieving maximal heart rate of 146 resulting in 85% of age-predicted maximal heart rate. Peak blood pressure was 132/60. The patient did not experience any chest discomfort during stress or recovery. The test was terminated due to leg fatigue and achieving target heart rate.,Electrocardiogram during stress and recovery did not reveal an additional 1 mm of ST depression compared to the baseline electrocardiogram. Technetium was injected at 5 minutes into stress.,IMPRESSION:,1. Good exercise tolerance.,2. Adequate heart rate and blood pressure response.,3. This maximal treadmill test did not evoke significant and diagnostic clinical or electrocardiographic evidence for significant occlusive coronary artery disease., cardiovascular / pulmonary, ekg, st depression, maximal heart rate, treadmill test, bruce protocol, blood pressure, heart rate, treadmill, electrocardiogram, Cardiovascular / Pulmonary Coronary artery bypass surgery and aortic stenosis. Transthoracic echocardiogram was performed of technically limited quality. Concentric hypertrophy of the left ventricle with left ventricular function. Moderate mitral regurgitation. Severe aortic stenosis, severe. Transthoracic Echocardiography REASON FOR EXAM: , Coronary artery bypass surgery and aortic stenosis.,FINDINGS: , Transthoracic echocardiogram was performed of technically limited quality. The left ventricle was normal in size and dimensions with normal LV function. Ejection fraction was 50% to 55%. Concentric hypertrophy noted with interventricular septum measuring 1.6 cm, posterior wall measuring 1.2 cm. Left atrium is enlarged, measuring 4.42 cm. Right-sided chambers are normal in size and dimensions. Aortic root has normal diameter.,Mitral and tricuspid valve reveals annular calcification. Fibrocalcific valve leaflets noted with adequate excursion. Similar findings noted on the aortic valve as well with significantly adequate excursion of valve leaflets. Atrial and ventricular septum are intact. Pericardium is intact without any effusion. No obvious intracardiac mass or thrombi noted.,Doppler study reveals mild-to-moderate mitral regurgitation. Severe aortic stenosis with peak velocity of 2.76 with calculated ejection fraction 50% to 55% with severe aortic stenosis. There is also mitral stenosis.,IMPRESSION:,1. Concentric hypertrophy of the left ventricle with left ventricular function.,2. Moderate mitral regurgitation.,3. Severe aortic stenosis, severe.,RECOMMENDATIONS: , Transesophageal echocardiogram is clinically warranted to assess the aortic valve area. cardiovascular / pulmonary, coronary artery bypass surgery, aortic stenosis, annular calcification, tricuspid, mitral, regurgitation, severe aortic stenosis, concentric hypertrophy, mitral regurgitation, transthoracic, echocardiogram, hypertrophy, ventricular, valve, stenosis, aortic Cardiovascular / Pulmonary Bilateral carotid ultrasound to evaluate pain. Ultrasound - Carotid - 2 EXAM: , Ultrasound carotid, bilateral.,REASON FOR EXAMINATION: , Pain.,COMPARISON:, None.,FINDINGS: , Bilateral common carotid arteries/branches demonstrate minimal, predominantly noncalcified plaquing with mild calcific plaquing in the left internal carotid artery. There are no different colors or spectral Doppler waveform abnormalities.,PARAMETRIC DATA:, Right CCA PSV 0.72 m/s. Right ICA PSV is 0.595 m/s. Right ICA EDV 0.188 m/s. Right vertebral 0.517 m/s. Right IC/CC is 0.826. Left CCA PSV 0.571 m/s, left ICA PSV 0.598 m/s. Left ICA EDV 0.192 m/s. Left vertebral 0.551 m/s. Left IC/CC is 1.047.,IMPRESSION:,1. No evidence for clinically significant stenosis.,2. Minimal, predominantly soft plaquing., cardiovascular / pulmonary, carotid, cca psv, doppler, ic/cc, ica edv, ica psv, ultrasound, arteries, calcific plaquing, common carotid, internal carotid artery, spectral, stenosis, waveform, ultrasound carotid bilateral, ultrasound carotid, plaquing, Cardiovascular / Pulmonary Insertion of a right brachial artery arterial catheter and a right subclavian vein triple lumen catheter. Hyperpyrexia/leukocytosis, ventilator-dependent respiratory failure, and acute pancreatitis. Triple Lumen Catheter Insertion PREOPERATIVE DIAGNOSES:,1. Hyperpyrexia/leukocytosis.,2. Ventilator-dependent respiratory failure.,3. Acute pancreatitis.,POSTOPERATIVE DIAGNOSES:,1. Hyperpyrexia/leukocytosis.,2. Ventilator-dependent respiratory failure.,3. Acute pancreatitis.,PROCEDURE PERFORMED:,1. Insertion of a right brachial artery arterial catheter.,2. Insertion of a right subclavian vein triple lumen catheter.,ANESTHESIA: , Local, 1% lidocaine.,BLOOD LOSS:, Less than 5 cc.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 46-year-old Caucasian female admitted with severe pancreatitis. She was severely dehydrated and necessitated some fluid boluses. The patient became hypotensive, required many fluid boluses, became very anasarcic and had difficulty with breathing and became hypoxic. She required intubation and has been ventilator-dependent in the Intensive Care since that time. The patient developed very high temperatures as well as leukocytosis. Her lines required being changed.,PROCEDURE:,1. RIGHT BRACHIAL ARTERIAL LINE: ,The patient's right arm was prepped and draped in the usual sterile fashion. There was a good brachial pulse palpated. The artery was cannulated with the provided needle and the kit. There was good arterial blood return noted immediately. On the first stick, the Seldinger wire was inserted through the needle to cannulate the right brachial artery without difficulty. The needle was removed and a catheter was inserted over the Seldinger wire to cannulate the brachial artery. The femoral catheter was used in this case secondary to the patient's severe edema and anasarca. We did not feel that the shorter catheter would provide enough length. The catheter was connected to the system and flushed without difficulty. A good waveform was noted. The catheter was sutured into place with #3-0 silk suture and OpSite dressing was placed over this.,2. RIGHT SUBCLAVIAN TRIPLE LUMEN CATHETER: ,The patient was prepped and draped in the usual sterile fashion. 1% Xylocaine was used to anesthetize an area just inferior and lateral to the angle of the clavicle. Using the anesthetic needle, we checked down to the soft tissues anesthetizing, as we proceeded to the angle of the clavicle, this was also anesthetized. Next, a #18 gauge thin walled needle was used following the same track to the angle of clavicle. We roughed the needle down off the clavicle and directed it towards the sternal notch. There was good venous return noted immediately. The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein. The needle was then removed. A small skin nick was made with a #11 blade scalpel and the provided dilator was used to dilate the skin, soft tissue and vein. Next, the triple lumen catheter was inserted over the guidewire without difficulty. The guidewire was removed. All the ports aspirated and flushed without difficulty. The catheter was sutured into place with #3-0 silk suture and a sterile OpSite dressing was also applied. The patient tolerated the above procedures well. A chest x-ray has been ordered, however, it has not been completed at this time, this will be checked and documented in the progress notes. cardiovascular / pulmonary, hyperpyrexia, leukocytosis, ventilator-dependen, respiratory failure, pancreatitis, brachial artery, arterial catheter, subclavian vein, triple lumen catheter, catheter, brachial, needle, Cardiovascular / Pulmonary Urgent cardiac catheterization with coronary angiogram. Urgent Cardiac Cath PROCEDURE: , Urgent cardiac catheterization with coronary angiogram.,PROCEDURE IN DETAIL: , The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest. The right groin was prepped and draped in usual manner. Under 2% lidocaine anesthesia, the right femoral artery was entered. A 6-French sheath was placed. The patient was already on anticoagulation. Selective coronary angiograms were then performed using a left and a 3DRC catheter. The catheters were reviewed. The catheters were then removed and an Angio-Seal was placed. There was some hematoma at the cath site.,RESULTS,1. The left main was free of disease.,2. The left anterior descending and its branches were free of disease.,3. The circumflex was free of disease.,4. The right coronary artery was free of disease. There was no gradient across the aortic valve.,IMPRESSION: , Normal coronary angiogram., cardiovascular / pulmonary, cardiac catheterization, coronary angiogram, angiogram Cardiovascular / Pulmonary Transesophageal echocardiographic examination report. Aortic valve replacement. Assessment of stenotic valve. Evaluation for thrombus on the valve. Transesophageal Echocardiogram - 3 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. cardiovascular / pulmonary, aortic valve replacement, stenotic valve, thrombus, stenosis, ventricular, esophageal, peak velocity, valve replacement, aortic valve, aortic, transesophageal, valve, oropharynx, atrium, interrogation, atrial, moderate, Cardiovascular / Pulmonary Transesophageal Echocardiogram. A woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry. Transesophageal Echocardiogram - 6 HISTORY OF PRESENT ILLNESS: , I was kindly asked to see this patient for transesophageal echocardiogram performance by Dr. A and Neurology. Please see also my cardiovascular consultation dictated separately. But essentially, this is a pleasant 72-year-old woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry. She has been recommended for a transesophageal echocardiogram for cardioembolic source of her CNS insult.,I discussed the procedure in detail with the patient as well as with her daughter, who was present at the patient's bedside with the patient's verbal consent. I then performed a risk/benefit/alternative analysis with benefits being more definitive exclusion of intracardiac thrombus as well as assessment for intracardiac shunts; alternatives being transthoracic echo imaging, which she had already had, with an inherent false negativity for this indication as well as empiric medical management, which the patient was not interested in; risks including, but not limited to, and the patient was aware this was not an all-inclusive list, of oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, risk of oropharyngeal, esophageal, oral, tracheal, pulmonary and/or gastric perforation, hemorrhage, or tear. The patient expressed understanding of this risk/benefit/alternative analysis, had the opportunity to ask questions, which I invited from her and her daughter, all of which were answered to their self-stated satisfaction. The patient then stated in a clear competent and coherent fashion that she wished to go forward with the transesophageal echocardiogram.,PROCEDURE: , The appropriate time-out procedure was performed as per Medical Center protocol under my direct supervision with appropriate identification of the patient, position, physician, procedure documentation; there were no safety issues identified by staff nor myself. She received 20 cc of viscous lidocaine for topical oral anesthetic effect. She received a total of 4 mg of Versed and 100 micrograms of fentanyl utilizing titrated conscious sedation with continuous hemodynamic and oximetric monitoring with reasonable effect. The multi-plane probe was passed using digital guidance for several passes, after an oral bite block had been put into place for protection of oral dentition. This was placed into the posterior oropharynx and advanced into the esophagus, then advanced into the stomach and then rotated and withdrawn and removed with adequate imaging obtained throughout. She was recovered as per the Medical Center conscious sedation protocol, and there were no apparent complications of the procedure.,FINDINGS: , Normal left ventricular size and systolic function. LVEF of 60%. Mild left atrial enlargement. Normal right atrial size. Normal right ventricular size and systolic function. No left ventricular wall motion abnormalities identified. The four pulmonary veins are identified. The left atrial appendage is interrogated, including with Doppler and color flow, and while there is good to-and-fro motion seen, echo smoke is seen, and in fact, an intracardiac thrombus is identified and circumscribed at 1.83 cm in circumference at the base of the left atrial appendage. No intracardiac vegetations nor endocarditis seen on any of the intracardiac valves. The mitral valve is seen. There is mild mitral regurgitation with two jets. No mitral stenosis. Four pulmonary veins were identified without reversible pulmonary venous flow. There are three cusps of the aortic valve seen. No aortic stenosis. There is trace aortic insufficiency. There is trace pulmonic insufficiency. The pulmonary artery is seen and is within normal limits. There is trace to mild tricuspid regurgitation. Unable to estimate PA systolic pressure accurately; however, on the recent transthoracic echocardiogram (which I would direct the reader to) on January 5, 2010, RVSP was calculated at 40 mmHg on that study. E wave velocity on average is 0.95 m/sec with a deceleration time of 232 milliseconds. The proximal aorta is within normal limits, annulus 1.19 cm, sinuses of Valsalva 2.54 cm, ascending aorta 2.61 cm. The intra-atrial septum is identified as are the SVC and IVC, and these are within normal limits. The intra-atrial septum is interrogated with color flow as well as agitated D5W and there is no evidence of intracardiac shunting, including no atrial septal defect nor patent foramen ovale. No pericardial effusion. There is mild nonmobile descending aortic atherosclerosis seen.,IMPRESSION:,1. Normal left ventricular size and systolic function. Left ventricular ejection fraction visually estimated at 60% without regional wall motion abnormalities.,2. Mild left atrial enlargement.,3. Intracardiac thrombus identified at the base of the left atrial appendage.,4. Mild mitral regurgitation with two jets.,5. Mild nonmobile descending aortic atherosclerosis.,Compared to the transthoracic echocardiogram done previously, other than identification of the intracardiac thrombus, other findings appear quite similar.,These results have been discussed with Dr. A of inpatient Internal Medicine service as well as the patient, who was recovering from conscious sedation, and her daughter with the patient's verbal consent. cardiovascular / pulmonary, echo, thrombus, intracardiac, cardiovascular, pulmonary veins, intracardiac thrombus, transesophageal echocardiogram, echocardiogram, atrial, mca, cva, transesophageal, pulmonary, ventricular, aortic Cardiovascular / Pulmonary Transesophageal echocardiogram. The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty. Transesophageal Echocardiogram - 4 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. cardiovascular / pulmonary, ventricle, atrium, mitral valve, aortic valve, tricuspid valve, pulmonic valve, regurgitation, transesophageal probe, transesophageal echocardiogram, posterior pharynx, transesophageal, valve Cardiovascular / Pulmonary Transesophageal echocardiogram. MRSA bacteremia, rule out endocarditis. The patient has aortic stenosis. Transesophageal Echocardiogram - 5 CLINICAL INDICATIONS: , MRSA bacteremia, rule out endocarditis. The patient has aortic stenosis.,DESCRIPTION OF PROCEDURE: , The transesophageal echocardiogram was performed after getting verbal and a written consent signed. Then a multiplane TEE probe was introduced into the upper esophagus, mid esophagus, lower esophagus, and stomach and multiple views were obtained. There were no complications. The patient's throat was numbed with Cetacaine spray and IV sedation was achieved with Versed and fentanyl.,FINDINGS:,1. Aortic valve is thick and calcified, a severely restricted end opening and there is 0.6 x 8 mm vegetation attached to the right coronary cusp. The peak velocity across the aortic valve was 4.6 m/sec and mean gradient was 53 mmHg and peak gradient 84 mmHg with calculated aortic valve area of 0.6 sq cm by planimetry.,2. Mitral valve is calcified and thick. No vegetation seen. There is mild-to-moderate MR present. There is mild AI present also.,3. Tricuspid valve and pulmonary valve are structurally normal.,4. There is a mild TR present.,5. There is no clot seen in the left atrial appendage. The velocity in the left atrial appendage was 0.6 m/sec.,6. Intraatrial septum was intact. There is no clot or mass seen.,7. Normal LV and RV systolic function.,8. There is thick raised calcified plaque seen in the thoracic aorta and arch.,SUMMARY:,1. There is a 0.6 x 0.8 cm vegetation present in the aortic valve with severe aortic stenosis. Calculated aortic valve area was 0.6 sq. cm.,2. Normal LV systolic function., cardiovascular / pulmonary, endocarditis, aortic stenosis, tee probe, mrsa bacteremia, transesophageal echocardiogram, aortic, echocardiogram, esophagus, vegetation, transesophageal Cardiovascular / Pulmonary Transesophageal echocardiogram due to vegetation and bacteremia. Normal left ventricular size and function. Echodensity involving the aortic valve suggestive of endocarditis and vegetation. Doppler study as above most pronounced being moderate-to-severe aortic insufficiency. Transesophageal Echocardiogram - 2 REASON FOR EXAM: , Vegetation and bacteremia.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION: , The procedure and its complications were explained to the patient in detail and formal consent was obtained. The patient was brought to special procedure unit. His throat was anesthetized with lidocaine spray. Subsequently, 2 mg of IV Versed was given for sedation. The patient was positioned. Probe was introduced without any difficulty. The patient tolerated the procedure very well. Probe was taken out. No complications were noted. Findings are as mentioned below.,FINDINGS:,1. Left ventricle has normal size and dimensions with normal function. Ejection fraction of 60%.,2. Left atrium and right-sided chambers were of normal size and dimensions.,3. Left atrial appendage is clean without any clot or smoke effect.,4. Atrial septum is intact. Bubble study was negative.,5. Mitral valve is structurally normal.,6. Aortic valve reveals echodensity suggestive of vegetation.,7. Tricuspid valve was structurally normal.,8. Doppler reveals moderate mitral regurgitation and moderate-to-severe aortic regurgitation.,9. Aorta is benign.,IMPRESSION:,1. Normal left ventricular size and function.,2. Echodensity involving the aortic valve suggestive of endocarditis and vegetation.,3. Doppler study as above most pronounced being moderate-to-severe aortic insufficiency. cardiovascular / pulmonary, ventricle, atrium, atrial, septum, mitral valv, aortic valve, tricuspid valve, doppler, ventricular size, transesophageal echocardiogram, severe aortic, bacteremia, transesophageal, echocardiogram, echodensity, vegetation, valve, aortic, Cardiovascular / Pulmonary Insertion of transesophageal echocardiography probe and unsuccessful insertion of arterial venous lines. Transesophageal Echocardiography Probe INDICATIONS FOR PROCEDURE:, Impending open heart surgery for closure of ventricular septal defect in a 4-month-old girl.,Procedures were done under general anesthesia. The patient was already in the operating room under general anesthesia. Antibiotic prophylaxis with cefazolin and gentamicin was already given prior to beginning the procedures.,PROCEDURE #1:, Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #1: , The probe was well lubricated and with digital manipulation, was passed into the esophagus without resistance. The probe was placed so that the larger diameter was in the anterior-posterior position during insertion. The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography. At the end, it was removed without trauma and there was no blood tingeing. It is to be noted that approximately 30 minutes after removing the cannula, I inserted a 14-French suction tube to empty the stomach and there were a few mL of blood secretions that were suctioned. There was no overt bleeding.,PROCEDURE #2: , Attempted and unsuccessful insertion of arterial venous lines.,DESCRIPTION OF PROCEDURE #2:, Both groins were prepped and draped. The patient was placed at 10 degrees head-up position. A Cook 4-French double-lumen 8-cm catheter kit was opened. Using the 21-gauge needle that comes with the kit, several attempts were made to insert central venous and then an arterial line in the left groin. There were several successful punctures of these vessels, but I was unable to advance Seldinger wire. After removal of the needles, the area was compressed digitally for approximately 5 minutes. There was a small hematoma that was not growing. Initially, the left leg was mildly mottled with prolonged capillary refill of approximately 3 seconds. Using 1% lidocaine, I infiltrated the vessels of the groin both medial and lateral to the vascular sheath. Further observation, the capillary refill and circulation of the left leg became more than adequate. The O2 saturation monitor that was on the left toe functioned well throughout the procedures, from the beginning to the end. At the end of the procedure, the circulation of the leg was intact., cardiovascular / pulmonary, impending open heart surgery, ventricular septal defect, antibiotic prophylaxis, cefazolin, transesophageal echocardiography probe, arterial venous lines, groin, transesophageal echocardiography, echocardiography probe, insertion, transesophageal, arterial, venous, groins, echocardiography, probe Cardiovascular / Pulmonary Tracheostomy change. A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension. Ventilator-dependent respiratory failure and laryngeal edema. Tracheostomy Change 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. cardiovascular / pulmonary, shiley, proximal extension, ventilator-dependent, respiratory failure, laryngeal edema, tracheostomy, cannula, respiratory, laryngeal, nasogastric, edema, ventilator Cardiovascular / Pulmonary Tracheostomy with skin flaps and SCOOP procedure FastTract. Oxygen dependency of approximately 5 liters nasal cannula at home and chronic obstructive pulmonary disease. Tracheostomy & SCOOP Procedure PREOPERATIVE DIAGNOSES:,1. Oxygen dependency.,2. Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1. Oxygen dependency.,2. Chronic obstructive pulmonary disease.,PROCEDURES PERFORMED:,1. Tracheostomy with skin flaps.,2. SCOOP procedure FastTract.,ANESTHESIA: , Total IV anesthesia.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: ,None.,INDICATIONS FOR PROCEDURE: , The patient is a 55-year-old Caucasian male with a history of chronic obstructive pulmonary disease and O2 dependency of approximately 5 liters nasal cannula at home. The patient with extensive smoking history who presents after risks, complications, and consequences of the SCOOP FastTract procedure were explained.,PROCEDURE:, The patient was brought to operating suite by Anesthesia and placed on the operating table in the supine position. After this, the patient was then placed under total IV anesthesia and the operating bed was then placed in reverse Trendelenburg. The patient's sternal notch along with cricoid and thyroid cartilages were noted and palpated and a sternal marker was utilized to mark the cricoid cartilage in the sternal notch. The midline was also marked and 1% lidocaine with epinephrine 1:100,000 at approximately 4 cc total was then utilized to localize the neck. After this, the patient was then prepped and draped with Hibiclens. A skin incision was then made in the midline with a #15 Bard-Parker in a vertical fashion. After this, the skin was retracted laterally and a small anterior jugular branch was clamped and cross clamped and tied with #2-0 undyed Vicryl ties. Further bleeding was controlled with monopolar cauterization and attention was then drawn down on to the strap muscles. The patient's sternohyoid muscle was identified and grasped on either side and the midline raphe was identified. Cauterization was then utilized to take down the midline raphe and further dissection was utilized with the skin hook and stat clamps. The anterior aspect of the thyroid isthmus was identified and palpation on the cricoid cartilage was performed. The cricoid cauterization over the cricoid cartilage was obtained with the monopolar cauterization and blunt dissection then was carried along the posterior aspect of the thyroid isthmus. Stats were then placed on either side of the thyroid isthmus and the mid portion was bisected with the monopolar cauterization. After this, the patient's anterior trachea was then identified and cleaned with pusher. After this, the cricoid cartilage along the first and second tracheal rings was identified. The cricoid hook was placed and the trachea was brought more anteriorly and superiorly. After this, the patient's head incision was placed below the second tracheal ring with a #15 Bard-Parker. After this, the patient had a tracheal punch with the SCOOP FastTract kit to create a small 4 mm punch within the tracheal cartilage. After this, the patient then had a tracheal stent placed within the tracheal punched lumen and the patient was then had the tracheal stent secured to the neck with a Vicryl strap. After this, the cricoid hook was removed and the patient then had FiO2 on the monitor noted with pulse oximetry of 100%. The patient was then turned back to the anesthesia and transferred to the recovery room in stable condition. The patient tolerated the procedure well and will stay in the hospital for approximately 23 hours. The patient will have the stent guidewire removed with a scoop catheter 11 cm placed. cardiovascular / pulmonary, oxygen dependency, chronic obstructive pulmonary disease, tracheostomy, scoop procedure, nasal cannula, scoop procedure fasttract, thyroid isthmus, cricoid cartilage, isthmus, oxygen, dependency, scoop, cartilages Cardiovascular / Pulmonary Transesophageal echocardiogram and direct current cardioversion. Transesophageal Echocardiogram 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. Cardiovascular / Pulmonary Tilt table test. A patient with past medical history of syncope. The patient is also complaining of dizziness. Tilt Table Test - 1 INDICATIONS: , The patient is a 22-year-old female with past medical history of syncope. The patient is also complaining of dizziness. She was referred here by Dr. X for tilt table.,TECHNIQUE: , Risks and benefits explained to the patient. Consent obtained. She was lying down on her back for 20 minutes and her blood pressure was 111/75 and heart rate 89. She was standing up on the tilt tablet for 20 minutes and her heart rate went up to 127 and blood pressure was still in 120/80. Then, the patient received sublingual nitroglycerin 0.4 mg. The patient felt dizzy at that time and heart rate was in the 120 and blood pressure was 110/50. The patient felt nauseous and felt hot at that time. She did not pass out.,COMPLICATIONS:, None.,Tilt table was then terminated.,SUMMARY:, Positive tilt table for vasovagal syncope with significant increase of heart rate with minimal decrease of blood pressure.,RECOMMENDATIONS: , I recommend followup in the office in one week and she will need Toprol-XL 12.5 mg every day if symptoms persist. cardiovascular / pulmonary, vasovagal syncope, tilt table test, blood pressure, heart rate, dizziness, Cardiovascular / Pulmonary Patient referred for evaluation of tracheostomy tube placement and treatment recommendations. Tracheostomy Tube Consult HISTORY: ,I had the pleasure of meeting and evaluating the patient today, referred for evaluation of tracheostomy tube placement and treatment recommendations. As you are well aware, he is a pleasant 64-year-old gentleman who unfortunately is suffering from end-stage COPD, who required tracheostomy tube placement about three months ago when being treated for acute exacerbation of COPD and having difficulty coming off ventilatory support. He now resides in an extended care facility with a capped tracheostomy tube, and he unfortunately states he has had not had to use the tracheostomy tube since his discharge and admission to the extended care facility. He requires constant oxygen administration and has been having no problems with shortness of breath, worsening, requiring opening the tracheostomy tube site. He states there has been some tenderness associated with the tracheostomy tube and difficulty with swallowing and he wishes to have it removed. Apparently there is no history of any airway issues while sleeping or need for uncapping the tube and essentially the tube has just remained present for months capped in his neck. No history of any previous tracheostomy tube insertion.,PAST MEDICAL HISTORY: , COPD, history of hypercarbic hypoxemia, history of coronary artery disease, history of previous myocardial infarction, and history of liver cirrhosis secondary to alcohol use.,PAST SURGICAL HISTORY: ,Tonsillectomy, adenoidectomy, cholecystectomy, appendectomy, hernia repair, and tracheostomy.,FAMILY HISTORY: ,Strong for heart disease, coronary artery disease, hypertension, diabetes mellitus, and cerebrovascular accident.,CURRENT MEDICATIONS:, Prevacid, folic acid, aspirin, morphine sulfate, Pulmicort, Risperdal, Colace, clonazepam, Lotrisone, Roxanol, Ambien, Zolpidem tartrate, simethicone, Robitussin, and prednisone.,ALLERGIES: , Nitroglycerin.,SOCIAL HISTORY: , The patient has a 25-year-smoking history, which I believe is quite heavy and he has a significant alcohol use in the past.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Age 64, blood pressure is 110/78, pulse 96, and temperature is 98.6.,GENERAL: The patient was examined in his wheelchair, resting comfortably, 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 patient has a stable-appearing tracheostomy tube site and the stoma appears to be without signs of infection. The previous incision was vertical in nature and there is no hypertrophic scar formation. No adenopathy noted. No stridor noted.,NEUROLOGIC: Cranial nerve VII intact bilaterally. No signs of tremor.,LUNGS: Diminished breath sounds in all four quadrants. No wheezes noted.,HEART: Regular rate and rhythm.,PROCEDURE: , Limited bronchoscopy and then fiberoptic laryngoscopy.,IMPRESSION: ,1. End-stage chronic obstructive pulmonary disease with a history of respiratory failure requiring mechanical ventilatory support with tracheostomy tube placement.,2. Difficulty tolerating tracheostomy tubes secondary to swallow discomfort and neck irritation with no further need for tracheostomy tube over the past few months with the patient tolerating capped tracheostomy tube 24 hours a day.,3. History of coronary artery disease.,4. History of myocardial infarction.,5. History of cirrhosis of liver.,RECOMMENDATIONS: , I discussed with the patient in detail after fiberoptic laryngoscopy and limited bronchoscopy was performed in the office whether or not to pull out the tracheostomy tube. His vocal cords moved well, and I do not see any signs of granuloma or airway obstruction either in the supraglottic or subglottic region, and I felt he would tolerate the tube being removed with close monitoring by nursing at his extended care facility. I did impress the fact that I believe he probably will have other events requiring airway support, which could include intubation, and if the intubation is prolonged a tracheostomy may be needed. Creation of a long-term tracheostoma may be beneficial whereas the patient would not need such a long tracheostomy tube, and I informed the patient there are other options other than the tube he has at the present time. The patient still wished to have the tube removed and he is aware he may need to have it replaced or he may have trouble with the area healing or scarring or he could end up having an emergent airway situation with the tube gone, but wishes to have it removed, and I did remove it today. Dressing was applied and we will see him back next week to make sure everything is healing properly. Cardiovascular / Pulmonary Tracheotomy for patient with respiratory failure. Tracheotomy - 1 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. cardiovascular / pulmonary, bivona tube, duoderm, tracheotomy tube, respiratory failure, cricoid cartilage, tracheotomy, tracheal, Cardiovascular / Pulmonary Transesophageal echocardiogram for aortic stenosis. Normal left ventricular size and function. Benign Doppler flow pattern. Doppler study essentially benign. Aorta essentially benign. Atrial septum intact. Study was negative. Transesophageal Echocardiogram - 1 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., cardiovascular / pulmonary, aortic valve, ejection fraction, planimetry, ventricular, transesophageal, echocardiogram, atrial septum, septum intact, transesophageal echocardiogram, aortic stenosis, doppler, aortic, valves Cardiovascular / Pulmonary Aortic stenosis. Insertion of a Toronto stentless porcine valve, cardiopulmonary bypass, and cold cardioplegia arrest of the heart. Toronto Porcine Valve Insertion PREOPERATIVE DIAGNOSIS:, Aortic stenosis.,POSTOPERATIVE DIAGNOSIS: ,Aortic stenosis.,PROCEDURES PERFORMED,1. Insertion of a **-mm Toronto stentless porcine valve.,2. Cardiopulmonary bypass.,3. Cold cardioplegia arrest of the heart.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , 300 cc.,INTRAVENOUS FLUIDS: , 1200 cc of crystalloid.,URINE OUTPUT: , 250 cc.,AORTIC CROSS-CLAMP TIME: , **,CARDIOPULMONARY BYPASS TIME TOTAL: , **,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 general endotracheal anesthesia was administered. Next the neck, chest and legs were prepped and draped in the standard surgical fashion. We used a #10-blade scalpel to make a midline median sternotomy incision. Dissection was carried down to the left of the sternum using Bovie electrocautery. The sternum was opened with a sternal saw. The chest retractor was positioned. Next, full-dose heparin was given. The pericardium was opened. Pericardial stay sutures were positioned. After obtaining adequate ACT, we prepared to place the patient on cardiopulmonary bypass. A 2-0 double pursestring of Ethibond suture was placed in the ascending aorta. Through this was passed an aortic cannula connected to the arterial side of the cardiopulmonary bypass machine. Next a 3-0 Prolene pursestring was placed in the right atrial appendage. Through this was passed our venous cannula connected to the venous portion of the cardiopulmonary bypass machine. A 4-0 U-stitch was placed in the right atrium. A retrograde cardioplegia catheter was positioned at this site. Next, scissors were used to dissect out the right upper pulmonary vein. A 4-0 Prolene pursestring was placed in the right upper pulmonary vein. Next, a right-angle sump was placed at this position. We then connected our retrograde cardioplegia catheter to the cardioplegia solution circuit. Bovie electrocautery was used to dissect the interface between the aorta and pulmonary artery. The aorta was completely encircled. Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta. We then prepared to cross-clamp the aorta. We went down on our flows and cross-clamped the aorta. We backed up our flows. We then gave antegrade and retrograde cold blood cardioplegia solution circuit so as to arrest the heart. The patient had some aortic insufficiency so we elected, after initially arresting the heart, to open the aorta and transect it and then give direct ostial infusion of cardioplegia solution circuit. Next, after obtaining complete diastolic arrest of the heart, we turned our attention to exposing the aortic valve, and 4-0 Tycron sutures were placed in the commissures. In addition, a 2-0 Prolene suture was placed in the aortic wall so as to bring the aortic wall and root up into view. Next, scissors were used to excise the diseased aortic valve leaflets. Care was taken to remove all the calcium from the aortic annulus. We then sized up the aortic annulus which came out to be a **-mm stentless porcine Toronto valve. We prepared the valve. Next, we placed our proximal suture line of interrupted 4-0 Tycron sutures for the annulus. We started with our individual commissural stitches. They were connected to our valve sewing ring. Next, we placed 5 interrupted 4-0 Tycron sutures in a subannular fashion at each commissural position. After doing so, we passed 1 end of the suture through the sewing portion of the Toronto stentless porcine valve. The valve was lowered into place and all of the sutures were tied. Next, we gave another round of cold blood antegrade and retrograde cardioplegia. Next, we sewed our distal suture line. We began with the left coronary cusp of the valve. We ran a 5-0 RB needle up both sides of the valve. Care was taken to avoid the left coronary ostia. This procedure was repeated on the right cusp of the stentless porcine valve. Again, care was taken to avoid any injury to the coronary ostia. Lastly, we sewed our non-coronary cusp. This was done without difficulty. At this point we inspected our aortic valve. There was good coaptation of the leaflets, and it was noted that both the left and the right coronary ostia were open. We gave another round of cold blood antegrade and retrograde cardioplegia. The antegrade portion was given in a direct ostial fashion once again. We now turned our attention to closing the aorta. A 4-0 Prolene double row of suture was used to close the aorta in a running fashion. Just prior to closing, we de-aired the heart and gave a warm shot of antegrade and retrograde cardioplegia. At this point, we removed our aortic cross-clamp. The heart gradually regained its electromechanical activity. We placed 2 atrial and 2 ventricular pacing wires. We removed our aortic vent and oversewed that site with another 4-0 Prolene on an SH needle. We removed our retrograde cardioplegia catheter. We oversewed that site with a 5-0 Prolene. By now, the heart was de-aired and resumed normal electromechanical activity. We began to wean the patient from cardiopulmonary bypass. We then removed our venous cannula and suture ligated that site with a #2 silk. We then gave full-dose protamine. After knowing that there was no evidence of a protamine reaction, we removed the aortic cannula. We buttressed that site with a 4-0 Prolene on an SH needle. We placed a mediastinal chest tube and brought it out through the skin. We also placed 2 Blake drains, 1 in the left chest and 1 in the right chest, as the patient had some bilateral pleural effusions. They were brought out through the skin. The sternum was closed with #7 wires in an interrupted figure-of-eight fashion. The fascia was closed with #1 Vicryl. We closed the subcu tissue with 2-0 Vicryl and the skin with 4-0 PDS. cardiovascular / pulmonary, cardioplegia, toronto stentless porcine valve, tycron sutures, coronary ostia, porcine valve, retrograde cardioplegia, cardiopulmonary bypass, sutures, valve, insertion, toronto, aortic, stentless, chest, coronary, porcine, cardiopulmonary, prolene, atrial, bypass, heart, aorta, Cardiovascular / Pulmonary Thrombosed left forearm loop fistula graft, chronic renal failure, and hyperkalemia. Thrombectomy of the left forearm loop graft. The venous outflow was good. There was stenosis in the mid-venous limb of the graft. Thrombectomy PREOPERATIVE DIAGNOSES:,1. Thrombosed left forearm loop fistula graft.,2. Chronic renal failure.,3. Hyperkalemia.,POSTOPERATIVE DIAGNOSES:,1. Thrombosed left forearm loop fistula graft.,2. Chronic renal failure.,3. Hyperkalemia.,PROCEDURE PERFORMED: , Thrombectomy of the left forearm loop graft.,ANESTHESIA: , Local with sedation.,ESTIMATED BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS:, None.,OPERATIVE FINDINGS:, The venous outflow was good. There was stenosis in the mid-venous limb of the graft.,INDICATIONS: , The patient is an 81-year-old African-American female who presents with an occluded left forearm loop graft. She was not able to have her dialysis as routine. Her potassium was dramatically elevated at 7 the initial evening of anticipated surgery. Both Surgery and Anesthesia thought this would be too risky to do. Thus, she was given medications to decrease her potassium and a temporary hemodialysis catheter was placed in the femoral vein noted for her to have dialysis that night as well as this morning. This morning her predialysis potassium was 6, and thus she was scheduled for surgery after her dialysis.,PROCEDURE: , The patient was taken to the operative suite and prepped and draped in the usual sterile fashion. A transverse incision was made at the region of the venous anastomosis of the graft. Further dissection was carried down to the catheter. The vein appeared to be soft and without thrombus. This outflow did not appear to be significantly impaired. A transverse incision was made with a #11 blade on the venous limb of the graft near the anastomosis. Next, a thrombectomy was done using a #4 Fogarty catheter. Some of the clot and thrombus was removed from the venous limb. The balloon did hang up in the multiple places along the venous limb signifying some degree of stenosis. Once removing most of the clots from the venous limb prior to removing the plug, dilators were passed down the venous limb also indicating the area of stenosis. At this point, we felt the patient would benefit from a curettage of the venous limb of the graft. This was done and subsequent passes with the dilator and the balloon were then very easy and smooth following the curettage. The Fogarty balloon was then passed beyond the clot and the plug. The plug was visualized and inspected. This also gave a good brisk bleeding from the graft. The patient was heparinized and hep saline solution was injected into the venous limb and the angle vascular clamp was applied to the venous limb. Attention was directed up to its anastomosis and the vein. Fogarty balloon and thrombectomy was also performed well enough into this way. There was good venous back bleeding following this. The area was checked for any stenosis with the dilators and none was present. Next, a #6-0 Prolene suture was used in a running fashion to close the graft. Just prior to tying the suture, the graft was allowed to flush to move any debris or air. The suture was also checked at that point for augmentation, which was good. The suture was tied down and the wound was irrigated with antibiotic solution. Next, a #3-0 Vicryl was used to approximate the subcutaneous tissues and a #4-0 undyed Vicryl was used in a running subcuticular fashion to approximate the skin edges. Steri-Strips were applied and the patient was taken to recovery in stable condition. She tolerated the procedure well. She will be discharged from recovery when stable. She is to resume her regular dialysis schedule and present for dialysis tomorrow. cardiovascular / pulmonary, thrombosed, hyperkalemia, thrombectomy, forearm loop graft, venous outflow, chronic renal failure, venous limb, loop graft, forearm loop, limb, forearm, graft, venous, anastomosis, stenosis, Cardiovascular / Pulmonary Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure. 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. Thromboendarterectomy 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. cardiovascular / pulmonary, cabg, thromboendarterectomy, carotid artery, coronary artery bypass, mammary, obtuse, papaverine-soaked, running prolene suture, cardiopulmonary bypass, internal carotid, running prolene, prolene suture, carotid, sutured, artery, prolene, coronary, bypass, veinNOTE Cardiovascular / Pulmonary Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis. Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis. Thrombectomy AV Shunt PREOPERATIVE DIAGNOSIS: , Thrombosed arteriovenous shunt left forearm.,POSTOPERATIVE DIAGNOSIS: ,Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.,PROCEDURE: ,Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis.,ANESTHESIA: , Local.,SKIN PREP: , Betadine.,DRAINS: , None.,PROCEDURE TECHNIQUE: ,The left arm was prepped and draped. Xylocaine 1% was administered and a transverse antecubital incision was made over the venous limb of the graft, which was dissected out and encircled with a vessel loop. The runoff vein was dissected out and encircled with the vessel loop as well. A longitudinal incision was made over the venous anastomosis. There was a narrowing in the area and slightly the incision was extended more proximally. There was good back bleeding from the vein as well as bleeding from the more distal vein. These were occluded with noncrushing DeBakey clamps and the patient was given 5000 units of heparin intravenously. A #4 Fogarty was used to extract thrombus from the graft systematically until the arterial plug was removed and excellent inflow was established. There was a narrowing in the mid portion of the venous limb of the graft, which was dilated with a #5 coronary dilator. The Fogarty catheter was then passed up the vein, but no clot was obtained. A patch PTFE material was fashioned and was sutured over the graftotomy with running 6-0 Gore-Tex suture. Clamps were removed and flow established. A thrill was easily palpable. Hemostasis was achieved and the wound was irrigated and closed with 3-0 Vicryl subcutaneous suture followed by 4-0 nylon on the skin. A sterile dressing was applied. The patient was taken to the recovery room in satisfactory condition having tolerated the procedure well. Sponge, instrument and needle counts were reported as correct. cardiovascular / pulmonary, angioplasty, venous, anastomosis, patch angioplasty, av shunt, venous anastomosis, av, thrombectomy, thrombosed, arteriovenous, vein, forearm, shunt, Cardiovascular / Pulmonary Left muscle sparing mini thoracotomy with left upper lobectomy and mediastinal lymph node dissection. Intercostal nerve block for postoperative pain relief at five levels. Thoracotomy & Lobectomy PREOPERATIVE DIAGNOSES:,1. Non-small-cell carcinoma of the left upper lobe.,2. History of lymphoma in remission.,POSTOPERATIVE DIAGNOSES:,1. Non-small-cell carcinoma of the left upper lobe.,2. History of lymphoma in remission.,PROCEDURE: , Left muscle sparing mini thoracotomy with left upper lobectomy and mediastinal lymph node dissection. Intercostal nerve block for postoperative pain relief at five levels.,INDICATIONS FOR THE PROCEDURE: , This is an 84-year-old lady who was referred by Dr. A for treatment of her left upper lobe carcinoma. The patient has a history of lymphoma and is in remission. An enlarged right axillary lymph node was biopsied recently and was negative for lymphoma. A mass in the left upper lobe was biopsied with fine-needle aspiration and shown to be a primary non-small-cell carcinoma of the lung. PET scan was, otherwise, negative for spread and resection was advised. All the risk and benefits were fully explained to the patient and she elected to proceed as planned. She was transferred to rehab for couple of weeks to buildup strength before the surgery.,PROCEDURE IN DETAIL:, In the operating room under anesthesia, she was prepped and draped suitably. Dr. B was the staff anesthesiologist. Left muscle sparing mini thoracotomy was made. The serratus and latissimus muscles were not cut but moved out to the way. Access to the chest was obtained through the fifth intercostal space. Two Tuffier retractors of right angles provided adequate exposure.,The inferior pulmonary ligament was not dissected free and lymph nodes from the station 9 were now sent for pathology. The parietal pleural reflexion around the hilum was now circumcised, and lymph nodes were taken from station 8 and station 5.,The branches of the pulmonary artery to the upper lobe were now individually stapled with a 30/2.5 staple gun or/and the smaller one were ligated with 2-0 silk. The left superior pulmonary vein was transected using a TA30/2.5 staple gun, and the fissure was completed using firings of an endo-GIA 60/4.8 staple gun. Finally, the left upper lobe bronchus was transected using a TA30/4.8 staple gun. Please note, that this patient had been somewhat unusual variant of a small bronchus that was coming out posterior to the main trunk of the pulmonary artery and supplying a small section of the posterior portion of the left upper lobe.,The specimen was delivered and sent to pathology. The mass was clearly palpable in the upper portion of the lingular portion of this left upper lobe. Frozen section showed that the margin was negative.,The chest was irrigated with warm sterile water and when the left lower lobe inflated, there was no air leak. A single 32-French chest tube was inserted, and intercostal block was done with Marcaine infiltrated two spaces above and two spaces below thus achieving a block at five levels 30 mL of Marcaine was used all together. A #2 Vicryl pericostal sutures were now applied. The serratus and latissimus muscles retracted back in place. A #19 French Blake drain placed in the subcutaneous tissues and 2-0 Vicryl used for the fat followed by 4-0 Monocryl for the skin. The patient was transferred to the ICU in a stable condition. cardiovascular / pulmonary, upper lobe, intercostal nerve block, non-small-cell carcinoma, axillary lymph node, endo-gia, latissimus, lobectomy, lymph node dissection, lymphoma, pulmonary vein, serratus, thoracotomy, muscle sparing mini thoracotomy, upper lobectomy, staple gun, intercostal, Cardiovascular / Pulmonary Left thoracotomy with total pulmonary decortication and parietal pleurectomy. Empyema of the chest, left. Thoracotomy & Pleurectomy PREOPERATIVE DIAGNOSIS: , Empyema of the chest, left.,POSTOPERATIVE DIAGNOSIS: , Empyema of the chest, left.,PROCEDURE: , Left thoracotomy with total pulmonary decortication and parietal pleurectomy.,PROCEDURE DETAIL: , After obtaining the informed consent, the patient was brought to the operating room, where he underwent a general endotracheal anesthetic using a double-lumen endotracheal tube. A time-out process had been followed and preoperative antibiotics were given.,The patient was positioned with the left side up for a left thoracotomy. The patient was prepped and draped in the usual fashion. A posterolateral thoracotomy was performed. It included the previous incision. The chest was entered through the fifth intercostal space. Actually, there was a very strong and hard parietal pleura, which initially did not allow us to obtain a good exposure, and actually the layer was so tough that the pin of the chest retractor broke. Thanks to Dr. X's ingenuity, we were able to reuse the chest retractor and opened the chest after I incised the thickened parietal pleura resulting in an explosion of gas and pus from a cavity that was obviously welled off by the parietal pleura. We aspirated an abundant amount of pus from this cavity. The sample was taken for culture and sensitivity.,Then, at least half an hour was spent trying to excise the parietal pleura and finally we were able to accomplish that up to the apex and back to the aorta __________ towards the heart including his diaphragm. Once we accomplished that, we proceeded to remove the solid exudate that was adhered to the lung. Further samples for culture and sensitivity were sent.,Then, we were left with the trapped lung. It was trapped by thickened visceral pleura. This was the most difficult part of the operation and it was very difficult to remove the parietal pleura without injuring the lung extensively. Finally, we were able to achieve this and after the corresponding lumen of the endotracheal tube was opened, we were able to inflate both the left upper and lower lobes of the lung satisfactorily. There was only one area towards the mediastinum that apparently I was not able to fill. This area, of course, was very rigid but any surgery in the direction __________ would have caused __________ injury, so I restrained from doing that. Two large chest tubes were placed. The cavity had been abundantly irrigated with warm saline. Then, the thoracotomy was closed in layers using heavy stitches of Vicryl as pericostal sutures and then several figure-of-eight interrupted sutures to the muscle layers and a combination of nylon stitches and staples to the skin.,The chest tubes were affixed to the skin with heavy sutures of silk. Dressings were applied and the patient was put back in the supine position and after a few minutes of observation and evaluation, he was able to be extubated in the operating room.,Estimated blood loss was about 500 mL. The patient tolerated the procedure very well and was sent to the ICU in a satisfactory condition. cardiovascular / pulmonary, total pulmonary decortication, pulmonary decortication, parietal pleurectomy, endotracheal tube, chest retractor, chest tubes, parietal pleura, pleurectomy, empyema, endotracheal, thoracotomy, pleura, chest Cardiovascular / Pulmonary Tilt table test. Tilt table test is negative for any evidence of vasovagal, orthostasis or vasodepressor syndrome. Tilt Table Test FINDINGS:,1. The patient's supine blood pressure was 153/88 with heart rate of 54 beats per minute.,2. There was no significant change in heart rate or blood pressure on 80-degree tilt.,3. No symptoms reported during the tilt study.,CONCLUSION: , Tilt table test is negative for any evidence of vasovagal, orthostasis or vasodepressor syndrome. cardiovascular / pulmonary, blood pressure, tilt table test, vasovagal, vasodepressor, orthostasisNOTE Cardiovascular / Pulmonary Empyema. Right thoracotomy, total decortication and intraoperative bronchoscopy. A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion. On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations. Thoracotomy & Bronchoscopy PREOPERATIVE DIAGNOSIS:, Empyema.,POSTOPERATIVE DIAGNOSIS: , Empyema.,PROCEDURE PERFORMED:,1. Right thoracotomy, total decortication.,2. Intraoperative bronchoscopy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, 300 cc.,FLUIDS: , 2600 cc IV crystalloid.,URINE: , 300 cc intraoperatively.,INDICATIONS FOR PROCEDURE: ,The patient is a 46-year-old Caucasian male who was admitted to ABCD Hospital since 08/14/03 with acute diagnosis of right pleural effusion. A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion. On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations. Decision was made to proceed with surgical intervention for a complete decortication and the patient understands the need for surgery and signed the preoperative informed consent.,OPERATIVE PROCEDURE: , The patient was taken to the operative suite and placed in the supine position under general anesthesia per Anesthesia Department. Intraoperative bronchoscopy was performed by Dr. Y and evaluation of carina, left upper and lower lobes with segmental evidence of diffuse mucous, thick secretions which were thoroughly lavaged with sterile saline lavage. Samples were obtained from both the left and the right subbronchiole segments for Gram stain cultures and ASP evaluation. The right bronchus lower, middle, and upper were also examined and subsegmental bronchiole areas were thoroughly examined with no evidence of masses, lesions, or suspicious extrinsic compressions on the bronchi. At this point, all mucous secretions were thoroughly irrigated and aspirated until the airways were clear. Bronchoscope was then removed. Vital signs remained stable throughout this portion of the procedure. The patient was re-intubated by Anesthesia with a double lumen endotracheal tube. At this point, the patient was repositioned in the left lateral decubitus position with protection of all pressure points and the table was extended in customary fashion. At this point, the right chest was prepped and draped in the usual sterile fashion. The chest tube was removed before prepping the patient and the prior thoracostomy site was cleansed thoroughly with Betadine. The first port was placed through this incision intrathoracically. A bronchoscope was placed for inspection of the intrathoracic cavity. Pictures were taken. There is extensive fibrinous exudate noted under parietal and visceral pleura, encompassing the lung surface, diaphragm, and the posterolateral aspect of the right thorax. At this point, a second port site anteriorly was placed under direct visualization. With the aid of the thoracoscopic view, a Yankauer resection device was placed in the thorax and blunt decortication was performed and aspiration of reminder of the pleural fluid. Due to the gelatinous nature of the fibrinous exudate, there were areas of right upper lobe that adhered to the chest wall and the middle and lower lobes appeared entrapped. Due to the extensive nature of the disease, decision was made to open the chest in a formal right thoracotomy fashion. Incision was made. The subcutaneous tissues were then electrocauterized down to the level of the latissimus dorsi, which was separated with electrocautery down to the anterior 6th rib space. The chest cavity was entered with the right lung deflated per Anesthesia at our request. Once the intrathoracic cavity was accessed, a thorough decortication was performed in meticulous systematic fashion starting with the right upper lobe, middle, and the right lower lobe. With the expansion of the lung and reduction of the pleural surface fibrinous extubate, warm irrigation was used and the lungs allowed to re-expand. There was no evidence of gross leakage or bleeding at the conclusion of surgery.,Full lung re-expansion was noted upon re-inflation of the lung. Two #32 French thoracostomy tubes were placed, one anteriorly straight and one posteriorly on the diaphragmatic sulcus. The chest tubes were secured in place with #0-silk sutures and placed on Pneumovac suction. Next, the ribs were reapproximated with five interrupted CTX sutures and latissimus dorsi was then reapproximated with a running #2-0 Vicryl suture. Next, subcutaneous skin was closed sequentially with a cosmetic layered subcutaneous closure. Steri-Strips were applied along with sterile occlusive dressings. The patient was awakened from anesthesia without difficulty and extubated in the operating room. The chest tubes were maintained on Pleur-Evac suction for full re-expansion of the lung. The patient was transported to the recovery with vital signs stable. Stat portable chest x-ray is pending. The patient will be admitted to the Intensive Care Unit for close monitoring overnight. cardiovascular / pulmonary, empyema, total decortication, intraoperative bronchoscopy, intrathoracic cavity, fibrinous exudate, latissimus dorsi, chest tubes, pleural effusion, bronchoscopy, thoracostomy, thoracotomy, decortication, anesthesia, pleural, Cardiovascular / Pulmonary Left thoracotomy with drainage of pleural fluid collection, esophageal exploration and repair of esophageal perforation, diagnostic laparoscopy and gastrostomy, and radiographic gastrostomy tube study with gastric contrast, interpretation. Thoracotomy & Esophageal Exploration PREOPERATIVE DIAGNOSIS: ,Esophageal rupture.,POSTOPERATIVE DIAGNOSIS:, Esophageal rupture.,OPERATION PERFORMED,1. Left thoracotomy with drainage of pleural fluid collection.,2. Esophageal exploration and repair of esophageal perforation.,3. Diagnostic laparoscopy and gastrostomy.,4. Radiographic gastrostomy tube study with gastric contrast, interpretation.,ANESTHESIA: , General anesthesia.,INDICATIONS OF THE PROCEDURE: , The patient is a 47-year-old male with a history of chronic esophageal stricture who is admitted with food sticking and retching. He has esophageal rupture on CT scan and comes now for a thoracotomy and gastrostomy.,DETAILS OF THE PROCEDURE: , After an extensive informed consent discussion process, the patient was brought to the operating room. He was placed in a supine position on the operating table. After induction of general anesthesia and placement of a double lumen endotracheal tube, he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll. Left chest was prepped and draped in a usual sterile fashion. After administration of intravenous antibiotics, a left thoracotomy incision was made, dissection was carried down to the subcutaneous tissues, muscle layers down to the fifth interspace. The left lung was deflated and the pleural cavity entered. The Finochietto retractor was used to help provide exposure. The sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed.,Immediately encountered was left pleural fluid including some purulent fluid. Cultures of this were sampled and sent for microbiology analysis. The left pleural space was then copiously irrigated. A careful expiration demonstrated that the rupture appeared to be sealed. There was crepitus within the mediastinal cavity. The mediastinum was opened and explored and the esophagus was explored. The tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus. It was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area. The area was copiously irrigated, this provided nice coverage and repair. After final irrigation and inspection, two chest tubes were placed including a #36 French right angled tube at the diaphragm and a posterior straight #36 French. These were secured at the left axillary line region at the skin level with #0-silk.,The intercostal sutures were used to close the chest wall with a #2 Vicryl sutures. Muscle layers were closed with running #1 Vicryl sutures. The wound was irrigated and the skin was closed with skin staples.,The patient was then turned and placed in a supine position. A laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed. A Veress needle was carefully inserted into the abdomen, pneumoperitoneum was established in the usual fashion, a bladeless 5-mm separator trocar was introduced. The laparoscope was introduced. A single additional left-sided separator trocar was introduced. It was not possible to safely pass a nasogastric or orogastric tube, pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance. The stomach however did have some air insufflation and we were able to place our T-fasteners through the anterior abdominal wall and through the anterior gastric wall safely. The skin incision was made and the gastric lumen was then accessed with the Seldinger technique. Guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire. #18 French Gastrostomy was then passed into the stomach lumen and the balloon was inflated. We confirmed that we were in the gastric lumen and the balloon was pulled up, creating apposition of the gastric wall and the anterior abdominal wall. The T-fasteners were all crimped and secured into position. As was in the plan, the gastrostomy was secured to the skin and into the tube. Sterile dressing was applied. Aspiration demonstrated gastric content.,Gastrostomy tube study, with interpretation. Radiographic gastrostomy tube study with gastric contrast, with cardiovascular / pulmonary, esophageal rupture, thoracotomy, drainage of pleural fluid, esophageal perforation, esophageal exploration, laparoscopy, gastrostomy, pleural fluid, diagnostic laparoscopy, radiographic gastrostomy, gastric lumen, gastrostomy tube, gastric contrast, gastric, interpretation, abdominal, pleural, lumen, esophageal, tube, Cardiovascular / Pulmonary Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung. Thoracoscopy/Thoracotomy "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." cardiovascular / pulmonary, empyema, biopsies, bronchus, declaudication, endothoracic, hydropneumothorax, left lower lobe, left lung, left upper lobe, mainstem, pleura, thoracoscopy, thoracotomy, thoracotomy with declaudication, declaudication and drainage, double lumen tube, sixth intercostal space, lung abscesses, pleural cavity, intercostal space, upper lobe, double lumen, chest tube, cavity, tube, chest, lung, pulmonary, pleural, intercostal, Cardiovascular / Pulmonary 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. Thoracoabdominal Aneurysm 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. cardiovascular / pulmonary, dacron graft, thoracoabdominal, cerebrospinal, thoracoabdominal aneurysm, running prolene, prolene suture, dissected free, graft, interposition, aneurysm, dacron, cannula, bifurcation, aorta, endotracheal, proleneNOTE Cardiovascular / Pulmonary Left mesothelioma, focal. Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall. Thoracoscopy & Thoracotomy - Mesothelioma 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. cardiovascular / pulmonary, mini thoracotomy, pleural based mass, pleural based nodule, chest wall, mesothelioma focal, pleural, chest, thoracotomy, mesothelioma, laparoscopic, thoracoscopy, Cardiovascular / Pulmonary The patient was originally hospitalized secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia. Telemetry Monitoring DIAGNOSES PROBLEMS:,1. Orthostatic hypotension.,2. Bradycardia.,3. Diabetes.,4. Status post renal transplant secondary polycystic kidney disease in 1995.,5. Hypertension.,6. History of basal cell ganglia cerebrovascular event in 2004 with left residual.,7. History of renal osteodystrophy.,8. Iron deficiency anemia.,9. Cataract status post cataract surgery.,10. Chronic left lower extremity pain.,11. Hyperlipidemia.,12. Status post hysterectomy secondary to uterine fibroids.,PROCEDURES:, Telemetry monitoring.,HISTORY FINDINGS HOSPITAL COURSE: , The patient was originally hospitalized on 04/26/07, secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia. She was transferred briefly to Psychiatry, however, on the second day in Psychiatry, she became very orthostatic and was transferred acutely back to the medicine. She briefly was on Cymbalta; however, this was discontinued when she was transferred back. She was monitored back medicine for 24 hours and was given intravenous fluids and these were discontinued. She was able to maintain her pressures then was able to ambulate without difficulty. We had wanted to pursue workup for possible causes for autonomic dysfunction; however, the patient was not interested in remaining in the hospital anymore and left really against our recommendations.,DISCHARGE MEDICATIONS:,1. CellCept - 500 mg twice a daily.,2. Cyclosporine - 25 mg in the morning and 15 mg in the evening.,3. Prednisone - 5 mg once daily.,4. Hydralazine - 10 mg four times a day.,5. Pantoprazole - 40 mg once daily.,6. Glipizide - 5 mg every morning.,7. Aspirin - 81 mg once daily.,FOLLOWUP CARE: ,The patient is to follow up with Dr. X in about 1 week's time. cardiovascular / pulmonary, orthostatic hypotension, bradycardia, basal cell ganglia cerebrovascular event, renal osteodystrophy, dizziness, disequilibrium, telemetry monitoring, Cardiovascular / Pulmonary Insertion of right internal jugular Tessio catheter and placement of left wrist primary submental arteriovenous fistula. Tessio Catheter Insertion 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. cardiovascular / pulmonary, internal jugular tessio catheter, arteriovenous, fistula, submental, tunneled, tessio catheter, internal jugular, radial artery, tessio, jugular, artery, catheterNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. Cardiovascular / Pulmonary Thoracentesis. Left pleural effusion. Left hemothorax. Thoracentesis 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. cardiovascular / pulmonary, pleural effusion, hemothorax, thoracentesis, chest, Cardiovascular / Pulmonary Quick note on tachypnea. Tachypnea cardiovascular / pulmonary, chest, cpr, breath sounds, tachypnea, epinephrine, rhythmNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., Cardiovascular / Pulmonary Thoracentesis, left. Malignant pleural effusion, left, with dyspnea. Thoracentesis - 1 PREOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,POSTOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,PROCEDURE: ,Thoracentesis, left.,DESCRIPTION OF PROCEDURE: , The patient was brought to the recovery area of the operating room. After obtaining the informed consent, the patient's posterior left chest wall was prepped and draped in usual fashion. Xylocaine 1% was infiltrated above the seventh intercostal space in the midscapular line. Initially, I tried to use the thoracentesis set after 1% Xylocaine had been infiltrated, but the needle of the system was just too short to reach the pleural cavity due to the patient's very thick chest wall. Therefore, I had to use a #18 spinal needle, which I had to use almost in its entire length to reach the fluid. From then on, I proceeded manually to withdraw 2000 mL of a light milky fluid.,The patient tolerated the procedure fairly well, but almost at the end of it she said that she was feeling like fainting and therefore we carefully withdrew the needle. At that time, it was getting difficult to withdraw fluid anyway and we allowed her to lie down and after a few minutes the patient was feeling fine. At any rate, we gave her bolus of 250 mL of normal saline and the patient returned to her room for additional hours of observation. We then thought that if she was doing fine, then we will send her home.,A chest x-ray was performed after the procedure which showed a dramatic reduction of the amount of pleural fluid and then there was no pneumothorax or no other obvious complications of her procedure., cardiovascular / pulmonary, malignant pleural effusion, chest wall, pleural effusion, dyspnea, thoracentesis, fluid, pleural, Cardiovascular / Pulmonary Insertion of a left subclavian Tesio hemodialysis catheter and surgeon-interpreted fluoroscopy. Tesio Hemodialysis Catheter Insertion 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. cardiovascular / pulmonary, needle, tesio hemodialysis catheter, hemodialysis catheter, fluoroscopy, catheters, catheter, tesio, hemodialysisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. Cardiovascular / Pulmonary The patient was undergoing a routine physical examination and was found to have right supraclavicular lymphadenopathy. She returned for followup examination and again was noted to have right supraclavicular lymphadenopathy. She is now referred to the thoracic surgery clinic for evaluation. Supraclavicular Lymphadenopathy 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 Cardiovascular / Pulmonary The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis. Supraventricular Tachycardia - Consult 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. cardiovascular / pulmonary, congenital heart disease, cyanotic, ductal-dependent, pulmonary blood flow, ventricular septal defect, blood flow, supraventricular tachycardia, tachycardia, ventricular, supraventricular, shunt, heart, pulmonary, Cardiovascular / Pulmonary Subxiphoid pericardiotomy. Symptomatic pericardial effusion. The patient had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic. Subxiphoid Pericardiotomy PREOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,POSTOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,PROCEDURE PERFORMED:, Subxiphoid pericardiotomy.,ANESTHESIA:, General via ET tube.,ESTIMATED BLOOD LOSS: , 50 cc.,FINDINGS:, This is a 70-year-old black female who underwent a transhiatal esophagectomy in November of 2003. She subsequently had repeat chest x-rays and CT scans and was found to have a moderate pericardial effusion. She had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic. Also, during that time, she had become significantly more short of breath. A dobutamine stress echocardiogram was performed, which was negative with the exception of the pericardial effusions. She had no tamponade physiology.,INDICATION FOR THE PROCEDURE: , For therapeutic and diagnostic management of this symptomatic pericardial effusion. Risks, benefits, and alternative measures were discussed with the patient. Consent was obtained for the above procedure.,PROCEDURE: , The patient was prepped and draped in the usual sterile fashion. A 4 cm incision was created in the midline above the xiphoid. Dissection was carried down through the fascia and the xiphoid was resected. The sternum was retracted superiorly the pericardium was identified and pericardial fat was cleared off the pericardium. An #0 silk suture was then placed into the pericardium with care taken not to enter the underlying heart.,This suture was used to retract the pericardium and the pericardium was nicked with #15 blade under direct visualization. Serous fluid exited through the pericardium and was sent for culture, cytology, and cell count etc. A section of pericardium was taken approximately 2 cm x 2 cm x 2 cm and was removed. The heart was visualized and appeared to be contracting well with no evidence of injury to the heart. The pericardium was then palpated. There was no evidence of studding. A right angle chest tube was then placed in the pericardium along the diaphragmatic of the pericardium and then brought out though a small skin incision in the epigastrium. It was sewn into place with #0 silk suture. There was some air leak of the left pleural cavity, so a right angle chest tube was placed in the left pleural cavity and brought out through a skin nick in the epigastrium. It was sewn in the similar way to the other chest tube. Once again, the area was inspected and found to be hemostatic and then closed with #0 Vicryl suture for fascial stitch, then #3-0 Vicryl suture in the subcutaneous fat, and then #4-0 undyed Vicryl in a running subcuticular fashion. The patient tolerated the procedure well. Chest tubes were placed on 20 cm of water suction. The patient was taken to PACU in stable condition. cardiovascular / pulmonary, subxiphoid pericardiotomy, symptomatic pericardial effusion, chest x-rays, echocardiogram, dobutamine, pleural cavity, chest tube, pericardial effusion, pericardium, inflammatory, subxiphoid, pericardiotomy, heart, chest, effusion, pericardial Cardiovascular / Pulmonary Emergent subxiphoid pericardial window, transesophageal echocardiogram. Subxiphoid Pericardial Window PREOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,POSTOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,PROCEDURE:,1. Emergent subxiphoid pericardial window.,2. Transesophageal echocardiogram.,ANESTHESIA:, General endotracheal.,FINDINGS:, The patient was noted to have 600 mL of dark bloody fluid around the pericardium. We could see the effusion resolve on echocardiogram. The aortic valve appeared to have good movement in the leaflets with no perivalvular leaks. There was no evidence of endocarditis. The mitral valve leaflets moved normally with some mild mitral insufficiency.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room emergently. After adequate general endotracheal anesthesia, his chest was prepped and draped in the routine sterile fashion. A small incision was made at the bottom of the previous sternotomy incision. The subcutaneous sutures were removed. The dissection was carried down into the pericardial space. Blood was evacuated without any difficulty. Pericardial Blake drain was then placed. The fascia was then reclosed with interrupted Vicryl sutures. The subcutaneous tissues were closed with a running Monocryl suture. A subdermal PDS followed by a subcuticular Monocryl suture were all performed. The wound was closed with Dermabond dressing. The procedure was terminated at this point. The patient tolerated the procedure well and was returned back to the intensive care unit in stable condition. cardiovascular / pulmonary, endocarditis, valve replacement, st. jude, echocardiogram, transesophageal, pericardium, blake drain, st jude mechanical valve, subxiphoid pericardial window, pericardial window, aortic valve, tamponade, subxiphoid, valve, pericardial, aortic Cardiovascular / Pulmonary Chest pain, Chest wall tenderness occurred with exercise. Stress Test Graded Exercise Treadmill INDICATIONS:, Chest pain.,PROCEDURE DONE:, Graded exercise treadmill stress test.,STRESS ECG RESULTS:, The patient was stressed by continuous graded treadmill testing for nine minutes of the standard Bruce protocol. The heart rate increased from 68 beats per minute to 178 beats per minute, which is 100% of the maximum predicted target heart rate. The blood pressure increased from 120/70 to 130/80. The baseline resting electrocardiogram reveals a regular sinus rhythm. The tracing is within normal limits. Symptoms of chest pain occurred with exercise. The pain persisted during the recovery process and was aggravated by deep inspiration. Marked chest wall tenderness noted. There were no ischemic ST segment changes seen during exercise or during the recovery process.,CONCLUSIONS,:,1. Stress test is negative for ischemia.,2. Chest wall tenderness occurred with exercise.,3. Blood pressure response to exercise is normal. cardiovascular / pulmonary, stress test, blood pressure, bruce protocol, chest pain, graded exercise, graded exercise treadmill, electrocardiogram, ischemia, sinus rhythm, treadmill, chest wall tenderness, chest wall, stress, chest, Cardiovascular / Pulmonary Insertion of right subclavian central venous catheter. Need for intravenous access, status post fall, and status post incision and drainage of left lower extremity. Subclavian Central Venous Catheter Insertion 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. cardiovascular / pulmonary, intravenous access, incision and drainage, subclavian central venous catheter, central venous catheter, lower extremity, venous, intravenous, lidocaine, subclavian, needle, catheter, insertion Cardiovascular / Pulmonary Dobutrex stress test for abnormal EKG Stress Test Dobutrex INDICATIONS:, cardiovascular / pulmonary, dobutrex stress test, abnormal ekg, dobutrex, inferior abnormality, ischemic heart disease, ventricle, µg/kg/minute, stress test, stress, Cardiovascular / Pulmonary Thallium stress test for chest pain. Stress Test Thallium INDICATIONS: ,Chest pain.,STRESS TECHNIQUE:, cardiovascular / pulmonary, chest pain, ecg stress, thallium stress test, aerobic capacity, ejection fraction, gated tomographic spect system, myocardial perfusion, thallous chloride, ventricle, wall motion, stress test, stress Cardiovascular / Pulmonary Chest pain, hypertension. Stress test negative for dobutamine-induced myocardial ischemia. Normal left ventricular size, regional wall motion, and ejection fraction. Stress Test Dobutamine Myoview 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. cardiovascular / pulmonary, chest pain, dobutamine myoview, dobutamine myoview stress test, spect imaging, stress test, dobutamine infusion, ejection fraction, hypertension, myocardial ischemia, myocardial perfusion, ventricular size, wall motion, dobutamine, stress, myocardial, myoview, ischemia, ventricular, perfusion, Cardiovascular / Pulmonary Subxiphoid pericardial window. A #10-blade scalpel was used to make an incision in the area of the xiphoid process. Dissection was carried down to the level of the fascia using Bovie electrocautery. Subxiphoid Pericardial Window - 1 OPERATION: , Subxiphoid pericardial window.,ANESTHESIA: , General endotracheal anesthesia.,OPERATIVE PROCEDURE IN DETAIL: ,After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered. Next, the neck and chest were prepped and draped in the standard surgical fashion. A #10-blade scalpel was used to make an incision in the area of the xiphoid process. Dissection was carried down to the level of the fascia using Bovie electrocautery. The xiphoid process was elevated, and the diaphragmatic attachments to it were dissected free. Next the pericardium was identified.,The pericardium was opened with Bovie electrocautery. Upon entering the pericardium, serous fluid was expressed. In total, ** cc of fluid was drained. A pericardial biopsy was obtained. The fluid was sent off for cytologic examination as well as for culture. A #24 Blake chest drain was brought out through the skin and placed in the posterior pericardium. The fascia was closed with #1 Vicryl followed by 2-0 Vicryl followed by 4-0 PDS in a running subcuticular fashion. Sterile dressing was applied. cardiovascular / pulmonary, xiphoid process, pericardium, subxiphoid pericardial window, endotracheal anesthesia, bovie electrocautery, subxiphoid pericardial, bovie, electrocautery, subxiphoid, window, pericardial, Cardiovascular / Pulmonary Stress test - Adenosine Myoview. Ischemic cardiomyopathy. Inferoseptal and apical transmural scar. Stress Test Adenosine Myoview 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. cardiovascular / pulmonary, stress test, adenosine, adenosine myoview stress test, ischemic cardiomyopathy, spect, cardiomyopathy, electrocardiogram, myocardial infarction, stress test adenosine myoview, adenosine myoview stress, myoview stress test, ptca and stenting, myoview stress, transmural scar, adenosine infusion, septal motion, adenosine myoview, myocardial perfusion, hypokinesis, inferoseptal, ischemic, myocardial, myoview, perfusion, scan Cardiovascular / Pulmonary Dobutamine stress test for atrial fibrillation. Stress Test Dobutamine INDICATIONS:, Atrial fibrillation, coronary disease.,STRESS TECHNIQUE:, The patient was infused with dobutamine to a maximum heart rate of 142. ECG exhibits atrial fibrillation.,IMAGE TECHNIQUE:, The patient was injected with 5.2 millicuries of thallous chloride and subsequently imaged on the gated tomographic SPECT system.,IMAGE ANALYSIS:, It should be noted that the images are limited slightly by the patient's obesity with a weight of 263 pounds. There is normal LV myocardial perfusion. The LV systolic ejection fraction is normal at 65%. There is normal global and regional wall motion.,CONCLUSIONS:,1. Basic rhythm of atrial fibrillation with no change during dobutamine stress, maximum heart rate of 142.,2. Normal LV myocardial perfusion.,3. Normal LV systolic ejection fraction of 65%.,4. Normal global and regional wall motion. cardiovascular / pulmonary, dobutamine stress test, atrial fibrillation, lv myocardial perfusion, lv systolic ejection fraction, coronary disease, dobutamine, ejection fraction, gated tomographic spect system, thallous chloride, wall motion, stress, fibrillation, atrial Cardiovascular / Pulmonary Stress test with Bruce protocol due to chest pain. Stress Test Bruce Protocol PROTOCOL:, Bruce.,PERTINENT MEDICATION: , None.,REASON FOR TEST:, Chest pain.,PROCEDURE AND INTERPRETATION: ,1. Baseline heart rate: 67.,2. Baseline blood pressure: 150/86.,3. Total time: 6 minute 51 seconds.,4. METs: 10.1.,5. Peak heart rate: 140.,6. Percent of maximum-predicted heart rate: 90.,7. Peak blood pressure: 200/92.,8. Reason test terminated: Shortness of breath and fatigue.,9. Estimated aerobic capacity: Average.,10. Heart rate response: Normal.,11. Blood pressure response: Hypertensive.,12. ST segment response: Normal.,13. Chest pain: None.,14. Symptoms: None.,15. Arrhythmia: None.,CONCLUSION:,1. Average aerobic capacity.,2. Normal heart rate and blood pressure response to exercise.,3. No symptomatic electrocardiographic evidence of ischemia.,CONDITION: , Stable with normal vital signs.,DISPOSITION: ,The patient was discharged home and was asymptomatic., Cardiovascular / Pulmonary Sick sinus syndrome, atrial fibrillation, pacemaker dependent, mild cardiomyopathy with ejection fraction 40% and no significant decompensation, and dementia of Alzheimer's disease with short and long term memory dysfunction Sick Sinus Syndrome HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old gentleman who has a history of sick sinus syndrome for which he has St. Jude permanent pacemaker. Pacemaker battery has reached end of life and the patient is dependent on his pacemaker with 100% pacing in the right ventricle. He also has a fairly advanced degree of Alzheimer's dementia and is living in an assisted care facility. The patient is unable to make his own health care decision and his daughter ABC has medical power of attorney. The patient's dementia has resulted in the patient's having sufficient and chronic anger and his daughter that he refuses to speak with her, refuses to be in a same room with her. For this reason the Casa Grande Regional Medical Center would obtain surgical and anesthesia consent from the patient's daughter in the fashion keeps the patient and daughter separated. Furthermore it is important to note that his degree of dementia has disabled the patient to adequately self monitor his status following surgery for significant changes and to seek appropriate medical care, hence he will be admitted after the pacemaker exchange.,PAST MEDICAL HISTORY:,1. Sick sinus syndrome, pacemaker dependence with 100% with right ventricular pacing.,2. Dementia of Alzheimer's disease.,3. Gastroesophageal reflux disease.,4. Multiple pacemaker implantation and exchanges.,FAMILY HISTORY: , Unobtainable.,SOCIAL HISTORY: , The patient resides full time at ABC supervised living facility. He is nonsmoker, nondrinker. He uses wheelchair and moves himself about with his feet. He is independent of activities of daily living and dependent on independent activities of daily living.,ALLERGIES TO MEDICATIONS: , No known drug allergies.,MEDICATIONS: ,Omeprazole 20 mg p.o. daily, furosemide 20 mg p.o. daily, citalopram 20 mg p.o. daily, loratadine 10 mg p.o. p.r.n.,REVIEW OF SYSTEMS: , A 10 systems review negative for chest pain, pressure, shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, syncope, near-syncopal episodes. Negative for recent falls. Positive for significant memory loss. All other review of systems is negative.,PHYSICAL EXAMINATION:,GENERAL: The patient is an 85-year-old gentleman in no acute distress, sitting in the wheelchair.,VITAL SIGNS: Blood pressure is 118/68, pulse is 80 and regular, respirations 16, weight is 200 pounds, oxygen saturation is 90% on room air.,HEENT: Head atraumatic and normocephalic. Eyes, pupils are equal and reactive to light and accommodate bilaterally, free from focal lesions. Ears, nose, mouth, and throat.,NECK: Supple. No lymphadenopathy, thyromegaly, or thyroid masses appreciated.,CARDIOVASCULAR: No JVD or no jugular venous distention. No carotid bruits bilaterally. Pacemaker pocket right upper thorax with healed surgical incisions. S1 and S2 are normal. No S3 or S4. There are no murmurs. No heaves or thrills, gout, or gallops. Trace edema at dorsum of his feet and ankles. Femoral pulses are present without bruits, posterior tibial pulses would be palpable bilaterally.,RESPIRATORY: Breath sounds are clear but diminished throughout AP diameters expanded. The patient speaks in full sentences. No wheezing, no accessory muscles used for breathing.,GASTROINTESTINAL: Abdomen is soft and nontender. Bowel sounds are active in all 4 quadrants. No palpable pulses. No abdominal bruit is appreciated. No hepatosplenomegaly.,GENITOURINARY: Nonfocal.,MUSCULOSKELETAL: Muscle strength in lower extremities is 4/5 bilaterally. Upper extremities are 5/5 bilaterally with adequate range of motion.,SKIN: Warm and dry. No obvious rashes, lesions, or ulcerations. ,NEUROLOGIC: Alert, not oriented to place and date. His speech is clear. There are no focal motor or sensory deficits.,PSYCHIATRIC: Talkative, pleasant affect with limited impulse control, severe short-term memory loss.,LABORATORY DATA:, Blood work dated 12/15/08, white count 4.7, hemoglobin 11.9, hematocrit 33.9, and platelets 115,000. BUN 19, creatinine 1.15, glucose 94, potassium 4.5, sodium 140, and calcium 8.6.,DIAGNOSTIC DATA:, St. Jude pacemaker interrogation dated 11/10/08 shows single chamber pacemaker and VVIR mode, implant date 08/2000, 100% paced in right ventricle, battery status is ERI. A 12-lead ECG 12/15/08 shows 100% paced rhythm with rate of 80. No Q waves at the baseline of atrial fibrillation. Last measured ejection fraction 40% 12/08 with no significant decompensation.,IMPRESSION/PLAN:,1. Sick sinus syndrome.,2. Atrial fibrillation.,3. Pacemaker dependent.,4. Mild cardiomyopathy with ejection fraction 40% and no significant decompensation.,5. Pacemaker battery end of life requiring exchange.,6. Dementia of Alzheimer's disease with short and long term memory dysfunction. The dementia disables the patient from recognizing changes in his health status in knowing if he needed to seek appropriate health care. Dementia also renders the patient incapable informed consent, schedule the patient for pacemaker. I explain the patient and reimplantation with any device in the surgical suite. He will require anesthesia assistance for adequate sedation as the patient possesses behavioral risk secondary to his advanced dementia.,7. Admit the patient after surgery for postoperative care and monitoring. Cardiovascular / Pulmonary Successful stenting of the left anterior descending. Angina pectoris, tight lesion in left anterior descending. Stenting NAME OF PROCEDURE:, Successful stenting of the left anterior descending.,DESCRIPTION OF PROCEDURE:, Angina pectoris, tight lesion in left anterior descending.,TECHNIQUE OF PROCEDURE:, Standard Judkins, right groin.,CATHETERS USED: , 6 French Judkins, right; wire, 14 BMW; balloon for predilatation, 25 x 15 CrossSail; stent 2.5 x 18 Cypher drug-eluting stent.,ANTICOAGULATION: ,The patient was on aspirin and Plavix, received 3000 of heparin and was begun on Integrilin.,COMPLICATIONS: , None.,INFORMED CONSENT: , I reviewed with the patient the pros, cons, alternatives and risks of catheter and sedation exactly as I had done before during his diagnostic catheterization, plus I reviewed the risks of intervention including lack of success, need for emergency surgery, need for later restenosis and further procedures.,HEMODYNAMIC DATA: , The aortic pressure was in the physiologic range.,ANGIOGRAPHIC DATA: , Left coronary artery: The left main coronary artery showed insignificant disease. The left anterior descending showed fairly extensive calcification. There was 90% stenosis in the proximal to midportion of the vessel. Insignificant disease in the circumflex.,SUCCESSFUL STENTING: , A wire crossed the lesion. We first predilated with a balloon, then advanced, deployed and post dilated the stent. Final angiography showed 0% stenosis, no tears or thrombi, excellent intimal appearance.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure 160/88, temperature 98.6, pulse 83, respirations 30. He is saturating at 96% on 4 L nonrebreather.,GENERAL: The patient is a 74 year-old white male who is cooperative with the examination and alert and oriented x3. The patient cannot speak and communicates through writing.,HEENT: Very small moles on face. However, pupils equal, round and regular and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is moist.,NECK: Supple. Tracheostomy site is clean without blood or discharge.,HEART: Regular rate and rhythm. No gallop, murmur or rub.,CHEST: Respirations congested. Mild crackles in the left lower quadrant and left lower base.,ABDOMEN: Soft, nontender and nondistended. Positive bowel sounds.,EXTREMITIES: No clubbing, cyanosis or edema.,NEUROLOGIC: Cranial nerves II-XII grossly intact. No focal deficit.,GENITALIA: The patient does have a right scrotal swelling, very much larger than the other side, not reproducible and mobile to touch.,CONCLUSIONS,1. Successful stenting of the left anterior descending. Initially, there was 90% stenosis. After stenting with a drug-eluting stent, there was 0% residual.,2. Insignificant disease in the other coronaries.,PLAN:, The patient will be treated with aspirin, Plavix, Integrilin, beta blockers and statins. I have discussed this with him, and I have answered his questions. Cardiovascular / Pulmonary The patient is admitted for shortness of breath, continues to do fairly well. The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72. The patient did undergo echocardiogram, which shows aortic stenosis, severe. The patient does have an outside cardiologist. SOAP - Shortness of Breath SUBJECTIVE: , The patient is admitted for shortness of breath, continues to do fairly well. The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72. The patient did undergo echocardiogram, which shows aortic stenosis, severe. The patient does have an outside cardiologist. I understand she was scheduled to undergo workup in this regard.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse of 78 and blood pressure 130/60.,LUNGS: Clear.,HEART: A soft systolic murmur in the aortic area.,ABDOMEN: Soft and nontender.,EXTREMITIES: No edema.,IMPRESSION:,1. Status shortness of breath responding well to medical management.,2. Atrial fibrillation, chronic, on anticoagulation.,3. Aortic stenosis.,RECOMMENDATIONS:,1. Continue medications as above.,2. The patient would like to follow with her cardiologist regarding aortic stenosis. She may need a surgical intervention in this regard, which I explained to her. The patient will be discharged home on medical management and she has an appointment to see her cardiologist in the next few days.,In the interim, if she changes her mind or if she has any concerns, I have requested to call me back. cardiovascular / pulmonary, shortness of breath, medical management, atrial fibrillation, aortic stenosis, atrial, fibrillation, breath, stenosis, cardiologist, aortic, anticoagulation, inr, Cardiovascular / Pulmonary Chest, Single view post OP for ASD (Atrial Septal Defect). Single Frontal View of Chest EXAM: , Single frontal view of the chest.,HISTORY: , Atelectasis. Patient is status-post surgical correction for ASD.,TECHNIQUE: , A single frontal view of the chest was evaluated and correlated with the prior film dated mm/dd/yy.,FINDINGS:, Current film reveals there is a right-sided central venous catheter, the distal tip appears to be in the superior vena cava. Endotracheal tube with the distal tip appears to be in appropriate position, approximately 2 cm superior to the carina. Sternotomy wires are noted. They appear in appropriate placement. There are no focal areas of consolidation to suggest pneumonia. Once again seen is minimal amount of bilateral basilar atelectasis. The cardiomediastinal silhouette appears to be within normal limits at this time. No evidence of any pneumothoraces or pleural effusions.,IMPRESSION:,1. There has been interval placement of a right-sided central venous catheter, endotracheal tube, and sternotomy wires secondary to patient's most recent surgical intervention.,2. Minimal bilateral basilar atelectasis with no significant interval changes from the patient's most recent prior.,3. Interval decrease in the patient's heart size which may be secondary to the surgery versus positional and technique. cardiovascular / pulmonary, atrial septal defect, central venous catheter, bilateral basilar atelectasis, single frontal view, distal tip, endotracheal tube, sternotomy wires, basilar atelectasis, atrial, venous, catheter, endotracheal, tube, sternotomy, atelectasis, chest, asd Cardiovascular / Pulmonary Pulmonary disorder with lung mass, pleural effusion, and chronic uncontrolled atrial fibrillation secondary to pulmonary disorder. The patient is admitted for lung mass and also pleural effusion. The patient had a chest tube placement, which has been taken out. The patient has chronic atrial fibrillation, on anticoagulation. SOAP - Lung Mass SUBJECTIVE:, The patient is admitted for lung mass and also pleural effusion. The patient had a chest tube placement, which has been taken out. The patient has chronic atrial fibrillation, on anticoagulation. The patient is doing fairly well. This afternoon, she called me because heart rate was in the range of 120 to 140. The patient is lying down. She does have shortness of breath, but denies any other significant symptoms.,PAST MEDICAL HISTORY:, History of mastectomy, chest tube placement, and atrial fibrillation; chronic.,MEDICATIONS:,1. Cardizem, which is changed to 60 mg p.o. t.i.d.,2. Digoxin 0.25 mg daily.,3. Coumadin, adjusted dose.,4. Clindamycin.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse 122 and blood pressure 102/68.,LUNGS: Air entry decreased.,HEART: PMI is displaced. S1 and S2 are irregular.,ABDOMEN: Soft and nontender.,IMPRESSION:,1. Pulmonary disorder with lung mass.,2. Pleural effusion.,3. Chronic uncontrolled atrial fibrillation secondary to pulmonary disorder.,RECOMMENDATIONS:,1. From cardiac standpoint, follow with pulmonary treatment.,2. The patient has an INR of 2.09. She is on anticoagulation. Atrial fibrillation is chronic with the rate increased.,Adjust the medications accordingly as above. cardiovascular / pulmonary, lung mass, pleural effusion, chest tube placement, chest tube, pulmonary disorder, atrial fibrillation, chest, anticoagulation, effusion, lung, pulmonary, atrial, fibrillation, Cardiovascular / Pulmonary Insertion of a #8 Shiley tracheostomy tube. A #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch. Dissection was carried down using Bovie electrocautery to the level of the trachea. Shiley Tracheostomy Tube Insertion OPERATION: , Insertion of a #8 Shiley tracheostomy tube.,ANESTHESIA: , General endotracheal anesthesia.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient's family, 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, a #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch. Dissection was carried down using Bovie electrocautery to the level of the trachea. The 2nd tracheal ring was identified. Next, a #11-blade scalpel was used to make a trap door in the trachea. The endotracheal tube was backed out. A #8 Shiley tracheostomy tube was inserted, and tidal CO2 was confirmed when it was connected to the circuit. We then secured it in place using 0 silk suture. A sterile dressing was applied. The patient tolerated the procedure well. cardiovascular / pulmonary, tracheostomy, shiley tracheostomy tube, sternal notch, bovie electrocautery, tracheostomy tube, electrocautery, endotracheal, shiley, tube, Cardiovascular / Pulmonary Repair of total anomalous pulmonary venous connection, ligation of patent ductus arteriosus, repair secundum type atrial septal defect (autologous pericardial patch), subtotal thymectomy, and insertion of peritoneal dialysis catheter. Septal Defect Repair TITLE OF OPERATION:,1. Repair of total anomalous pulmonary venous connection.,2. Ligation of patent ductus arteriosus.,3. Repair secundum type atrial septal defect (autologous pericardial patch).,4. Subtotal thymectomy.,5. Insertion of peritoneal dialysis catheter.,INDICATION FOR SURGERY: , This neonatal was diagnosed postnatally with total anomalous pulmonary venous connection. Following initial stabilization, she was transferred to the Hospital for complete correction.,PREOP DIAGNOSIS: ,1. Total anomalous pulmonary venous connection.,2. Atrial septal defect.,3. Patent ductus arteriosus.,4. Operative weight less than 4 kilograms (3.2 kilograms).,COMPLICATIONS: , None.,CROSS-CLAMP TIME: , 63 minutes.,CARDIOPULMONARY BYPASS TIME MONITOR:, 35 minutes, profound hypothermic circulatory arrest time (4 plus 19) equals 23 minutes. Low flow perfusion 32 minutes.,FINDINGS:, Horizontal pulmonary venous confluence with right upper and middle with two veins entering the confluence on the right and multiple entry sites for left-sided veins. Large patulous anastomosis between posterior aspect of the left atrium and anterior aspect of the pulmonary venous confluence. Nonobstructed ascending vein ligated. Patent ductus arteriosus diminutive left atrium with posterior atrial septal defect with deficient inferior margin. At completion of the procedure, right ventricular pressure approximating one-half of systemic, normal sinus rhythm, good biventricular function by visual inspection.,PROCEDURE: , After the informed consent, the patient was brought to the operating room and placed on the operating room table in supine position. Upon induction of general endotracheal anesthesia and placement of indwelling arterial and venous monitoring lines. The patient was prepped and draped in the usual sterile fashion from chin to groins. A median sternotomy incision was performed. Dissection was carried through the deeper planes until the sternum was scored and divided with an oscillating saw. A subtotal thymectomy was performed. Systemic heparinization was achieved and the pericardium was entered and fashioned until cradle. A small portion of the anterior pericardium was procured and fixed in glutaraldehyde for patch closure of segment of the atrial septal defect during the procedure. Pursestrings were deployed on the ascending aorta on the right. Atrial appendage. The aorta was then cannulated with an 8-French aorta cannula and the right atrium with an 18-French Polystan right-angle cannula. With an ACT greater than 400, greater pulmonary bypass was commenced with excellent cardiac decompression and the patent ductus arteriosus was ligated with a 2-0 silk tie. Systemic cooling was started and the head was packed and iced and systemic steroids were administered. During cooling, traction suture was placed in the apex of the left ventricle. After 25 minutes of cooling, the aorta was cross-clamped and the heart arrested by administration of 30 cubic centimeter/kilogram of cold-blood cardioplegia delivered directly within the aortic root following the aorta cross-clamping. Following successful cardioplegic arrest, a period of low flow perfusion was started and a 10-French catheter was inserted into the right atrial appendage substituting the 18-French Polystan venous cannula. The heart was then rotated to the right side and the venous confluence was exposed. It was incised and enlarged and a corresponding incision in the dorsal and posterior aspect of the left atrium was performed. The two openings were then anastomosed in an end-to-side fashion with several interlocking sutures to avoid pursestring effect with a running 7-0 PDS suture. Following completion of the anastomosis, the heart was returned into the chest and the patient's blood volume was drained into the reservoir. A right atriotomy was then performed during the period of circulatory arrest. The atrial septal defect was very difficult to expose, but it was sealed with an autologous pericardial patch was secured in place with a running 6-0 Prolene suture. The usual deairing maneuvers were carried out and lining was administered and the right atriotomy was closed in two layers with a running 6-0 Prolene sutures. The venous cannula was reinserted. Cardiopulmonary bypass restarted and the aorta cross-clamp was released. The patient returned to normal sinus rhythm spontaneously and started regaining satisfactory hemodynamics which, following a prolonged period of rewarming, allow for us to wean her from cardiopulmonary bypass successfully and moderate inotropic support and sinus rhythm. Modified ultrafiltration was carried out and two sets of atrial and ventricular pacing wires were placed as well as the peritoneal dialysis catheter and two 15-French Blake drains. Venous decannulation was followed by aortic decannulation and administration of protamine sulfate. All cannulation sites were oversewn with 6-0 Prolene sutures and the anastomotic sites noticed to be hemostatic. With good hemodynamics and hemostasis, the sternum was then smeared with vancomycin, placing closure with stainless steel wires. The subcutaneous tissues were closed in layers with the reabsorbable monofilament sutures. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was transferred in very stable condition to the pediatric intensive care unit .,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case. Given the magnitude of the operation, the unavailability of an appropriate level, cardiac surgical resident, Mrs. X (attending pediatric cardiac surgery at the Hospital) participated during the cross-clamp time of the procedure in quality of first assistant. cardiovascular / pulmonary, total anomalous pulmonary venous connection, patent ductus arteriosus, ligation, secundum type atrial septal defect, atrial septal defect, subtotal thymectomy, peritoneal dialysis catheter, cross clamp, cardiopulmonary bypass, pulmonary venous, atrial septal, septal defect, anomalous, venous, atrial, arteriosus, patent, ductus, septal, aorta, pulmonary, Cardiovascular / Pulmonary The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia. Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission. Shortness Of Breath - Progress Note "She was evaluated this a.m. and was without any significant clinical change. Her white count has been improving and down to 12,000. A chest x-ray obtained today showed some bilateral infiltrates, but no acute cardiopulmonary change. There was a suggestion of a bilateral lower lobe pneumonitis or pneumonia.,She has been on Zosyn for the infection.,Throughout her hospitalization, we have been trying to adjust her pain medications. She states that the methadone did not work for her. She was ""immune"" to oxycodone. She had been on tramadol before and was placed back on that. There was some question that this may have been causing some dizziness. She also was on clonazepam and alprazolam for the underlying bipolar disorder.,Apparently, her husband was in this afternoon. He had a box of her pain medications. It is unclear whether she took a bunch of these or precisely what happened. I was contacted that she was less responsive. She periodically has some difficulty to arouse due to pain medications, which she has been requesting repeatedly, though at times does not appear to have objective signs of ongoing pain. The nurse found her and was unable to arouse her at this point. There was a concern that she had taken some medications from home. She was given Narcan and appeared to come around some. Breathing remained somewhat labored and she had some diffuse scattered rhonchi, which certainly changed from this a.m. Additional Narcan was given as well as some medications to reverse a possible benzodiazepine toxicity. With O2 via mask, oxygenation was stable at 90% to 95% after initial hypoxia was noted. A chest x-ray was obtained at this time. An ECG was obtained, which shows a sinus tachycardia, noted to have ischemic abnormalities.,In light of the acute decompensation, she was then transferred to the ICU. We will continue the IV Zosyn. Respiratory protocol with respiratory management. Continue alprazolam p.r.n., but avoid if she appears sedated. We will attempt to avoid additional pain medications, but we will continue with the Dilaudid for time being. I suspect she will need something to control her bipolar disorder.,Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission. At this juncture, she does not appear to need an intubation. Pending chest x-ray, she may require additional IV furosemide." cardiovascular / pulmonary, shortness of breath, pulmonary medicine, bipolar disorder, icuNOTE Cardiovascular / Pulmonary Ligation and stripping of left greater saphenous vein to the level of the knee. Stripping of multiple left lower extremity varicose veins. Varicose veins. Saphenous Vein - Ligation & Stripping PREOPERATIVE DIAGNOSIS:, Varicose veins.,POSTOPERATIVE DIAGNOSIS: , Varicose veins.,PROCEDURE PERFORMED:,1. Ligation and stripping of left greater saphenous vein to the level of the knee.,2. Stripping of multiple left lower extremity varicose veins.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 150 mL.,SPECIMENS: , Multiple veins.,COMPLICATIONS:, None.,BRIEF HISTORY:, This is a 30-year-old Caucasian male who presented for elective evaluation from Dr. X's office for evaluation of intractable pain from the left lower extremity. The patient has had painful varicose veins for number of years. He has failed conservative measures and has felt more aggressive treatment to alleviate his pain secondary to his varicose veins. It was recommended that the patient undergo a saphenous vein ligation and stripping. He was explained the risks, benefits, and complications of the procedure including intractable pain. He gave informed consent to proceed.,OPERATIVE FINDINGS:, The left greater saphenous vein femoral junction was identified and multiple tributaries were ligated surrounding this region.,The vein was stripped from the saphenofemoral junction to the level of the knee. Multiple tributaries of the greater saphenous vein and varicose veins from the left lower extremity were ligated and stripped accordingly. Additionally, there were noted to be multiple regions within these veins that were friable and edematous consistent with acute and chronic inflammatory changes making stripping of these varicose veins extremely difficult.,OPERATIVE PROCEDURE: ,The patient was marked preoperatively in the Preanesthesia Care Unit. The patient was brought to the operating suite, placed in the supine position. The patient underwent general endotracheal intubation. After adequate anesthesia was obtained, the left lower extremity was prepped and draped circumferentially from the foot all the way to the distal section of the left lower quadrant and just right of midline. A diagonal incision was created in the direction of the inguinal crease on the left. A self-retaining retractor was placed and the incision was carried down through the subcutaneous tissues until the greater saphenous vein was identified. The vein was isolated with a right angle. The vein was followed proximally until a multiple tributary branches were identified. These were ligated with #3-0 silk suture. The dissection was then carried to the femorosaphenous vein junction. This was identified and #0 silk suture was placed proximally and distally and ligated in between. The proximal suture was tied down. Distal suture was retracted and a vein stripping device was placed within the greater saphenous vein. An incision was created at the level of the knee. The distal segment of the greater saphenous vein was identified and the left foot was encircled with #0 silk suture and tied proximally and then ligated. The distal end of the vein stripping device was then passed through at its most proximal location. The device was attached to the vein stripping section and the greater saphenous vein was then stripped free from its canal within the left lower extremity. Next, attention was made towards the multiple tributaries of the varicose vein within the left lower leg. Multiple incisions were created with a #15 blade scalpel. The incisions were carried down with electrocautery. Next, utilizing sharp dissection with a hemostat, the tissue was spread until the vein was identified. The vein was then followed to T3 and in all these locations intersecting segments of varicose veins were identified and removed. Additionally, some segments were removed. The stripping approach would be vein stripping device. Multiple branches of the saphenous vein were then ligated and/or removed. Occasionally, dissection was unable to be performed as the vein was too friable and would tear from the hemostat. Bleeding was controlled with direct pressure. All incisions were then closed with interrupted #3-0 Vicryl sutures and/or #4-0 Vicryl sutures.,The femoral incision was closed with interrupted multiple #3-0 Vicryl sutures and closed with a running #4-0 subcuticular suture. The leg was then cleaned, dried, and then Steri-Strips were placed over the incisions. The leg was then wrapped with a sterile Kerlix. Once the Kerlix was achieved, an Ace wrap was placed over the left lower extremity for compression. The patient tolerated the procedure well and was transferred to Postanesthesia Care Unit extubated in stable condition. He will undergo evaluation postoperatively and will be seen shortly in the postanesthesia care unit. cardiovascular / pulmonary, varicose veins, saphenous vein, stripping, ligation, vein stripping, lower extremity, saphenous, varicose, vein, ligated, Cardiovascular / Pulmonary Complete heart block with pacemaker malfunction and a history of Shone complex. Shone complex HISTORY AND PHYSICAL: ,The patient is a 13-year-old, who has a history of Shone complex and has a complete heart block. He is on the pacemaker. He had a coarctation of the aorta and that was repaired when he was an infant. He was followed in our Cardiology Clinic here and has been doing well. However last night, he was sleeping, and he states he felt as if he has having a dream, and there was thunder in this dream, which woke him up. He then felt that his defibrillator was going off and this has continued and feels like his heart rate is not normal. Thus, his dad put him in the car and transported him here. He has been evaluated here. He had some scar tissue at one point when the internal pacemaker was not working properly and had to have that replaced. It was 2 a.m. when he woke, and again, he was brought here by private vehicle. He was well prior to going to bed. No cough, cold, runny nose, fever. No trauma has been noted.,PAST MEDICAL HISTORY:, Shone complex, pacemaker dependent.,MEDICATIONS: , He is on no medications at this time.,ALLERGIES:, He has no allergies.,IMMUNIZATIONS:, Up to date.,SOCIAL HISTORY: , He lives with his parents.,FAMILY HISTORY: , Negative.,REVIEW OF SYSTEM: , Twelve asked, all negative, except as noted above.,PHYSICAL EXAMINATION:,GENERAL: This is an awake, alert male, who appears to be in mild distress.,HEENT: Pupils are equal, round, and reactive to light. Extraocular movements are intact. His TMs are clear. His nares are clear. The mucous membranes are pink and moist. Throat is clear.,NECK: Supple without lymphadenopathy or masses. Trachea is midline.,LUNGS: Clear.,HEART: Shows bradycardia at 53. He has good distal pulses.,ABDOMEN: Soft, nontender. Positive bowel sounds. No guarding, no rebound. No rashes are seen.,HOSPITAL COURSE:, Initial blood pressure is 164/90. He was moved in room 1. He was placed on nasal cannula. Pulse ox was 100%, which is normal. We placed him on a monitor. We did an EKG; it has not appear to be capturing his pacemaker at this time. Shortly after the patient's arrival, the Medtronic technician came and worked out his pacemaker. Medtronic representative informed me that the lead that he has in place has been recalled because it has been prone to microfractures, oversensing, and automatic defibrillation. As noted, he was transferred to room 1, placed on a monitor, pulse ox. An IV was placed. A standard blood work was sent. A chest x-ray was done showing normal heart size, lead appeared to be in placed. There was no evidence of pulmonary edema. His pacemaker did not appear to be capturing. We placed him on transthoracic leads. However, it is difficult to get good placement with these because of the area where his pacemaker was placed. The Medtronic technician initially turned off his defibrillation mode and turned down his sensor. However, we could not get our transthoracic pacer to capture his heart. When the Medtronic representative turned off the pacemaker, the heart rate seemed to drop into the 40s. The patient appeared to be in pain. We placed it back on a rate of 60 at that time. He has remained in sinus bradycardia, but no evidence of ectopic beats. No widening of his QRS complex. I spoke with Cardiology. Cardiology service has come in, has evaluated him at bedside with me. Again, we turned up the transthoracic pacer, but it is again not seem to be picking up, and his heart rate is still going with the Medtronic's internal pacemaker. So with the ICU physician on call, Dr. X, he has agreed with taking this young man to the ICU.,An hour after presentation here, the ICU was ready for bed. I accompanied the patient up to the ICU. He remained awake and alert. Initially, he was complaining of a lot of chest pain. Once the defibrillator was turned off, he had no more pain. He was transported to the Pediatrics PICU and delivered in stable condition.,LABORATORY DATA: , CBC was normal. Chem-20 was normal as well.,IMPRESSION: ,Complete heart block with pacemaker malfunction.,PLAN: ,He is admitted to the ICU.,TIME SEEN: , Critical care time outside billable procedures was 45 minutes with this patient. I should note that a 12-lead EKG was done here showing sinus bradycardia, normal intervals otherwise. Cardiovascular / Pulmonary Selective coronary angiography, coronary angioplasty. Acute non-ST-elevation MI. Selective Coronary Angiography & Angioplasty 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. cardiovascular / pulmonary, non-st-elevation mi, selective coronary angiography, coronary angioplasty, calcified plaque, coronary angiography, st elevation, stenosis, lad, coronary, selective, angiography, angioplasty, balloon, vessel, stent, Cardiovascular / Pulmonary Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors. No evidence of exercise induced ischemia at a high myocardial workload. This essentially excludes obstructive CAD as a cause of her elevated troponin. Radionuclide Stress Test INDICATION FOR STUDY: , Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.,MEDICATIONS:, Femara, verapamil, Dyazide, Hyzaar, glyburide, and metformin.,BASELINE EKG: , Sinus rhythm at 84 beats per minute, poor anteroseptal R-wave progression, mild lateral ST abnormalities.,EXERCISE RESULTS:,1. The patient exercised for 3 minutes stopping due to fatigue. No chest pain.,2. Heart rate increased from 84 to 138 or 93% of maximum predicted heart rate. Blood pressure rose from 150/88 to 210/100. There was a slight increase in her repolorization abnormalities in a non-specific pattern.,NUCLEAR PROTOCOL: ,Same day rest/stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test.,NUCLEAR RESULTS:,1. Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition. The resting images showed decreased uptake in the anterior wall. However the apex is spared of this defect. There is no significant change between rest and stress images. The sum score is 0.,2. The Gated SPECT shows moderate LVH with slightly low EF of 48%.,IMPRESSION:,1. No evidence of exercise induced ischemia at a high myocardial workload. This essentially excludes obstructive CAD as a cause of her elevated troponin.,2. Mild hypertensive cardiomyopathy with an EF of 48%.,3. Poor exercise capacity due to cardiovascular deconditioning.,4. Suboptimally controlled blood pressure on today's exam. cardiovascular / pulmonary, sinus rhythm, cardiac enzymes, abnormal ekg, stress test, elevated troponin, heart rate, blood pressure, radionuclide, chest, ekg, stress, ischemia Cardiovascular / Pulmonary A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever. Reactive Airway Disease 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. Cardiovascular / Pulmonary Pulmonary function test. Mild restrictive airflow limitation. Clinical correlation is recommended. Pulmonary Function Test - 5 OBSERVATIONS: , FEV1 is 3.76, 103% predicted. FVC is 4.98, 110% predicted. Ratio is 75. FEF 25-75 is 3.053, 82% predicted, postbronchodilator improves by 35%. DLCO is 35, 121% predicted. Residual volume is 3.04, 139% predicted. Total lung capacity is 8.34, 120% predicted.,Flow volume loop reviewed.,INTERPRETATION:, Mild restrictive airflow limitation. Clinical correlation is recommended. cardiovascular / pulmonary, fev1, fvc, fef, dlco, lung capacity, postbronchodilator, pulmonary function test, restrictive airflowNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. Cardiovascular / Pulmonary A 16-year-old male with Q-fever endocarditis. Q-Fever Endocarditis HISTORY OF PRESENT ILLNESS: , This is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q-fever endocarditis. He is also taking digoxin, aspirin, warfarin, and furosemide. Mother reports that he does have problems with 2-3 loose stools per day since September, but tolerates this relatively well. This has not increased in frequency recently.,Mark recently underwent surgery at Children's Hospital and had on 10/15/2007, replacement of pulmonary homograft valve, resection of a pulmonary artery pseudoaneurysm, and insertion of Gore-Tex membrane pericardial substitute. He tolerated this procedure well. He has been doing well at home since that time.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature is 98.5, pulse 84, respirations 19, blood pressure 101/57, weight 77.7 kg, and height 159.9 cm.,GENERAL APPEARANCE: Well-developed, well-nourished, slightly obese, slightly dysmorphic male in no obvious distress.,HEENT: Remarkable for the badly degenerated left lower molar. Funduscopic exam is unremarkable.,NECK: Supple without adenopathy.,CHEST: Clear including the sternal wound.,CARDIOVASCULAR: A 3/6 systolic murmur heard best over the upper left sternal border.,ABDOMEN: Soft. He does have an enlarged spleen, however, given his obesity, I cannot accurately measure its size.,GU: Deferred.,EXTREMITIES: Examination of extremities reveals no embolic phenomenon.,SKIN: Free of lesions.,NEUROLOGIC: Grossly within normal limits.,LABORATORY DATA: , Doxycycline level obtained on 10/05/2007 as an outpatient was less than 0.5. Hydroxychloroquine level obtained at that time was undetectable. Of note is that doxycycline level obtained while in the hospital on 10/21/2007 was 6.5 mcg/mL. Q-fever serology obtained on 10/05/2007 was positive for phase I antibodies in 1/2/6 and phase II antibodies at 1/128, which is an improvement over previous elevated titers. Studies on the pulmonary valve tissue removed at surgery are pending.,IMPRESSION: , Q-fever endocarditis.,PLAN: ,1. Continue doxycycline and hydroxychloroquine. I carefully questioned mother about compliance and concomitant use of dairy products while taking these medications. She assures me that he is compliant with his medications. We will however repeat his hydroxychloroquine and doxycycline levels.,2. Repeat Q-fever serology.,3. Comprehensive metabolic panel and CBC.,4. Return to clinic in 4 weeks.,5. Clotting times are being followed by Dr. X. cardiovascular / pulmonary, q-fever, q-fever endocarditis, endocarditis, doxycycline, fever, Cardiovascular / Pulmonary Pulmonary valve stenosis, supple pulmonic narrowing, and static encephalopathy Pulmonary Valve Stenosis HISTORY: , The patient is a 19-year-old boy with a membranous pulmonary atresia, underwent initial repair 12/04/1987 consisting of pulmonary valvotomy and placement of 4 mm Gore-Tex shunt between the ascending aorta and pulmonary artery with a snare. This was complicated by shunt thrombosis __________ utilizing a 10-mm balloon. Resulting in significant hypoxic brain injury where he has been left with static encephalopathy and cerebral palsy. On 04/07/1988, he underwent heart catheterization and balloon pulmonary valvuloplasty utilizing a 10-mm balloon. He has been followed conservatively since that time. A recent echocardiogram demonstrated possibly a significant right ventricle outflow tract obstruction with tricuspid valve regurgitation velocity predicting a right ventricular systolic pressure in excess of 180 mmHg. Right coronary artery to pulmonary artery fistula was also appreciated. The patient underwent cardiac catheterization to assess hemodynamics associated with his current state of repair.,PROCEDURE:, The patient was placed under general endotracheal anesthesia breathing on 30% oxygen throughout the case. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 7-French sheath, a 6-French wedge catheter was inserted. The right femoral vein advanced through the right heart structures out to the branch pulmonary arteries. This catheter was then exchanged over wire for a 5-French marker pigtail catheter, which was directed into the main pulmonary artery.,Using a 5-French sheath, a 5-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle. This catheter was then exchanged for a Judkins right coronary catheter for selective cannulation of the right coronary artery.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the main pulmonary artery and right coronary artery.,After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.,DISCUSSION:, Oxygen consumption was assumed to be normal. Mixed venous saturation was normal with no evidence of intracardiac shunt. Left-sided heart was fully saturated. Phasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure. Right ventricular systolic pressure was mildly elevated at 45% systemic level. There was a 25 mmHg peak systolic gradient across the outflow tract to the main branch pulmonary arteries. Phasic branch pulmonary artery pressures were normal. Right-to-left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg. Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta. Phasic ascending and descending pressures were similar and normal. The calculated systemic and pulmonary flows were equal and normal. Vascular resistances were normal. Angiogram with contrast injection in the main pulmonary artery showed catheter induced pulmonary insufficiency. The right ventricle appeared mildly hypoplastic with a good contractility and mild tricuspid valve regurgitation. There is dynamic narrowing of the infundibulum with hypoplastic pulmonary annulus. The pulmonary valve appeared to be thin and moved well. The median branch pulmonary arteries were of good size with normal distal arborization. Angiogram with contrast injection in the right coronary artery showed a non-dominant coronary with a small fistula arising from the proximal right coronary artery coursing over the infundibulum and entering the left facing sinus of the main pulmonary artery.,INITIAL DIAGNOSES:,1. Membranous pulmonary atresia.,2. Atrial septal defect.,3. Right coronary artery to pulmonary artery fistula.,SURGERIES (INTERVENTIONS): ,1. Pulmonary valvotomy surgical.,2. Aortopulmonary artery central shunt.,3. Balloon pulmonary valvuloplasty.,CURRENT DIAGNOSES: ,1. Pulmonary valve stenosis supplemented to hypoplastic pulmonary annulus.,2. Mild right ventricle outflow tract obstruction due to supple pulmonic narrowing.,3. Small right coronary artery to main pulmonary fistula.,4. Static encephalopathy.,5. Cerebral palsy.,MANAGEMENT: , The case to be discussed with combined Cardiology/Cardiothoracic Surgery case conference. Given the mild degree of outflow tract obstruction in this sedentary patient, aggressive intervention is not indicated. Conservative outpatient management is to be recommended. Further patient care will be directed by Dr. X. cardiovascular / pulmonary, membranous pulmonary atresia, atrial septal defect, pulmonary artery fistula, pulmonary valvotomy, central shunt, pulmonary valvuloplasty, static encephalopathy, cerebral palsy, hypoplastic pulmonary annulus, pulmonary valve stenosis, outflow tract obstruction, ventricular systolic pressure, branch pulmonary arteries, systolic pressure, pulmonary arteries, pulmonary valve, branch pulmonary, coronary artery, catheterization, artery, pulmonary, pressures, coronary, Cardiovascular / Pulmonary Increasing oxygen requirement. Baby boy has significant pulmonary hypertension. Pulmonary Hypertension - Pediatric Consult 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. cardiovascular / pulmonary, high-frequency ventilator, structural anatomy, foramen ovale, oxygen requirement, hypertension, pulmonary Cardiovascular / Pulmonary Patient returns to Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema. Pulmonary Medicine Clinic Followup SUBJECTIVE:, The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema. She was last seen in the clinic in March 2004. Since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility. She is very frustrated with her living situation and would like to return to her own apartment, however, some believes she is to ill to care for herself.,At the present time, respiratory status is relatively stable. She is still short of breath with activity, but all-in-all her pulmonary disease has not changed significantly since her last visit. She does have occasional cough and a small amount of sputum production. No fever or chills. No chest pains.,CURRENT MEDICATIONS:, The patient’s current medications are as outlined.,ALLERGIES TO MEDICATIONS:, Erythromycin.,REVIEW OF SYSTEMS:, Significant for problems with agitated depression. Her respiratory status is unchanged as noted above.,EXAMINATION:,General: The patient is in no acute distress.,Vital signs: Blood pressure is 152/80, pulse 80 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 throughout all lung fields, coarse but relatively clear.,Cardiovascular: Distant heart tones. Regular rate and rhythm.,Abdomen: Soft and nontender.,Extremities: Without edema.,Oxygen saturation was checked today on room air, at rest it was 90%.,ASSESSMENT:,1. Chronic obstructive pulmonary disease/emphysema, severe but stable.,2. Mild hypoxemia, however, oxygen saturation at rest is stable without supplemental oxygen.,3. History of depression and schizophrenia.,PLAN:, At this point, I have recommended that she continue current respiratory medicine. I did suggest that she would not use her oxygen when she is simply sitting, watching television or reading. I have recommended that she use it with activity and at night. I spoke with her about her living situation. Encouraged her to speak with her family, as well as primary care physician about making efforts for her to return to her apartment. Follow up evaluation is planned in Pulmonary Medicine Clinic in approximately three months or sooner if need be. cardiovascular / pulmonary, respiratory, copd, chronic obstructive pulmonary disease, pulmonary medicine clinic, depression, emphysema, followup, hypoxemia, oxygen, schizophrenia, oxygen saturation, pulmonary medicine, medicine clinic, chest, medicine, pulmonary, Cardiovascular / Pulmonary Sample of Pulmonary Function Test Pulmonary Function Test - 4 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., cardiovascular / pulmonary, fev1, fev1/fvc, fvc, fef25, frc, lung volumes, saturation on room air, pulmonary function test, diffusion capacity, oxygen saturation, pulmonary function, function test, spirometry, fev, bronchodilator, diffusion, capacity, oxygen, saturation, pulmonary, Cardiovascular / Pulmonary 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. Pulmonary Edema - Consult 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. Cardiovascular / Pulmonary Patient felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds. Pulmonary Embolism REASON FOR CONSULTATION: , Pulmonary embolism.,HISTORY:, The patient is a 78-year-old lady who was admitted to the hospital yesterday with a syncopal episode that happened for the first time in her life. The patient was walking in a store when she felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds. At that time, her daughter was with her. No tonic-clonic movements. No cyanosis. The patient woke up on her own. The patient currently feels fine, has mild shortness of breath upon exertion, but this is her usual for the last several years. She cannot get up one flight of stairs, but feels short of breath. She gets exerted and thinks to take a shower. She does not have any chest pain, no fever or syncopal episodes.,PAST MEDICAL HISTORY,1. Pulmonary embolism diagnosed one year ago. At that time, she has had an IVC filter placed due to massive GI bleed from diverticulosis and gastric ulcers. Paroxysmal atrial fibrillation and no anticoagulation due to history of GI bleed.,2. Coronary artery disease status post CABG at that time. She has had to stay in the ICU according to the daughter for 3 weeks due to again lower GI bleed.,3. Mitral regurgitation.,4. Gastroesophageal reflux disease.,5. Hypertension.,6. Hyperlipidemia.,7. History of aortic aneurysm.,8. History of renal artery stenosis.,9. Peripheral vascular disease.,10. Hypothyroidism.,PAST SURGICAL HISTORY,1. CABG.,2. Hysterectomy.,3. IVC filter.,4. Tonsillectomy.,5. Adenoidectomy.,6. Cosmetic surgery.,7. Renal stent.,8. Right femoral stent.,HOME MEDICATIONS,1. Aspirin.,2. Potassium.,3. Lasix.,4. Levothyroxine.,5. Lisinopril.,6. Pacerone.,7. Protonix.,8. Toprol.,9. Vitamin B.,10. Zetia.,11. Zyrtec.,ALLERGIES:, SULFA,SOCIAL HISTORY: , She used to be a smoker, not anymore. She drinks 2 to 3 glasses of wine per week. She is retired.,REVIEW OF SYSTEMS: , She has a history of snoring, choking for breath at night, and dry mouth in the morning.,PHYSICAL EXAMINATION,GENERAL APPEARANCE: In no acute distress.,VITAL SIGNS: Temperature 98.6, respirations 18, pulse 61, blood pressure 155/57, and oxygen saturation 93-98% on room air.,HEENT: No lymph nodes or masses.,NECK: No jugular venous distension.,LUNGS: Clear to auscultation bilaterally. Cardiovascular / Pulmonary Pulmonary Function Test in a patient with smoking history. Pulmonary Function Test - 1 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., cardiovascular / pulmonary, pulmonary function test, diffusion capacity, dyspnea, fef, fev1, fev1/fvc ratio, fvc, pft, residual volume, svc, smoking history, bronchodilator, bronchospastic, fibrosis, inspiratory capacity, lung capacity, obstructive lung disease, pulmonary function, Cardiovascular / Pulmonary Sample of Pulmonary Function Test Pulmonary Function Test - 3 SPIROMETRY: , Spirometry reveals the FVC to be adequate.,FEV1 is also normal at 98% predicted and FVC is 90.5% predicted. FEF25-75% is also within normal limits at 110% predicted. FEV1/FVC ratio is within normal limits at 108% predicted.,After the use of bronchodilator, there is some improvement with 10%. MVV is within normal limits.,LUNG VOLUMES:, Shows total lung capacity to be normal. RV as well as RV/TLC ratio they are within normal limits.,DIFFUSION CAPACITY:, Shows that after correction for alveolar ventilation, is also normal.,Oxygen Saturation on Room Air: 98%.,FINAL INTERPRETATION:, Pulmonary function test shows no evidence of obstructive or restrictive pulmonary disease. There is some improvement after the use bronchodilator. Diffusion capacity is within normal limits. Oxygen saturation on room air is also normal. Clinical correlation will be necessary in this case. cardiovascular / pulmonary, fvc, fev1, fev1/fvc ratio, fef, lung volumes, saturation on room air, pulmonary function test, pulmonary function, oxygen saturation, spirometry, bronchodilator, lung, diffusion, oxygen, saturation, pulmonary, capacity, Cardiovascular / Pulmonary Pulmonary function test. Mild-to-moderate obstructive ventilatory impairment. Some improvement in the airflows after bronchodilator therapy. Pulmonary Function Test OBSERVATIONS: , The forced vital capacity is 2.84 L and forced expiratory volume in 1 second is 1.93 L. The ratio between the two is 68%. Small improvement is noted in the airflows after bronchodilator therapy. Lung volumes are increased with a residual volume of 196% of predicted and total lung capacity of 142% of predicted. Single-breath diffusing capacity is slightly reduced.,IMPRESSION: , Mild-to-moderate obstructive ventilatory impairment. Some improvement in the airflows after bronchodilator therapy. cardiovascular / pulmonary, lung volume, forced expiratory volume, forced vital capacity, airflows, total lung capacity, bronchodilator therapy, bronchodilatorNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., Cardiovascular / Pulmonary Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study. Pulmonary Consultation - 1 "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." Cardiovascular / Pulmonary Patient with complaints of significant coughing and wheezing. Pulmonary Consultation - 2 PAST MEDICAL HISTORY:, Unremarkable, except for diabetes and atherosclerotic vascular disease.,ALLERGIES:, PENICILLIN.,CURRENT MEDICATIONS:, Include Glucovance, Seroquel, Flomax, and Nexium.,PAST SURGICAL HISTORY: , Appendectomy and exploratory laparotomy.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: ,The patient is a non-smoker. No alcohol abuse. The patient is married with no children.,REVIEW OF SYSTEMS:, Significant for an old CVA.,PHYSICAL EXAMINATION:, The patient is an elderly male alert and cooperative. Blood pressure 96/60 mmHg. Respirations were 20. Pulse 94. Afebrile. O2 was 94% on room air. HEENT: Normocephalic and atraumatic. Pupils are reactive. Oral mucosa is grossly normal. Neck is supple. Lungs: Decreased breath sounds. Disturbed breath sounds with poor exchange. Heart: Regular rhythm. Abdomen: Soft and nontender. No organomegaly or masses. Extremities: No cyanosis, clubbing, or edema.,LABORATORY DATA: , Oropharyngeal evaluation done on 11/02/2006 revealed mild oropharyngeal dysphagia with no evidence of laryngeal penetration or aspiration with food or liquid. Slight reduction in tongue retraction resulting in mild residual remaining in the palatal sinuses, which clear with liquid swallow and double-saliva swallow.,ASSESSMENT:,1. Cough probably multifactorial combination of gastroesophageal reflux and recurrent aspiration.,2. Old CVA with left hemiparesis.,3. Oropharyngeal dysphagia.,4. Diabetes.,PLAN:, At the present time, the patient is recommended to continue on a regular diet, continue speech pathology evaluation as well as perform double-swallow during meals with bolus sensation. He may use Italian lemon ice during meals to help clear sinuses as well. The patient will follow up with you. If you need any further assistance, do not hesitate to call me. cardiovascular / pulmonary, pulmonary evaluation, cough, wheezing, congestion, coughing and wheezing, breath sounds, oropharyngeal dysphagia, pulmonary, breath, sounds, dysphagia, aspiration, sinuses, oropharyngeal, coughing, swallowing, Cardiovascular / Pulmonary Pulmonary Function Test to evaluate dyspnea. Pulmonary Function Test - 2 HISTORY:, Smoking history zero.,INDICATION: , Dyspnea with walking less than 100 yards.,PROCEDURE:, FVC was 59%. FEV1 was 61%. FEV1/FVC ratio was 72%. The predicted was 70%. The FEF 25/75% was 45%, improved from 1.41 to 2.04 with bronchodilator, which represents a 45% improvement. SVC was 69%. Inspiratory capacity was 71%. Expiratory residual volume was 61%. The TGV was 94%. Residual volume was 113% of its predicted. Total lung capacity was 83%. Diffusion capacity was diminished.,IMPRESSION:,1. Moderate restrictive lung disease.,2. Some reversible small airway obstruction with improvement with bronchodilator.,3. Diffusion capacity is diminished, which might indicate extrapulmonary restrictive lung disease.,4. Flow volume loop was consistent with the above and no upper airway obstruction., cardiovascular / pulmonary, pulmonary function test, diffusion capacity, dyspnea, fef, fev1, fev1/fvc ratio, fvc, flow volume loop, pft, svc, smoking history, airway obstruction, bronchodilator, extrapulmonary, residual volume, restrictive lung disease, walking, pulmonary function, lung disease, pulmonary, function, lung, capacity Cardiovascular / Pulmonary The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids. Pulmonary Atresia HISTORY: , The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids. He also has VACTERL association with hydrocephalus. As an infant, he underwent placement of a right modified central shunt. On 05/26/1999, he underwent placement of a bidirectional Glenn shunt, pulmonary artery angioplasty, takedown of the central shunt, PDA ligation, and placement of a 4 mm left-sided central shunt. On 08/01/2006, he underwent cardiac catheterization and coil embolization of the central shunt. A repeat catheterization on 09/25/2001 demonstrated elevated Glenn pressures and significant collateral vessels for which he underwent embolization. He then underwent repeat catheterization on 11/20/2003 and further embolization of residual collateral vessels. Blood pressures were found to be 13 mmHg with the pulmonary vascular resistance of 2.6-3.1 Wood units. On 03/22/2004, he returned to the operating room and underwent successful 20 mm extracardiac Fontan with placement of an 8-mm fenestration and main pulmonary artery ligation. A repeat catheterization on 09/07/2006, demonstrated mildly elevated Fontan pressures in the context of a widely patent Fontan fenestration and intolerance of Fontan fenestration occlusion. The patient then followed conservatively since that time. The patient is undergoing a repeat evaluation to assess his candidacy for a Fontan fenestration occlusion, as well as consideration for a tricuspid valvuloplasty in attempt to relieve right ventricular hypertension and associated membranous ventricular aneurysm protruding into the left ventricular outflow tract.,PROCEDURE:, After sedation and local Xylocaine anesthesia, the patient was placed under general endotracheal 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 7-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava along the Fontan conduit into the main left pulmonary artery, as well as the superior vena cava. This catheter was then exchanged for a 5-French VS catheter of a distal wire. Apposition of the right pulmonary artery over, which the wedge catheter was advanced. The wedge catheter could then be easily advanced across the Fontan fenestration into the right atrium and guidewire manipulation allowed access across the atrial septal defect to the pulmonary veins, left atrium, and left ventricle.,Using a 5-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle. Attempt was then made to cross the tricuspid valve from the right atrium and guidewire persisted to prolapse through the membranous ventricular septum into the left ventricle. The catheter distal wire position was finally achieved across what appeared to be the posterior aspect of the tricuspid valve, both angiographically as well as equal guidance. Left ventricular pressure was found to be suprasystemic. A balloon valvoplasty was performed using a Ranger 4 x 2 cm balloon catheter with no waste at minimal inflation pressure. Echocardiogram, which showed no significant change in the appearance of a tricuspid valve and persistence of aneurysmal membranous ventricular septum. Further angioplasty was then performed first utilizing a 6 mm cutting balloon directed through 7-French flexor sheath positioned within the right atrium. There was a disappearance of a mild waist prior to spontaneous tear of the balloon. The balloon catheter was then removed in its entirety.,Echocardiogram again demonstrated no change in the appearance of the tricuspid valve. A final angioplasty was performed utilizing a 80 mm cutting balloon with the disappearance of a distinctive waste. Echocardiogram; however, demonstrated no change and intact appearing tricuspid valve and no decompression of the right ventricle. Further attempts to cross tricuspid valve were thus abandoned. Attention was then directed to a Fontan fenestration. A balloon occlusion then demonstrated minimal increase in Fontan pressures from 12 mmHg to 15 mmHg. With less than 10% fall in calculated cardiac index. The angiogram in the inferior vena cava demonstrated a large fenestration measuring 6.6 mm in diameter with a length of 8 mm. A 7-French flexor sheath was again advanced cross the fenestration. A 10-mm Amplatzer muscular ventricular septal defect occluder was loaded on delivery catheter and advanced through the sheath where the distal disk was allowed to be figured in the right atrium. Entire system was then brought into the fenestration and withdrawal of the sheath allowed reconfiguration of the proximal disk. Once the stable device configuration was confirmed, device was released from the delivery catheter. Hemodynamic assessment and the angiograms were then repeated.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Angiograms with injection in the right coronary artery, left coronary artery, superior vena cava, inferior vena cava, and right ventricle.,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 was low due to systemic arterial desaturation. There was modest increased saturation of the branch pulmonary arteries due to the presumed aortopulmonary collateral flow. The right pulmonary veins were fully saturated. Left pulmonary veins were not entered. There was a fall in saturation within the left ventricle and descending aorta due to a right to left shunt across the Fontan fenestration. Mean Fontan pressures were 12 mmHg with a 1 mmHg fall in mean pressure into the distal left pulmonary artery. Right and left pulmonary capillary wedge pressures were similar to left atrial phasic pressure with an A-wave similar to the normal left ventricular end-diastolic pressure of 11 mmHg. Left ventricular systolic pressure was normal with at most 5 mmHg systolic gradient pressure pull-back to the ascending aorta. Phasic ascending and descending aortic pressures were similar and normal. The calculated systemic flow was normal. Pulmonary flow was reduced to the QT-QS ratio of 0.7621. Pulmonary vascular resistance was normal at 1 Wood units.,Angiogram with injection in the right coronary artery demonstrated diminutive coronary with an extensive sinusoidal communication to the rudimentary right ventricle. The left coronary angiogram showed a left dominant system with a brisk flow to the left anterior descending and left circumflex coronary arteries. There was communication to the right-sided coronary sinusoidal communication to the rudimentary right ventricle. Angiogram with injection in the superior vena cava showed patent right bidirectional Glenn shunt with mild narrowing of the proximal right pulmonary artery, as well as the central pulmonary artery, diameter of which was augmented by the Glenn anastomosis and the Fontan anastomosis. There was symmetric contrast flow to both pulmonary arteries. A large degree of contrast flowed retrograde into the Fontan and shunting into the right atrium across the fenestration. There is competitive flow to the upper lobes presumably due to aortopulmonary collateral flow. The branch pulmonaries appeared mildly hypoplastic. Levo phase contrast returned into the heart, appeared unobstructed demonstrating good left ventricular contractility. Angiogram with injection in the Fontan showed a widely patent anastomosis with the inferior vena cava. Majority of the contrast flowing across the fenestration into the right atrium with a positive flow to the branch pulmonary arteries.,Following the device occlusion of Fontan fenestration, the Fontan and mean pressure increased to 15 mmHg with a 3 mmHg, a mean gradient in the distal left pulmonary artery and no gradient into the right pulmonary artery. There was an increase in the systemic arterial pressures. Mixed venous saturation increased from the resting state as with increase in systemic arterial saturation to 95%. The calculated systemic flow increased slightly from the resting state and pulmonary flow was similar with a QT-QS ratio of 0.921. Angiogram with injection in the inferior vena cava showed a stable device configuration with a good disk apposition to the anterior surface of the Fontan with no protrusion into the Fontan and no residual shunt and no obstruction to a Fontan flow. An ascending aortogram that showed a left aortic arch with trace aortic insufficiency and multiple small residual aortopulmonary collateral vessels arising from the intercostal arteries. A small degree of contrast returned to the heart.,INITIAL DIAGNOSES: ,1. Pulmonary atresia.,2. VACTERL association.,3. Persistent sinusoidal right ventricle to the coronary communications.,4. Hydrocephalus.,PRIOR SURGERIES AND INTERVENTIONS: ,1. Systemic to pulmonary shunts.,2. Right bidirectional Glenn shunt.,3. Revision of the central shunt.,4. Ligation and division of patent ductus arteriosus.,5. Occlusion of venovenous and arterial aortopulmonary collateral vessels.,6. Extracardiac Fontan with the fenestration.,CURRENT DIAGNOSES: ,1. Favorable Fontan hemodynamics.,2. Hypertensive right ventricle.,3. Aneurysm membranous ventricular septum with mild left ventricle outflow tract obstruction.,4. Patent Fontan fenestration.,CURRENT INTERVENTION: ,1. Balloon dilation tricuspid valve attempted and failed.,2. Occlusion of a Fontan fenestration.,MANAGEMENT: ,He will be discussed at Combined Cardiology/Cardiothoracic Surgery case conference. A careful monitoring of ventricle outflow tract will be instituted with consideration for a surgical repair. Further cardiologic care will be directed by Dr. X. Cardiovascular / Pulmonary Port-A-Cath insertion template. Catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed. Port-A-Cath Insertion 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. cardiovascular / pulmonary, hemostasis, port a cath insertion, fluoroscopic confirmation, cath insertion, insertion, fluoroscopic, subcutaneous, catheter, sheath, dilators, wire, Cardiovascular / Pulmonary Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis. Pulmonary - Followup Note 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. cardiovascular / pulmonary, pulmonary medicine clinic, cat scan, lupus, respiratory status, chest x-ray, interstitial disease, lupus pneumonitis, pneumonitis, pulmonary function test, pulmonary status, respiratory difficulties, chest x ray, interstitial, respiratory, chest, pulmonary, Cardiovascular / Pulmonary Aspiration pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation. Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation. Systemic inflammatory response syndrome secondary to aspiration pneumonia. No bacteria identified with blood cultures or sputum culture. Pneumonia & COPD - Discharge Summary "ADMISSION DIAGNOSES:,1. Pneumonia, likely secondary to aspiration.,2. Chronic obstructive pulmonary disease (COPD) exacerbation.,3. Systemic inflammatory response syndrome.,4. Hyperglycemia.,DISCHARGE DIAGNOSES:,1. Aspiration pneumonia.,2. Aspiration disorder in setting of severe chronic obstructive pulmonary disease.,3. Chronic obstructive pulmonary disease (COPD) exacerbation.,4. Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation.,5. Hypercapnia on admission secondary to chronic obstructive pulmonary disease.,6. Systemic inflammatory response syndrome secondary to aspiration pneumonia. No bacteria identified with blood cultures or sputum culture.,7. Atrial fibrillation with episodic rapid ventricular rate, now rate control.,8. Hyperglycemia secondary to poorly controlled type ii diabetes mellitus, insulin requiring.,9. Benign essential hypertension, poorly controlled on admission, now well controlled on discharge.,10. Aspiration disorder exacerbated by chronic obstructive pulmonary disease and acute respiratory failure.,11. Hyperlipidemia.,12. Acute renal failure on chronic renal failure on admission, now resolved.,HISTORY OF PRESENT ILLNESS:, Briefly, this is 73-year-old white male with history of multiple hospital admissions for COPD exacerbation and pneumonia who presented to the emergency room on 04/23/08, complaining of severe shortness of breath. The patient received 3 nebulizers at home without much improvement. He was subsequently treated successfully with supplemental oxygen provided by normal nasal cannula initially and subsequently changed to BiPAP.,HOSPITAL COURSE: ,The patient was admitted to the hospitalist service, treated with frequent small volume nebulizers, treated with IV Solu-Medrol and BiPAP support for COPD exacerbation. The patient also noted with poorly controlled atrial fibrillation with a rate in the low 100s to mid 100s. The patient subsequently received diltiazem, also received p.o. digoxin. The patient subsequently responded well as well received IV antibiotics including Levaquin and Zosyn. The patient made slow, but steady improvement over the course of his hospitalization. The patient subsequently was able to be weaned off BiPAP during the day, but continued BiPAP at night and will continue with BiPAP if needed. The patient may require a sleep study after discharge, but by the third day prior to discharge he was no longer utilizing BiPAP, was simply using supplemental O2 at night and was able to maintain appropriate and satisfactory O2 saturations on one-liter per minute supplemental O2 per nasal cannula. The patient was able to participate with physical therapy, able to ambulate from his bed to the bathroom, and was able to tolerate a dysphagia 2 diet. Note that speech therapy did provide a consultation during this hospitalization and his modified barium swallow was thought to be unremarkable and really related only to the patient's severe shortness of breath during meal time. The patient's chest x-ray on admission revealed some mild vascular congestion and bilateral pleural effusions that appeared to be unchanged. There was also more pronounced patchy alveolar opacity, which appeared to be, ""mass like"" in the right suprahilar region. This subsequently resolved and the patient's infiltrate slowly improved over the course of his hospitalization. On the day prior to discharge, the patient had a chest x-ray 2 views, which allowing for differences in technique revealed little change in the bibasilar infiltrates and atelectatic changes at the bases bilaterally. This was compared with an examination performed 3 days prior. The patient also had minimal bilateral effusions. The patient will continue with clindamycin for the next 2 weeks after discharge. Home health has been ordered and the case has been discussed in detail with Shaun Eagan, physician assistant at Eureka Community Health Center. The patient was discharged as well on a dysphagia 2 diet, thin liquids are okay. The patient discharged on the following medications.,DISCHARGE MEDICATIONS:,1. Home oxygen 1 to 2 liters to maintain O2 saturations at 89 to 91% at all times.,2. Ativan 1 mg p.o. t.i.d.,3. Metformin 1000 mg p.o. b.i.d.,4. Glucotrol 5 mg p.o. daily.,5. Spiriva 1 puff b.i.d.,6. Lantus 25 units subcu q.a.m.,7. Cardizem CD 180 mg p.o. q.a.m.,8. Advair 250/50 mcg, 1 puff b.i.d. The patient is instructed to rinse with mouthwash after each use.,9. Iron 325 mg p.o. b.i.d.,10. Aspirin 325 mg p.o. daily.,11. Lipitor 10 mg p.o. bedtime.,12. Digoxin 0.25 mg p.o. daily.,13. Lisinopril 20 mg p.o. q.a.m.,14. DuoNeb every 4 hours for the next several weeks, then q.6 h. thereafter, dispensed 180 DuoNeb ampule's with one refill.,15. Prednisone 40 mg p.o. q.a.m. x3 days followed by 30 mg p.o. q.a.m. x3 days, then followed by 20 mg p.o. q.a.m. x5 days, then 10 mg p.o. q.a.m. x14 days, then discontinue, #30 days supply given. No refills.,16. Clindamycin 300 mg p.o. q.i.d. x2 weeks, dispensed #64 with one refill.,The patient's aspiration pneumonia was discussed in detail. He is agreeable to obtaining a chest x-ray PA and lateral after 2 weeks of treatment. Note that this patient did not have community-acquired pneumonia. His discharge diagnosis is aspiration pneumonia. The patient will continue with a dysphagia 2 diet with thin liquids after discharge. The patient discharged with home health. A dietary and speech therapy evaluation has been ordered. Speech therapy to treat for chronic dysphagia and aspiration in the setting of severe chronic obstructive pulmonary disease.,Total discharge time was greater than 30 minutes." Cardiovascular / Pulmonary Insertion of subclavian dual-port Port-A-Cath and surgeon-interpreted fluoroscopy. Port-A-Cath Insertion - 5 PROCEDURES PERFORMED,1. Insertion of subclavian dual-port Port-A-Cath.,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 general endotracheal anesthesia was administered. Next, the chest was prepped and draped in a standard surgical fashion. A #18-gauge spinal needle was used to aspirate blood from the subclavian vein. After aspiration of venous blood, Seldinger technique was used to thread a J wire. The distal tip of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next a #15-blade scalpel was used to make an incision in the skin. Dissection was carried down to the level of the pectoralis muscle. A pocket was created. A dual-port Port-A-Cath was lowered into the pocket and secured with #2-0 Prolene. Both ports were flushed. The distal tip was pulled through to the wire exit site with a Kelly clamp. It was cut to the appropriate length. Next a dilator and sheath were threaded over the J wire. The J wire and dilator were removed, and the distal tip of the dual-port Port-A-Cath was threaded over the sheath, which was simultaneously withdrawn. Both ports of the dual-port Port-A-Cath were flushed and aspirated without difficulty. The distal tip was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. The wire access site was closed with a 4-0 Monocryl. The port pocket was closed in 2 layers with 2-0 Vicryl followed by 4-0 Monocryl in a running subcuticular fashion. Sterile dressing was applied. The patient tolerated the procedure well and was transferred to the PACU in good condition cardiovascular / pulmonary, surgeon-interpreted fluoroscopy, j wire, dual-port port-a-cath, port a cath, subclavian, fluoroscopy, cathNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. Cardiovascular / Pulmonary Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. Pneumoconiosis 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. Cardiovascular / Pulmonary Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure. 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. Preeclampsia 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. Cardiovascular / Pulmonary Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency. This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission. Pneumonia - Discharge Summary 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. cardiovascular / pulmonary, adrenal insufficiency, hypoxia, cough, fevers, weakness, chills, atypical pneumonia, loose stools, rheumatoid arthritis, azithromycin, arthritis, pneumonia, Cardiovascular / Pulmonary Consult for subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma. Pneumothorax & Subcutaneous Emphysema REASON FOR CONSULTATION:, Pneumothorax and subcutaneous emphysema.,HISTORY OF PRESENT ILLNESS: , The patient is a 48-year-old male who was initially seen in the emergency room on Monday with complaints of scapular pain. The patient presented the following day with subcutaneous emphysema and continued complaints of pain as well as change in his voice. The patient was evaluated with a CT scan of the chest and neck which demonstrated significant subcutaneous emphysema, a small right-sided pneumothorax, but no other findings. The patient was admitted for observation.,PAST SURGICAL HISTORY: , Hernia repair and tonsillectomy.,ALLERGIES: , Penicillin.,MEDICATIONS: , Please see chart.,REVIEW OF SYSTEMS:, Not contributory.,PHYSICAL EXAMINATION:,GENERAL: Well developed, well nourished, lying on hospital bed in minimal distress.,HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact.,NECK: Supple. Trachea is midline.,CHEST: Clear to auscultation bilaterally.,CARDIOVASCULAR: Regular rate and rhythm.,ABDOMEN: Soft, nontender, and nondistended. Normoactive bowel sounds.,EXTREMITIES: No clubbing, edema, or cyanosis.,SKIN: The patient has significant subcutaneous emphysema of the upper chest and anterior neck area although he states that the subcutaneous emphysema has improved significantly since yesterday.,DIAGNOSTIC STUDIES:, As above.,IMPRESSION: , The patient is a 48-year-old male with subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma. These are likely a result of either a parenchymal lung tear versus a small tracheobronchial tree rend.,RECOMMENDATIONS:, At this time, the CT Surgery service has been consulted and has left recommendations. The patient also is awaiting bronchoscopy per the Pulmonary Service. At this time, there are no General Surgery issues. cardiovascular / pulmonary, trauma, tracheobronchial, bronchoscopy, scapular pain, subcutaneous emphysema, pneumothorax, subcutaneous, emphysema, Cardiovascular / Pulmonary Cardiology consultation regarding preoperative evaluation for right hip surgery. Patient with a history of coronary artery disease status post bypass surgery Preop Cardiac Consult "HISTORY OF PRESENT ILLNESS: , I was kindly asked to see Ms. ABC by Dr. X for cardiology consultation regarding preoperative evaluation for right hip surgery. She is a patient with a history of coronary artery disease status post bypass surgery in 1971 who tripped over her oxygen last p.m. she states and fell. She suffered a right hip fracture and is being considered for right hip replacement. The patient denies any recent angina, but has noted more prominent shortness of breath.,Past cardiac history is significant for coronary artery disease status post bypass surgery, she states in 1971, I believe it was single vessel. She has had stress test done in our office on September 10, 2008, which shows evidence of a small apical infarct, no area of ischemia, and compared to study of December of 2005, there is no significant change. She had a transthoracic echocardiogram done in our office on August 29, 2008, which showed normal left ventricular size and systolic function, dilated right ventricle with septal flattening of the left ventricle consistent with right ventricular pressure overload, left atrial enlargement, severe tricuspid regurgitation with estimated PA systolic pressure between 75-80 mmHg consistent with severe pulmonary hypertension, structurally normal aortic and mitral valve. She also has had some presumed atrial arrhythmias that have not been sustained. She follows with Dr. Y my partner at Cardiology Associates.,PAST MEDICAL HISTORY: ,Other medical history includes severe COPD and she is oxygen dependent, severe pulmonary hypertension, diabetes, abdominal aortic aneurysm, hypertension, dyslipidemia. Last ultrasound of her abdominal aorta done June 12, 2009 states that it was fusiform, infrarenal shaped aneurysm of the distal abdominal aorta measuring 3.4 cm unchanged from prior study on June 11, 2008.,MEDICATIONS:, As an outpatient:,1. Lanoxin 0.125 mg, 1/2 tablet once a day.,2. Tramadol 50 mg p.o. q.i.d. as needed.,3. Verapamil 240 mg once a day.,4. Bumex 2 mg once a day.,5. ProAir HFA.,6. Atrovent nebs b.i.d.,7. Pulmicort nebs b.i.d.,8. Nasacort 55 mcg, 2 sprays daily.,9. Quinine sulfate 325 mg p.o. q.h.s. p.r.n.,10. Meclizine 12.5 mg p.o. t.i.d. p.r.n.,11. Aldactone 25 mg p.o. daily.,12. Theo-24 200 mg p.o., 2 in the morning.,13. Zocor 40 mg once a day.,14. Vitamin D 400 units twice daily.,15. Levoxyl 125 mcg once a day.,16. Trazodone 50 mg p.o. q.h.s. p.r.n.,17. Janumet 50/500, 1 tablet p.o. b.i.d.,ALLERGIES: , To medications are listed as:,1. LEVAQUIN.,2. AZITHROMYCIN.,3. ADHESIVE TAPE.,4. BETA BLOCKERS. When I talked to the patient about the BETA BLOCKER, she states that they made her more short of breath in the past.,She denies shrimp, seafood or dye allergy.,FAMILY HISTORY: ,Significant for heart problems she states in her mother and father.,SOCIAL HISTORY: ,She used to smoke cigarettes and smoked from the age of 14 to 43 and quit at the time of her bypass surgery. She does not drink alcohol nor use illicit drugs. She lives alone and is widowed. She is a retired custodian at University. Of note, she is accompanied with her verbal consent by her daughter and grandson at the bedside.,REVIEW OF SYSTEMS: ,Unable to obtain as the patient is somnolent from her pain medication, but she is alert and able to answer my direct questions.,PHYSICAL EXAM: , Height 5'2"", weight 160 pounds, temperature is 99.5 degrees ranging up to 101.6, blood pressure 137/67 to 142/75, pulse 92, respiratory rate 16, O2 saturation 93-89%. On general exam, she is an elderly, chronically ill appearing woman in no acute distress. She is able to lie flat, she does have pain if she moves. HEENT shows the cranium is normocephalic, atraumatic. She has dry mucosal membranes. Neck veins are not distended. There are no carotid bruits. Visible skin is warm and she appears pale. Affect appropriate and she is somnolent from her pain medications, but arouses easily and answers my direct questions appropriately. Lungs are clear to auscultation anteriorly, no wheezes. Cardiac exam S1, S2 regular rate, soft holosystolic murmur heard over the tricuspid region. No rub nor gallop. PMI is nondisplaced, unable to appreciate RV heave. Abdomen soft, mildly distended, appears benign. Extremities with trivial peripheral edema. Pulses grossly intact. She has quite a bit of pain at the right hip fracture.,DIAGNOSTIC/LABORATORY DATA: ,Sodium 135, potassium 4.7, chloride 99, bicarbonate 33, BUN 22, creatinine 1.3, glucose 149, troponin was 0.01 followed by 0.04. Theophylline level 16.6 on January 23, 2009. TSH 0.86 on March 10, 2009. INR 1.06. White blood cell count 9.5, hematocrit 35, platelet count 160.,EKG done July 16, 2009 at 7:31:15, shows sinus rhythm, which showed PR interval of about 118 milliseconds, nonspecific T wave changes. When compared to EKG done July 15, 2009 at 1948, previously there more frequent PVCs seen. This ECG appears similar to the ones she has had done previously in our office including on June 11, 2009, although the T wave changes are a bit more prominent, which is a nonspecific finding.,IMPRESSION: , She is an 81-year-old woman with severe O2 requiring chronic obstructive pulmonary disease with evidence of right heart overload, as well as known coronary artery disease status post single-valve bypass in 1971 suffering a right hip fracture for whom a right hip replacement is being considered. I have had a long discussion with the patient, as well as her daughter and grandson at the bedside today. There are no clear absolute cardiac contraindications that I can see. Of note at the time of this dictation a chest x-ray report is pending. With that being said, however, she is extremely high risk more from a pulmonary than cardiac standpoint. We did also however review that untreated hip fractures themselves have very high morbidity and mortality incidences. The patient is deciding on surgery and is clearly aware that she is very high risk for proposed surgery, as well as if she were to not pursue surgery.,PLAN/RECOMMENDATIONS:,1. The patient is going to decide on surgery. If she does have the right hip surgery, I would recommend overnight observation in the intensive care unit.,2. Optimize pulmonary function and pursue aggressive DVT prophylaxis.,3. Continue digoxin and verapamil. Again, the patient describes clear INTOLERANCE TO BETA BLOCKERS by her history." Cardiovascular / Pulmonary Left hemothorax, rule out empyema. Insertion of a 12-French pigtail catheter in the left pleural space. Pigtail Catheter Insertion PREOPERATIVE DIAGNOSIS: ,Left hemothorax, rule out empyema.,POSTOPERATIVE DIAGNOSIS: , Left hemothorax rule out empyema.,PROCEDURE: , Insertion of a 12-French pigtail catheter in the left pleural space.,PROCEDURE DETAIL: ,After obtaining informed consent, the patient was taken to the minor OR in the Same Day Surgery where his posterior left chest was prepped and draped in a usual fashion. Xylocaine 1% was injected and then a 12-French pigtail catheter was inserted in the medial scapular line about the eighth intercostal space. It was difficult to draw fluid by syringe, but we connected the system to a plastic bag and by gravity started draining at least 400 mL while we were in the minor OR. Samples were sent for culture and sensitivity, aerobic and anaerobic.,The patient and I decided to admit him for a period of observation at least overnight.,He tolerated the procedure well and the postprocedure chest x-ray showed no complications. cardiovascular / pulmonary, chest, pleural space, pigtail catheter, insertion, empyema, hemothorax, Cardiovascular / Pulmonary Chest tube talc pleurodesis of the right chest. Pleurodesis 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. cardiovascular / pulmonary, chest tube talc pleurodesis, lateral decubitus position, decubitus position, talc pleurodesis, pleural effusion, chest tube, chest, pleurodesis, talc, recurrent, pleural, effusion, tube Cardiovascular / Pulmonary Ultrasound-guided right pleurocentesis for right pleural effusion with respiratory failure and dyspnea. Pleurocentesis 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. cardiovascular / pulmonary, pleural effusion, dyspnea, gliding sign, hemidiaphragm, pleural catheter, pleurocentesis, respiratory, serosanguinous fluid, ultrasound, pleural, Cardiovascular / Pulmonary A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation. Paroxysmal Atrial Fibrillation 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. Cardiovascular / Pulmonary Coil embolization of patent ductus arteriosus. Patent Ductus Arteriosus HISTORY: , The patient is a 5-1/2-year-old, who recently presented with a cardiac murmur diagnosed due to a patent ductus arteriosus. An echocardiogram from 09/13/2007 demonstrated a 3.8-mm patent ductus arteriosus with restrictive left-to-right shunt. There is mild left atrial chamber enlargement with an LA/AO ratio of 1.821. An electrocardiogram demonstrated normal sinus rhythm with possible left atrial enlargement and left ventricular hypertrophy. The patient underwent cardiac catheterization for device closure of a ductus arteriosus.,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 5-French sheath, a 5-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures up to the branch pulmonary arteries. The atrial septum was not probe patent.,Using a 4-French sheath, a 4-French marker pigtail catheter was inserted into the right femoral artery advanced retrograde to the descending aorta, ascending aorta, and left ventricle. A descending aortogram demonstrated a small, type A patent ductus arteriosus with a small left-to-right angiographic shunt. Minimal diameter was approximately 1.6 mm with ampulla diameter of 5.8 mm and length of 6.2 mm. The wedge catheter could be directed from the main pulmonary artery across the ductus arteriosus to the descending aorta. This catheter exchanged over wire for a 5-French nit-occlude delivery catheter through which a nit-occlude 6/5 flex coil that was advanced and allowed to reconfigure the descending aorta. Entire system was then brought into the ductal ampulla or one loop of coil was delivered in the main pulmonary artery. Once the stable device configuration was confirmed by fluoroscopy, device was released from the delivery catheter. Hemodynamic measurements and angiogram in the descending aorta were then repeated approximately 10 minutes following device implantation.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection in the descending aorta.,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 was normal with a slight increased saturation of the branch pulmonary arteries due to left-to-right shunt through the ductus arteriosus. The left-sided heart was fully saturated. The phasic right-sided and left-sided pressures were normal. The calculated systemic flow was normal and pulmonary flow was slightly increased with a QP:QS ratio of 1:1. Vascular resistances were normal. A cineangiogram with contrast injection in the descending aorta showed a small conical shaped ductus arteriosus with a small left-to-right angiographic shunt. The branch pulmonary arteries appeared normal. There is otherwise a normal left aortic arch.,Following coil embolization of the ductus arteriosus, there is no change in mixed venous saturation. No evidence of residual left-to-right shunt. There is no change in right-sided pressures. There is a slight increase in the left-sided phasic pressures. Calculated systemic flow was unchanged from the resting state and pulmonary flow was similar with a QP:QS ratio of 1:1. Final angiogram with injection in the descending aorta showed a majority of coil mass to be within the ductal ampulla with minimal protrusion in the descending aorta as well as the coil in the main pulmonary artery. There is a trace residual shunt through the center of coil mass.,INITIAL DIAGNOSES:, Patent ductus arteriosus.,SURGERIES (INTERVENTIONS): ,Coil embolization of patent ductus arteriosus.,MANAGEMENT: ,The case to be discussed at Combined Cardiology/Cardiothoracic Surgery case conference. The patient will require a cardiologic followup in 6 months and 1 year's time including clinical evaluation and echocardiogram. Further patient care be directed by Dr. X., cardiovascular / pulmonary, cardiac murmur, coil embolization, cineangiograms, patent ductus arteriosus, pulmonary artery, patent ductus, descending aorta, ductus, arteriosus, catheterization Cardiovascular / Pulmonary 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. PAF - 6-Month Followup 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. cardiovascular / pulmonary, atrial fibrillation, ekg, paroxysmal atrial fibrillation, chest pains, pedal edema, hyperthyroidism, paf, atrial, Cardiovascular / Pulmonary The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness. Low-grade fever was noted last few weeks. The patient also has chest pain described as dull aching type in precordial region. No relation to exertion or activity. No aggravating or relieving factors. Pericardial Effusion REASON FOR CONSULTATION:, Pericardial effusion.,HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness. Low-grade fever was noted last few weeks. The patient also has chest pain described as dull aching type in precordial region. No relation to exertion or activity. No aggravating or relieving factors. A CT of the chest was done, which shows pericardial effusion. This consultation is for the same. The patient denies any lightheadedness or dizziness. No presyncope or syncope. Activity is fairly stable.,CORONARY RISK FACTORS: , History of borderline hypertension. No history of diabetes mellitus. Nonsmoker. Cholesterol status is within normal limits. No history of established coronary artery disease. Family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,PAST SURGICAL HISTORY: ,Hysterectomy and bladder surgery.,MEDICATIONS AT HOME: ,Aspirin and thyroid supplementation.,ALLERGIES:, None.,PERSONAL HISTORY:, She is a nonsmoker. She does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY:,1. Hypothyroidism.,2. Borderline hypertension.,3. Arthritis.,4. Presentation at this time with chest pain and shortness of breath.,REVIEW OF SYSTEMS,CONSTITUTIONAL: Weakness, fatigue, and tiredness.,HEENT: No history of cataract, blurring of vision, or glaucoma.,CARDIOVASCULAR: Chest pain. No congestive heart failure. No arrhythmia.,RESPIRATORY: No history of pneumonia in the past, valley fever.,GASTROINTESTINAL: Epigastric discomfort. No hematemesis or melena.,UROLOGICAL: Frequency. No urgency. No hematuria.,MUSCULOSKELETAL: Arthritis and muscle weakness.,CNS: No TIA. No CVA. No seizure disorder.,ENDOCRINE: Nonsignificant.,HEMATOLOGICAL: Nonsignificant.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse of 86, blood pressure 93/54, afebrile, respiratory rate 16 per minute.,HEENT: Atraumatic and normocephalic.,NECK: Supple. Neck veins flat. No significant carotid bruit.,LUNGS: Air entry bilaterally fair.,HEART: PMI displaced. S1 and S2 regular.,ABDOMEN: Soft and nontender.,EXTREMITIES: No edema. Pulses palpable. No clubbing or cyanosis.,CNS: Grossly intact.,LABORATORY DATA: ,White count of 20 and H&H 13 and 39. BUN and creatinine within normal limits. Cardiac enzyme profile negative.,RADIOGRAPHIC STUDIES: , CT of the chest preliminary report, pericardial effusion. Echocardiogram shows pericardial effusion, which appears to be chronic. There is no evidence of hemodynamic compromise.,IMPRESSION:,1. The patient is an 84-year-old female admitted with chest pain and shortness of breath, possibly secondary to pulmonary disorder. She has elevated white count, possible infection.,2. Pericardial effusion without any hemodynamic compromise, could be chronic. Cardiovascular / Pulmonary Ligation (clip interruption) of patent ductus arteriosus. 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. Patent Ductus Arteriosus Ligation 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. cardiovascular / pulmonary, clip interruption, ligation, patent ductus arteriosus, premature baby, intercostal space, arteriosus, interruption, pulmonary, circulation Cardiovascular / Pulmonary PICC line insertion PICC line insertion PROCEDURE PERFORMED:, PICC line insertion.,DESCRIPTION OF PROCEDURE:, The patient was identified by myself on presentation to the angiography suite. His right arm was prepped and draped in sterile fashion from the antecubital fossa up. Under ultrasound guidance, a #21-gauge needle was placed into his right cephalic vein. A guidewire was then threaded through the vein and advanced without difficulty. An introducer was then placed over the guidewire. We attempted to manipulate the guidewire to the superior vena cava; however, we could not pass the point of the subclavian vein and we tried several maneuvers and then opted to do a venogram. What we did was we injected approximately 4 mL of Visipaque 320 contrast material through the introducer and did a mapping venogram and it turned out that the cephalic vein was joining into the subclavian vein. It was very tortuous area. We made several more attempts using the mapping system to pass the glide over that area, but we were unable to do that. Decision was made at that point then to just do a midline catheter. The catheter was cut to 20 cm, then we inserted back to the introducer. The introducer was removed. The catheter was secured by two #3-0 silk sutures. Appropriate imaging was then taken. Sterile dressing was applied. The patient tolerated the procedure nicely and was discharged from Angiography in satisfactory condition back to the general floor. We may make another attempt in the near future using a different approach., cardiovascular / pulmonary, picc, picc line, angiography, guidewire, superior vena cava, subclavian vein, venogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. Cardiovascular / Pulmonary Peripheral effusion on the CAT scan. The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy. She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis. Peripheral Effusion - Consult REASON FOR CONSULT: , Peripheral effusion on the CAT scan.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy. She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis. The patient had a visiting nurse for Christmas and started having abdominal pain, nausea and vomiting for which, she was admitted. She had a CAT scan of the abdomen done, showed moderate pericardial effusion for which cardiology consult was requested. She had an echo done, which shows moderate pericardial effusion with early tamponade. The patient has underlying shortness of breath because of COPD, emphysema and chronic cough. However, denies any dizziness, syncope, presyncope, palpitation. Denies any prior history of coronary artery disease.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , At this time, she is on hydromorphone p.r.n., erythromycin, ceftriaxone, calcium carbonate, Ambien. She is on oxygen and nebulizer.,PAST MEDICAL HISTORY: , History of COPD, emphysema, pneumonia, and lung cancer.,PAST SURGICAL HISTORY: ,Hip surgery and resection of the lung cancer 10 years ago.,SOCIAL HISTORY:, Still smokes, but less than before. Drinks socially.,FAMILY HISTORY:, Noncontributory.,REVIEW OF SYSTEMS: , Denies any syncope, presyncope, palpitations, shortness of breath, cough, nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,GENERAL: The patient is comfortable not in any distress.,VITAL SIGNS: Blood pressure 121/79, Pulse rate 94, respiratory rate 19, and temperature 97.6.,HEENT: Atraumatic and normocephalic.,NECK: Supple. No JVD. No carotid bruit.,CHEST: Breath sounds vesicular. Clear on auscultation.,HEART: PMI could not be localized. S2 and S2 regular. No S3, no S4. No murmur.,ABDOMEN: Soft and nontender. Positive bowel sounds.,EXTREMITIES: No cyanosis, clubbing, or edema. Pulse 2+.,CNS: Alert, awake, and oriented x3.,EKG shows normal sinus rhythm, low voltage.,LABORATORY DATA: , White cell count 7.3, hemoglobin 12.9, hematocrit 38.1, and platelet at 322,000. Sodium 135, potassium 5, BUN 6, creatinine 1.2, glucose 71, alkaline phosphatase 263, total protein 5.3, lipase 414, and amylase 57.,DIAGNOSTIC STUDIES:, Chest x-ray shows left upper lobe airspace disease consistent with pneumonia _______. CT abdomen showed diffuse replacement of the _______ metastasis, hepatomegaly, perihepatic ascites, moderate pericardial effusion, small left _______ sigmoid diverticulosis.,ASSESSMENT:,1. Moderate peripheral effusion with early tamponade, probably secondary to lung cancer.,2. Lung cancer with metastasis most likely.,3. Pneumonia.,4. COPD.,PLAN: , We will get CT surgery consult for pericardial window. Continue present medication. Cardiovascular / Pulmonary Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead. Right ventricular pacemaker lead placement and lead revision. Pacemaker Lead Placement & Rrevision. PROCEDURE: , Right ventricular pacemaker lead placement and lead revision.,INDICATIONS:, Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead.,EQUIPMENT: , A new lead is a Medtronic model #12345, threshold sensing at 5.7, impedance of 1032, threshold of 0.3, atrial threshold is 0.3, 531, and sensing at 4.1. The original chronic ventricular lead had a threshold of 3.5 and 6 on the can.,ESTIMATED BLOOD LOSS: , 5 mL.,PROCEDURE DESCRIPTION: ,Conscious sedation with Versed and fentanyl over left subclavicular area with pacemaker pocket was anesthetized with local anesthetic with epinephrine. The patient received a venogram documenting patency of the subclavian vein. Skin incision with blunt and sharp dissection. Electrocautery for hemostasis. The pocket was opened and the pacemaker was removed from the pocket and disconnected from the leads. The leads were sequentially checked. Through the pocket a puncture of the vein with a thin wall needle was made and a long sheath was used to help carry it along the tortuosity of the proximal subclavian and innominate superior vena cava. Ultimately, a ventricular lead was placed in apex of the right ventricle, secured to base pocket with 2-0 silk suture. Pocket was irrigated with antibiotic solution. The pocket was packed with bacitracin-soaked gauze. This was removed during the case and then irrigated once again. The generator was attached to the leads, placed in the pocket, secured with 2-0 silk suture and the pocket was closed with a three layer of 4-0 Monocryl.,CONCLUSION: , Successful replacement of a right ventricular lead secondary to poor lead thresholds in a chronic lead and placement of the previous Vitatron pulse generator model # 12345. cardiovascular / pulmonary, medtronic, atrial, subclavian, sick sinus syndrome, pacemaker lead placement, ventricular pacemaker, ventricular lead, lead, bradycardia, pacemaker, threshold, ventricular Cardiovascular / Pulmonary Nuclear cardiac stress report. Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy. Nuclear Cardiac Stress Report NUCLEAR CARDIOLOGY/CARDIAC STRESS REPORT,INDICATION FOR STUDY: , Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.,PROCEDURE: , The patient was studied in the resting state following intravenous delivery of adenosine triphosphate at 140 mcg/kg/min delivered over a total of 4 minutes. At completion of the second minute of infusion, the patient received technetium Cardiolite per protocol. During this interval, the blood pressure 150/86 dropped to near 136/80 and returned to near 166/84 at completion. No diagnostic electrocardiographic abnormalities were elaborated during this study.,REGIONAL MYOCARDIAL PERFUSION WITH ADENOSINE PROVOCATION: , Scintigraphic study reveals at this time multiple fixed defects in perfusion suggesting indeed multivessel coronary artery disease, yet no active ischemia at this time. A fixed defect is seen in the high anterolateral segment. A further fixed perfusion defect is seen in the inferoapical wall extending from close to the septum. There is no evidence for active ischemia in either distribution. Lateral wall moving towards the apex of the left ventricle is further involved from midway through the ventricle moving upward and into the high anterolateral vicinity. When viewed from the vertical projection, the high septal wall is preserved with significant loss of the mid anteroapical wall moving to the apex and in a wraparound fashion in the inferoapical wall. A limited segment of apical myocardium is still viable.,No gated wall motion study was obtained.,CONCLUSIONS: ,Cardiolite perfusion findings support multivessel coronary artery disease and likely previous multivessel infarct as has been elaborated above. There is no indication for active ischemia at this time. cardiovascular / pulmonary, angina pectoris, ischemic cardiomyopathy, myocardial perfusion, adenosine provocation, cardiolite perfusion, nuclear cardiac stress report, coronary artery disease, active ischemia, ischemic, angina, Cardiovascular / Pulmonary Implantation of a dual-chamber pacemaker and fluoroscopic guidance for implantation of a dual-chamber pacemaker. Pacemaker (Dual Chamber) - 1 PREPROCEDURE DIAGNOSIS: , Complete heart block.,POSTPROCEDURE DIAGNOSIS: ,Complete heart block.,PROCEDURES PLANNED AND PERFORMED,1. Implantation of a dual-chamber pacemaker.,2. Fluoroscopic guidance for implantation of a dual-chamber pacemaker.,FLUOROSCOPY TIME: , 2.6 minutes.,MEDICATIONS AT THE TIME OF STUDY,1. Versed 2.5 mg.,2. Fentanyl 150 mcg.,3. Benadryl 50 mg.,CLINICAL HISTORY: , the patient is a pleasant 80-year-old female who presented to the hospital with complete heart block. She has been referred for a pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives to implantation of a dual-chamber pacemaker were discussed with the patient. The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state. The region of the left deltopectoral groove was prepped and draped in the usual sterile manner. Lidocaine 1% (20 mL) was administered to the area. After achieving appropriate anesthesia, percutaneous access of the left axillary vein was then performed under fluoroscopy. A guide wire was advanced into the vein. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Hemostasis was achieved with electrocautery. Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision. A pocket was then fashioned in the medial direction. Using the previously placed wire, a 7-French side-arm sheath was advanced over the wire into the left axillary vein. The dilator was then removed over the wire. A second wire was then advanced into the sheath into the left axillary vein. The sheath was then removed over the top of the two wires. One wire was then pinned to the drape. Using the remaining wire, a 7 French side-arm sheath was advanced back into the left axillary vein. The dilator and wire were removed. A passive pacing lead was then advanced down into the right atrium. The peel-away sheath was removed. The lead was then passed across the tricuspid valve and positioned in the apical location. Adequate pacing and sensing functions were established. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. With the remaining wire, a 7-French side-arm sheath was advanced over the wire into the axillary vein. The wire and dilating sheaths were removed. An active pacing lead was then advanced down into the right atrium. The peel-away sheath was removed. Preformed J stylet was then advanced into the lead. The lead was positioned in the appendage location. Lead body was then turned, and the active fix screw was fixed to the tissue. Adequate pacing and sensing function were established. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. The pocket was then washed with antibiotic-impregnated saline. Pulse generator was obtained and connected securely to the leads. The leads were then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket. The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. Sponge and needle counts were correct at the end of the procedure. No acute complications were noted.,DEVICE DATA,1. Pulse generator, manufacturer Boston Scientific, model # 12345, serial #1234.,2. Right atrial lead, manufacturer Guidant, model #12345, serial #1234.,3. Right ventricular lead, manufacturer Guidant, model #12345, serial #1234.,MEASURED INTRAOPERATIVE DATA,1. Right atrial lead impedance 534 ohms. P waves measured at 1.2 millivolts. Pacing threshold 1.0 volt at 0.5 milliseconds.,2. Right ventricular lead impedance 900 ohms. R-waves measured 6.0 millivolts. Pacing threshold 1.0 volt at 0.5 milliseconds.,DEVICE SETTINGS: , DDD 60 to 130.,CONCLUSIONS,1. Successful implantation of a dual-chamber pacemaker with adequate pacing and sensing function.,2. No acute complications.,PLAN,1. The patient will be taken back to her room for continued observation. She can be dismissed in 24 hours provided no acute complications at the discretion of the primary service.,2. Chest x-ray to rule out pneumothorax and verified lead position.,3. Completion of the course of antibiotics.,4. Home dismissal instructions provided in written format.,5. Device interrogation in the morning.,6. Wound check in 7 to 10 days.,7. Enrollment in device clinic. Cardiovascular / Pulmonary Insertion of transvenous pacemaker for tachybrady syndrome Pacemaker Insertion 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. cardiovascular / pulmonary, insertion of transvenous pacemaker, fluoroscopy, tachybrady, tachybrady syndrome, chest, pacemaker, subclavian, subcutaneous, superior vena cava, syndrome, transvenous pacemaker, wire, insertion, Cardiovascular / Pulmonary DDDR permanent pacemaker. Tachybrady syndrome. A ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium. Pacemaker - DDDR PROCEDURE PERFORMED: ,DDDR permanent pacemaker.,INDICATION: , Tachybrady syndrome.,PROCEDURE:, After all risks, benefits, and alternatives of the procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. The patient was taken to the Cardiac Catheterization Suite where the right subclavian region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the left subclavian vein. Once adequate anesthesia had been obtained, a thin-walled #18-gauze Argon needle was used to cannulate the left subclavian vein. A steel guidewire was inserted through the needle into the vascular lumen without resistance. The needle was then removed over the guidewire and the guidewire was secured to the field. A second #18 gauze Argon needle was used to cannulate the left subclavian vein and once again a steel guidewire was inserted through the needle into the vascular lumen. Likewise, the needle was removed over the guidewire and the guidewire was then secured to the field. Next, a #15-knife blade was used to make a 1 to 1.5 inch linear incision over the area. A #11-knife blade was used to make a deeper incision. Hemostasis was made complete. The edges of the incision were grasped and retracted. Using Metzenbaum scissors, dissection was carried down to the pectoralis muscle fascial plane. Digital blunt dissection was used to make a pacemaker pocket large enough to accommodate the pacemaker generator. Metzenbaum scissors were then used to dissect cephalad to expose the guide wires. The guidewires were then pulled through the pacemaker pocket. One guidewire was secured to the field.,A bloodless introducer sheath was then advanced over a guidewire into the vascular lumen under fluoroscopic guidance. The guidewire and dilator were then removed. Next, a ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium. The pacemaker lead was then placed in the appropriate position in the right ventricle. Pacing and sensing thresholds were obtained. The lead was sewn at the pectoralis muscle plane using #2-0 silk suture in an interrupted stitch fashion around the ________. Pacing and sensing threshold were then reconfirmed. Next, a second bloodless introducer sheath was advanced over the second guidewire into the vascular lumen. The guidewire and dilator were then removed. Under fluoroscopic guidance, the atrial lead was passed into the right atrium. The sheath was then turned away in standard fashion. Using fluoroscopic guidance, the atrial lead was then placed in the appropriate position. Pacing and sensing thresholds were obtained. The lead was sewn to the pectoralis muscle facial plane utilizing #2-0 silk suture around the ________. Sensing and pacing thresholds were then reconfirmed. The leads were wiped free of blood and placed into the pacemaker generator. The pacemaker generator leads were then placed into pocket with the leads posteriorly. The deep tissues were closed utilizing #2-0 Chromic suture in an interrupted stitch fashion. A #4-0 undyed Vicryl was then used to close the subcutaneous tissue in a continuous subcuticular stitch. Steri-Strips overlaid. A sterile gauge dressing was placed over the site. The patient tolerated the procedure well and was transferred to the Cardiac Catheterization Room in stable and satisfactory condition.,PACEMAKER DATA (GENERATOR DATA):,Manufacturer: Medtronics.,Model: Sigma.,Model #: 1234.,Serial #: 123456789.,LEAD INFORMATION:,Right Atrial Lead:,Manufacturer: Medtronics.,Model #: 1234.,Serial #: 123456789.,VENTRICULAR LEAD:,Manufacturer: Medtronics.,Model #: 1234.,Serial #: 123456789.,PACING AND SENSING THRESHOLDS:,Right Atrial Bipolar Lead: Pulse width 0.50 milliseconds, impedance 518 ohms, P-wave sensing 2.2 millivolts, polarity is bipolar.,Ventricular Bipolar Lead: Pulse width 0.50 milliseconds, voltage 0.7 volts, current 1.5 milliamps, impedance 655 ohms, R-wave sensing 9.7 millivolts, polarity is bipolar.,PARAMETER SETTINGS:, Pacing mode DDDR: Mode switch is on, low rate 60, upper 120, ________ is 33.0 milliseconds.,IMPRESSION:, Successful implantation of DDDR permanent pacemaker.,PLAN:,1. The patient will be monitored on telemetry for 24 hours to ensure adequate pacemaker function.,2. The patient will be placed on antibiotics for five days to avoid pacemaker infection. Cardiovascular / Pulmonary Implantation of a single-chamber pacemaker. Fluoroscopic guidance for implantation of single-chamber pacemaker. Pacemaker (Single Chamber) - 1 REFERRAL INDICATION,1. Tachybrady syndrome.,2. Chronic atrial fibrillation.,PROCEDURES PLANNED AND PERFORMED,1. Implantation of a single-chamber pacemaker.,2. Fluoroscopic guidance for implantation of single-chamber pacemaker.,FLUOROSCOPY TIME: ,1.2 minutes.,MEDICATIONS AT THE TIME OF STUDY,1. Ancef 1 g.,2. Benadryl 50 mg.,3. Versed 3 mg.,4. Fentanyl 150 mcg.,CLINICAL HISTORY: , The patient is a pleasant 73-year-old female with chronic atrial fibrillation. She has been found to have tachybrady syndrome, has been referred for pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives of implantation of a single-chamber pacemaker were discussed with the patient. The patient agreed both verbally and via written consent. Risks that were discussed included but were not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, need for urgent cardiovascular surgery, and death were discussed with the patient. The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in a fasting state. The region of the left deltopectoral groove was prepped and draped in the usual sterile manner. Lidocaine 1% (20 mL) was administered to the area. Percutaneous access of the left axillary vein was then performed. A wire was then advanced in the left axillary vein using fluoroscopy. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision and a pocket was fashioned in the medial direction. Using the previously placed guidewire, a 7-French sidearm sheath was advanced over the wire into the vein. The dilator and wire were removed. An active pacing lead was then advanced down in the right atrium. The peel-away sheath was removed. Lead was passed across the tricuspid valve and positioned in an apical septal location. This was an active fixed lead and the screw was deployed. Adequate pacing and sensing function were established. The suture sleeve was then advanced to the entry point of the tissue and connected securely to the tissue. The pocket was washed with antibiotic-impregnated saline. A pulse generator was obtained and connected securely to the lead. The lead was then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket. Pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. No acute complications were noted.,DEVICE DATA,1. Pulse generator, manufacturer St. Jude model 12345, serial #123456.,2. Right ventricular lead, manufacturer St. Jude model 12345, serial #ABCD123456.,MEASURED INTRAOPERATIVE DATA:, Right ventricular lead impedance 630 ohms. R wave measures 17.5 mV. Pacing threshold of 0.8 V at 0.5 msec.,DEVICE SETTINGS: , VVI 70 to 120.,CONCLUSIONS,1. Successful implantation of the single-chamber pacemaker with adequate pacing and sensing function.,2. No acute complications.,PLAN,1. The patient will be admitted for overnight observation and dismissed at the discretion of primary service.,2. Chest x-ray to rule out pneumothorax and verify lead position.,3. Completion of course of antibiotics.,4. Device interrogation in the morning.,5. Home dismissal instructions provided in a written format.,6. Wound check in 7 to 10 days.,7. Enrollment in Device Clinic. Cardiovascular / Pulmonary Pacemaker ICD interrogation. Severe nonischemic cardiomyopathy with prior ventricular tachycardia. Pacemaker Interrogation PROCEDURE NOTE: , Pacemaker ICD interrogation.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old gentleman who was admitted to the hospital. He has had ICD pacemaker implantation. This is a St. Jude Medical model current DRRS, 12345 pacemaker.,DIAGNOSIS: , Severe nonischemic cardiomyopathy with prior ventricular tachycardia.,FINDINGS: , The patient is a DDD mode base rate of 60, max tracking rate of 110 beats per minute, atrial lead is set at 2.5 volts with a pulse width of 0.5 msec, ventricular lead set at 2.5 volts with a pulse width of 0.5 msec. Interrogation of the pacemaker shows that atrial capture is at 0.75 volts at 0.5 msec, ventricular capture 0.5 volts at 0.5 msec, sensing in the atrium is 5.34 to 5.8 millivolts, R sensing is 12-12.0 millivolts, atrial lead impendence 590 ohms, ventricular lead impendence 750 ohms. The defibrillator portion is set at VT1 at 139 beats per minute with SVT discrimination on therapy is monitor only. VT2 detection criteria is 169 beats per minute with SVT discrimination on therapy of ATP times 3 followed by 25 joules, followed by 36 joules, followed by 36 joules times 2. VF detection criteria set at 187 beats per minute with therapy of 25 joules, followed by 36 joules times 5. The patient is in normal sinus rhythm.,IMPRESSION: ,Normally functioning pacemaker ICD post implant day number 1. cardiovascular / pulmonary, cardiomyopathy, ventricular, tachycardia, pacemaker icd interrogation, millivolts, impendence, interrogation, pacemaker, Cardiovascular / Pulmonary Single chamber pacemaker implantation. 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. Pacemaker (Single Chamber) 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. cardiovascular / pulmonary, mobitz, av dissociation, syncope, mobitz type ii block, boston scientific altrua, subclavian, venogram, ventricular, single chamber pacemaker implantation, single chamber pacemaker, pacemaker implantation, pacemaker, vein, chest, atrium, ventricle, atrial, implantation, chamber, Cardiovascular / Pulmonary A patient with non-Q-wave myocardial infarction. No definite chest pains. The patient is breathing okay. The patient denies orthopnea or PND. Non-Q-wave Myocardial Infarction REASON FOR CONSULT: , A patient with non-Q-wave myocardial infarction.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 52-year-old gentleman with a history of diabetes mellitus, hypertension, and renal failure, on dialysis, who presented with emesis, dizziness, and nausea for the last few weeks. The patient reports having worsening emesis and emesis a few times. No definite chest pains. The patient is breathing okay. The patient denies orthopnea or PND.,PAST MEDICAL HISTORY:,1. Diabetes mellitus.,2. Hypertension.,3. Renal failure, on dialysis.,MEDICATIONS:, Aspirin, Coreg, doxazosin, insulin, metoclopramide, simvastatin, and Starlix.,ALLERGIES: ,NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies tobacco, alcohol or drug use.,FAMILY HISTORY: , Negative for early atherosclerotic heart disease.,REVIEW OF SYSTEMS: , General: The patient denies fever or chills. Pulmonary: The patient denies hemoptysis. Cardiovascular: Refer to HPI. GI: The patient denies hematemesis or melena. The rest of systems review is negative.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse 71, blood pressure 120/70, and respiratory rate 18.,GENERAL: A well-nourished, well-developed male in no acute distress.,HEENT: Normocephalic, atraumatic. Pupils seem to be equal, round, and reactive. Extraocular muscles are full, but the patient has left eye ptosis.,NECK: Supple without JVD or lymphadenopathy.,LUNGS: Clear to auscultation bilaterally.,CARDIOVASCULAR: PMI is displaced 0.5 cm lateral to the midclavicular line. Regular rate and rhythm, S1, S2. No definite S3, 2/6 holosystolic murmur at the apex radiating to the axilla.,ABDOMEN: Positive bowel sounds, nondistended and nontender. No hepatosplenomegaly.,EXTREMITIES: Trace pedal edema.,EKG shows atrial fibrillation with rapid ventricular response at 164 with old anteroseptal myocardial infarction and old inferior wall myocardial infarction. Subsequent EKG in sinus rhythm shows sinus rhythm with old inferior wall myocardial infarction and probable anteroseptal myocardial infarction with Q-waves in V1, V2, and up to V3.,LABORATORY EXAM: , WBC 28,800, hemoglobin 13.6, hematocrit 40, and platelets 266,000. PT 11.3, INR 1.1, and PTT 24.1. Sodium 126, potassium 4.3, chloride 86, CO2 26, glucose 371, BUN 80, and creatinine 8.4. CK was 261, then 315, and then 529 with CK-MB of 8.06, then 8.69, and then 24.6. Troponin was 0.051, then 0.46, and then 19.8 this morning.,IMPRESSION:,1. Paroxysmal atrial fibrillation. The heart rate was slowed down with IV Cardizem, the patient converted to sinus rhythm. The patient is currently in sinus rhythm.,2. Emesis. The etiology is unclear. The patient reports that the emesis is better. The patient is just having some nausea.,3. Non-Q-wave myocardial infarction. EKG shows atrial fibrillation with old anteroseptal myocardial infarction and old inferior wall myocardial infarction.,4. Diabetes mellitus.,5. Renal failure.,6. Hypertension.,7. Hypercholesterolemia.,PLAN:,1. We will start amiodarone to keep from going back into atrial fibrillation.,2. Echocardiogram.,3. Aspirin and IV heparin.,4. Serial CK-MB and troponin.,5. Cardiac catheterization, possible percutaneous coronary intervention. The risks, benefits, and alternatives were explained to the patient through a translator. The patient understands and wishes to proceed.,6. IV Integrilin. Cardiovascular / Pulmonary Implantation of a dual chamber permanent pacemaker Pacemaker (Dual Chamber) 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. cardiovascular / pulmonary, medtronic enrhythm, cephalic vein, dual chamber, dual chamber permanent pacemaker, dyspnea on exertion, echocardiogram, fatigue, hypertension, lightheadedness, normal sinus rhythm, pacemaker, permanent pacemaker, sinoatrial exit block, sinus bradycardia, valvular heart disease, bradycardia, medtronic, atrial, Cardiovascular / Pulmonary Myocardial perfusion imaging - patient with history of MI, stents placement, and chest pain. Myocardial Perfusion Imaging - 1 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. cardiovascular / pulmonary, myocardial perfusion imaging, bruce protocol, cardiolite, ekg, mets, mi, spect, st-t, bigeminy, blood pressure, chest pain, exercise tolerance, myocardial perfusion, normal sinus rhythm, peak workload, sestamibi, stents, stress, tachycardia, ventricular, ventricular cavity, stress myocardial perfusion, perfusion imaging, myocardial, perfusion, mci, hypokinesis, imaging, Cardiovascular / Pulmonary Myocardial perfusion imaging - patient had previous abnormal stress test. Stress test with imaging for further classification of CAD and ischemia. Myocardial Perfusion Imaging - 2 CLINICAL HISTORY: , This is a 64-year-old male patient, who had a previous stress test, which was abnormal and hence has been referred for a stress test with imaging for further classification of coronary artery disease and ischemia.,PERTINENT MEDICATIONS:, Include Tylenol, Robitussin, Colace, Fosamax, multivitamins, hydrochlorothiazide, Protonix and flaxseed oil.,With the patient at rest 10.5 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 4 minutes and 41 seconds on the standard Bruce protocol. The peak workload was 7 METs. The resting heart rate was 61 beats per minute and the peak heart rate was 173 beats per minute, which was 85% of the age-predicted maximum heart rate response. The blood pressure response was normal with the resting blood pressure 126/86, and the peak blood pressure of 134/90. EKG at rest showed normal sinus rhythm with a right-bundle branch block. The peak stress EKG was abnormal with 2 mm of ST segment depression in V3 to V6, which remained abnormal till about 6 to 8 minutes into recovery. There were occasional PVCs, but no sustained arrhythmia. The patient had an episode of supraventricular tachycardia at peak stress. The ischemic threshold was at a heart rate of 118 beats per minute and at 4.6 METs. 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 images.,MYOCARDIAL PERFUSION IMAGING:,1. The overall quality of the scan was fair in view of increased abdominal uptake, increased bowel uptake seen.,2. There was a large area of moderate to reduced tracer concentration seen in the inferior wall and the inferior apex. This appeared to be partially reversible in the resting images.,3. The left ventricle appeared normal in size.,4. Gated SPECT images revealed normal wall motion and normal left ventricular systolic function with normal wall thickening. The calculated ejection fraction was 70% at rest.,CONCLUSIONS:,1. Average exercise tolerance.,2. Adequate cardiac stress.,3. Abnormal EKG response to stress, consistent with ischemia. No symptoms of chest pain at rest.,4. Myocardial perfusion imaging was abnormal with a large-sized, moderate intensity partially reversible inferior wall and inferior apical defect, consistent with inferior wall ischemia and inferior apical ischemia.,5. The patient had run of SVT at peak stress.,6. Gated SPECT images revealed normal wall motion and normal left ventricular systolic function. cardiovascular / pulmonary, stress test, arrhythmia, baseline heart rate, bruce, chest pain, mets, protocol, peak heart rate, spect, st segment response, svt, aerobic capacity, blood pressure, exercise, heart rate, ischemia, ventricular systolic function, myocardial perfusion imaging, cardiolite technetium, inferior apical, myocardial perfusion, perfusion imaging, stress, myocardial, imaging, perfusion Cardiovascular / Pulmonary Myocardial perfusion study at rest and stress, gated SPECT wall motion study at stress and calculation of ejection fraction. Myocardial Perfusion Imaging - 3 DIAGNOSIS: ,Shortness of breath. Fatigue and weakness. Hypertension. Hyperlipidemia.,INDICATION: , To evaluate for coronary artery disease., cardiovascular / pulmonary, myocardial perfusion imaging, spect wall motion study at stress, rest and stress, perfusion study at rest, calculation of ejection fraction, normal left ventricular wall, spect wall motion study, ventricular wall motion, myocardial perfusion study, perfusion imaging, blood pressure, nonspecific st, ventricular wall, gated spect, spect wall, motion study, stress test, heart rate, ejection fraction, myocardial perfusion, technetium, tetrofosmin, ischemia, ekg, imaging, spect, heart, ventricular, mci, resting, perfusion, stress, myocardial, Cardiovascular / Pulmonary Multiple stent placements with Impella circulatory assist device. Multiple Stent Placements 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. cardiovascular / pulmonary, impella circulatory assist device, impella assist device, unstable angina, congestive heart failure, heart catheterization, ventriculogram, aortogram, angiogram, ventricular dysfunction, pigtail catheter was advanced, femoral artery and vein, artery and vein, asahi soft wire, circumflex coronary artery, common femoral artery, modified seldinger technique, multiple stent placements, timi flow, multiple stent, impella circulatory, french sheath, femoral artery, endeavor stent, descending artery, coronary artery, common femoral, asahi soft, anterior descending, femoral, coronary, artery, impella, catheterization, Cardiovascular / Pulmonary Resting Myoview perfusion scan and gated myocardial scan. Findings consistent with an inferior non-transmural scar Myoview Perfusion Scan 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. cardiovascular / pulmonary, myoview perfusion scan, rest study, spect imaging, dobutamine myoview stress test, ejection fraction, gated myocardial scan, hypokinesis, ventricular systolic function, resting myoview perfusion scan, myoview stress test, resting myoview, myocardial perfusion, myoview perfusion, perfusion scan, myocardial scan, myocardial, myoview, perfusion Cardiovascular / Pulmonary MRI: Right parietal metastatic adenocarcinoma (LUNG) metastasis. MRI of Lung - Adenocarcinoma "CC:, Found unresponsive.,HX: , 39 y/o RHF complained of a severe HA at 2AM 11/4/92. It was unclear whether she had been having HA prior to this. She took an unknown analgesic, then vomited, then lay down in bed with her husband. When her husband awoke at 8AM he found her unresponsive with ""stiff straight arms"" and a ""strange breathing pattern."" A Brain CT scan revealed a large intracranial mass. She was intubated and hyperventilated to ABG (7.43/36/398). Other local lab values included: WBC 9.8, RBC 3.74, Hgb 13.8, Hct 40.7, Cr 0.5, BUN 8.5, Glucose 187, Na 140, K 4.0, Cl 107. She was given Mannitol 1gm/kg IV load, DPH 20mg/kg IV load, and transferred by helicopter to UIHC.,PMH:, 1)Myasthenia Gravis for 15 years, s/p Thymectomy,MEDS:, Imuran, Prednisone, Mestinon, Mannitol, DPH, IV NS,FHX/SHX:, Married. Tobacco 10 pack-year; quit nearly 10 years ago. ETOH/Substance Abuse unknown.,EXAM:, 35.8F, 99BPM, BP117/72, Mechanically ventilated at a rate of 22RPM on !00%FiO2. Unresponsive to verbal stimulation. CN: Pupils 7mm/5mm and unresponsive to light (fixed). No spontaneous eye movement or blink to threat. No papilledema or intraocular hemorrhage noted. Trace corneal reflexes bilaterally. No gag reflex. No oculocephalic reflex. MOTOR/SENSORY: No spontaneous movement. On noxious stimulation (Deep nail bed pressure) she either extended both upper extremities (RUE>LUE), or withdrew the stimulated extremity (right > left). Gait/Station/Coordination no tested. Reflexes: 1+ on right and 2+ on left with bilateral Babinski signs.,HCT 11/4/92: Large heterogeneous mass in the right temporal-parietal region causing significant parenchymal distortion and leftward subfalcine effect . There is low parenchymal density within the white matter. A hyperdense ring lies peripherally and may represent hemorrhage or calcification. The mass demonstrates inhomogeneous enhancement with contrast.,COURSE:, Head of bed elevated to 30 degrees, Mannitol and DPH were continued. MRI of Brain demonstrated a large right parietal mass with necrotic appearing center and leftward shift of midline structures. She underwent surgical resection of the tumor. Pathological analysis was consistent with adenocarcinoma. GYN exam, CT Abdomen and Pelvis, Bone scan were unremarkable. CXR revealed an right upper lobe lung nodule. She did not undergo thoracic biopsy due to poor condition. She received 3000 cGy cranial XRT in ten fractions and following this was discharged to a rehabilitation center.,In March, 1993 the patient exhibited right ptosis, poor adduction and abduction OD, 4/4 strength in the upper extremities and 5-/5- strength in the lower extremities. She was ambulatory with an ataxic gait.,She was admitted on 7/12/93 for lower cervical and upper thoracic pain, paraparesis and T8 sensory level. MRI brainstem/spine on that day revealed decreased T1 signal in the C2, C3, C6 vertebral bodies, increased T2 signal in the anterior medulla, and tectum, and spinal cord (C7-T3). Following injection of Gadolinium there was diffuse leptomeningeal enhancement from C7-T7 These findings were felt consistent with metastatic disease including possible leptomeningeal spread. Neurosurgery and Radiation Oncology agreed that the patients symptoms could be due to either radiation injury and/or metastasis. The patient was treated with Decadron and analgesics and discharged to a hospice center (her choice). She died a few months later." cardiovascular / pulmonary, mri, lung, metastatic adenocarcinoma, parietal, breathing pattern, cranial xrt, t1 signal, sensory level, iv load, adenocarcinoma, metastatic, leptomeningeal Cardiovascular / Pulmonary " Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, and congestive heart failure." Multiple Medical Problems - Discharge Summary ADMISSION DIAGNOSES:,1. Seizure.,2. Hypoglycemia.,3. Anemia.,4. Hypotension.,5. Dyspnea.,6. Edema.,DISCHARGE DIAGNOSES:,1. Colon cancer, status post right hemicolectomy.,2. Anemia.,3. Hospital-acquired pneumonia.,4. Hypertension.,5. Congestive heart failure.,6. Seizure disorder.,PROCEDURES PERFORMED:,1. Colonoscopy.,2. Right hemicolectomy.,HOSPITAL COURSE: , The patient is a 59-year-old female with multiple medical problems including diabetes mellitus requiring insulin for 26 years, previous MI and coronary artery disease, history of seizure disorder, GERD, bipolar disorder, and anemia. She was admitted due to a seizure and myoclonic jerks as well as hypoglycemia and anemia. Regarding the seizure disorder, Neurology was consulted. Noncontrast CT of the head was negative. Neurology felt that the only necessary intervention at that time would be to increase her Lamictal to 150 mg in the morning and 100 mg in the evening with gradual increase of the dosage until she was on 200 mg b.i.d. Regarding the hypoglycemia, the patient has diabetic gastroparesis and was being fed on J-tube intermittent feedings throughout the night at the rate of 120 an hour. Her insulin pump had a basal rate of roughly three at night during the feedings. While in the hospital, the insulin pump rate was turned down to 1.5 and then subsequently decreased a few other times. She seemed to tolerate the insulin pump rate well throughout her hospital course. There were a few episodes of hypoglycemia as well as hyperglycemia, but the episode seem to be related to the patient's n.p.o. status and the changing rates of tube feedings throughout her hospital course.,At discharge, her endocrinologist was contacted. It was decided to change her insulin pump rate to 3 units per hour from midnight till 6 a.m., from 0.8 units per hour from 6 a.m. until 8 a.m., and then at 0.2 units per hour from 8 a.m. until 6 p.m. The insulin was to be NovoLog. Regarding the anemia, the gastroenterologists were consulted regarding her positive Hemoccult stools. A colonoscopy was performed, which found a mass at the right hepatic flexure. General Surgery was then consulted and a right hemicolectomy was performed on the patient. The patient tolerated the procedure well and tube feeds were slowly restarted following the procedure, and prior to discharge were back at her predischarge rates of 120 per hour. Regarding the cancer itself, it was found that 1 out of 53 nodes were positive for cancer. CT of the abdomen and pelvis revealed no metastasis, a CT of the chest revealed possible lung metastasis. Later in hospital course, the patient developed a septic-like picture likely secondary to hospital-acquired pneumonia. She was treated with Zosyn, Levaquin, and vancomycin, and tolerated the medications well. Her symptoms decreased and serial chest x-rays were followed, which showed some resolution of the illness. The patient was seen by the Infectious Disease specialist. The Infectious Disease specialist recommended vancomycin to cover MRSA bacteria, which was found at the J-tube site. At discharge, the patient was given three additional days of p.o. Levaquin 750 mg as well as three additional days of Bactrim DS every 12 hours. The Bactrim was used to cover the MRSA at the J-tube site. It was found that MRSA was sensitive to Bactrim. Throughout her hospital course, the patient continued to receive Coreg 12.5 mg daily and Lasix 40 mg twice a day for her congestive heart failure, which remains stable. She also received Lipitor for her high cholesterol. Her seizure disorder remained stable and she was discharged on a dose of 100 mg in the morning and 150 mg at night. The dosage increases can begin on an outpatient basis.,DISCHARGE INSTRUCTIONS/MEDICATIONS: , The patient was discharged to home. She was told to shy away from strenuous activity. Her discharge diet was to be her usual diet of isotonic fiber feeding through the J-tube at a rate of 120 per hour throughout the night. The discharge medications were as follows:,1. Coreg 12.5 mg p.o. b.i.d.,2. Lipitor 10 mg p.o. at bedtime.,3. Nitro-Dur patch 0.3 mg per hour one patch daily.,4. Phenergan syrup 6.25 mg p.o. q.4h. p.r.n.,5. Synthroid 0.175 mg p.o. daily.,6. Zyrtec 10 mg p.o. daily.,7. Lamictal 100 mg p.o. daily.,8. Lamictal 150 mg p.o. at bedtime.,9. Ferrous sulfate drops 325 mg, PEG tube b.i.d.,10. Nexium 40 mg p.o. at breakfast.,11. Neurontin 400 mg p.o. t.i.d.,12. Lasix 40 mg p.o. b.i.d.,13. Fentanyl 50 mcg patch transdermal q.72h.,14. Calcium and vitamin D combination, calcium carbonate 500 mg/vitamin D 200 units one tab p.o. t.i.d.,15. Bactrim DS 800mg/160 mg tablet one tablet q.12h. x3 days.,16. Levaquin 750 mg one tablet p.o. x3 days.,The medications listed above, one listed as p.o. are to be administered via the J-tube.,FOLLOWUP: ,The patient was instructed to see Dr. X in approximately five to seven days. She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X. She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer. She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes. We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment. She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube.,CONDITION ON DISCHARGE: , Stable. Cardiovascular / Pulmonary A female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever. Murmur & Bacteremia. REASON FOR CONSULTATION: , New murmur with bacteremia.,HISTORY OF PRESENT ILLNESS:, The patient is an 84-year-old female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever. The patient states that apart from the fever, she was having no other symptoms and denies any previous cardiac history. She denies any orthopnea or paroxysmal nocturnal dyspnea. Denies any edema, chest pain, palpitations, or syncope. She has had TIAs in the past, but none recently.,PAST MEDICAL HISTORY:, Significant for diabetes, hypertension, and TIA.,MEDICATIONS: , Include:,1. Acidophilus supplement.,2. Cholestyramine.,3. Creon 20 three times daily.,4. Diovan 160 mg twice daily.,6. Lantus 10 daily.,7. Norvasc 5 mg daily.,8. NovoLog 70/30, 10 units at 12 noon daily.,9. Pamelor 15 mL every evening.,10. Vitamin D3 one tablet weekly.,ALLERGIES: , THE PATIENT IS ALLERGIC TO CODEINE, COREG, AND VANCOMYCIN.,FAMILY HISTORY: ,The patient's daughter apparently has history of a murmur, but no diagnosis of congenital heart disease. The patient's father died in his 80s of CHF.,SOCIAL HISTORY: , The patient denies ever having smoked, denies any significant alcohol use, and lives with her daughter in Pasadena.,REVIEW OF SYSTEMS: , The patient has had fever and chills. She has also had some jaundice. Denies any nausea or vomiting. Denies any chest pain or abdominal pain. Denies orthopnea, paroxysmal nocturnal dyspnea or edema. She has had TIAs in the past, but denies any recent neurological symptoms such as motor weakness or focal sensory deficits. Denies melena or hematochezia. All other systems were reviewed and were found to be negative.,PHYSICAL EXAMINATION,GENERAL: An elderly Caucasian female, awake and alert, and in no distress.,VITAL SIGNS: Temperature is 98.8, heart rate 96, sinus, blood pressure 138/55, respiratory rate 20, and oxygen saturation 92%.,HEAD AND NECK: Her head is atraumatic. She is normocephalic. Her neck is supple. There is no JVD. No palpable adenopathy or thyromegaly. There is some icterus of the sclerae bilaterally. Oral mucosa is moist.,CHEST: Symmetrical expansion with normal percussion note. There are no inspiratory crackles or expiratory wheeze.,CARDIAC: Heart sounds S1 and S2 are regular. There is a 2/6 systolic murmur heard through the precordium. There is no gallop or rub. There is no palpable thrill or retrosternal lift.,ABDOMEN: Soft, nondistended, and nontender with normal bowel sounds. No audible bruits.,EXTREMITIES: No pitting edema, no clubbing, no cyanosis, and peripheral pulses are 2+.,NEUROLOGIC: She exhibits no focal motor or sensory findings.,LABORATORY DATA: , The patient's sodium was 133, potassium 2.8, chloride 99, bicarbonate 31, glucose 75, BUN 12, creatinine 0.8, calcium 8.6, total bilirubin 3.2, AST 63, and ALT 43. White count 5.4, hemoglobin 9.1, hematocrit 26.6, and platelet count 128,000. Lipase less than 10.,DIAGNOSTIC IMAGING: , The patient had a CT scan of the abdomen that demonstrated a pancreatic mass with biliary obstruction. Previous biliary stent was present.,EKG shows normal sinus rhythm. There are no acute ST-T changes.,ASSESSMENT: , This is an 84-year-old female with newly found murmur. No previous history of heart disease. This murmur has occurred in the setting of fever and bacteremia. The patient also has a pancreatic mass with jaundice, history of hypertension, and now has hyponatremia and hypokalemia.,PLAN: ,The patient should undergo an echocardiogram to assess for the possibility of endocarditis, which may be contributing to her symptoms. Blood pressure control should be maintained with Diovan and Norvasc. Potassium should be replaced, and hyponatremia should be on proactive. Cardiovascular / Pulmonary Loculated left effusion, multilobar pneumonia. Patient had a diagnosis of multilobar pneumonia along with arrhythmia and heart failure as well as renal insufficiency. Multilobar Pneumonia REASON FOR CONSULTATION: , Loculated left effusion, multilobar pneumonia. cardiovascular / pulmonary, neck bruits, nasal cannula, rhythm, pneumonia, chest tube, fluid collection, pleural effusion, multilobar pneumonia, pleural, loculations, multilobar, Cardiovascular / Pulmonary Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet. Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band. Posterior leaflet abscess resection. Mitral Valve Repair & Annuloplasty 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. cardiovascular / pulmonary, mitral valve repair, mitral valve, abscess resection, leaflet abscess, cosgrove galloway medtronic, bovie electrocautery, cannulation, bypass, annuloplasty, cardioplegia, mitral, Cardiovascular / Pulmonary Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis. Microlaryngoscopy PREOPERATIVE DIAGNOSIS:, Airway obstruction secondary to laryngeal subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: ,Airway obstruction secondary to laryngeal subglottic stenosis and tracheal stenosis.,OPERATION PERFORMED: , Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.,INDICATIONS FOR SURGERY: ,The patient is a 56-year-old white female with a history of relapsing polychondritis, which resulted in saddle nose deformity in glottic and subglottic stenosis for which she has undergone number of procedures in the past to the upper airway. She currently is trach dependent for her airway because of glottic and subglottic stenosis, but she is having no significant problems breathing and talking around her trach tube and came for further evaluation. Endoscopic reevaluation of her tube and nature of the proposed procedure done. Risk and complications of bleeding, infection, alteration of with speech or swallowing, failure to improve her airway, and loss of voice. Cardiorespiratory anesthetic results were discussed in length. The patient states she understood and wished to proceed.,DESCRIPTION OF OPERATION:, The patient was taken to the operating room and placed in the supine position. Under adequate general endotracheal anesthesia, the patient's #5 metal tracheostomy tube was removed and a #5 laser-safe endotracheal tube was inserted. The patient was then prepared for endoscopy. The Kantor laryngoscope was then inserted. Oral cavity, hypopharynx, larynx, and nasal cavity showed good dentition with good tongue, buccal cavity, and mucosa without lesions. Larynx was then ***** short epiglottis. Larynx was suspended with significant scarring beginning in the supraglottic area with loss of laryngeal contour beginning in the supraglottis with extensive scar tissue at the level of the false cord obliteration of ventricles and true cords. This appeared to be stable, and airway was patent at the supraglottic and glottic level with some narrowing at the subglottic level with mild-to-moderate subglottic stenosis, otherwise this appeared to be stable. However, distally, the level of the trach site examined with the microscope and 0 and 30-degree telescopes. The patient noted to have marked narrowing with dense scarring posterolaterally on the left securing good visualization of the trach tube. The laryngoscope was removed, and a 5 x 30 pediatric rigid bronchoscope was then passed. The LP contact tip laser was utilized to vaporize the scar tissue and release the scar banding following which the scope was passed and further dilation carried out. Mid and distal trachea were widely patent. Trachea and mainstem bronchi were patent without obvious disease. The patient did not appear to have any relapsing polychondritis with progressive scar tissue at the level of the trach site and the posterior trachea wall was significant. This was further dilated and following which was removed and a new #5 metal tracheostomy tube inserted. The patient tolerated the procedure well without complications and was taken to recovery room in satisfactory condition. cardiovascular / pulmonary, airway obstruction, oral cavity, bronchoscopy, buccal cavity, hypopharynx, laryngeal, larynx, microlaryngoscopy, nasal cavity, polychondritis, subglottic, tracheal stenosis, tracheostomy tube, scar tissue, subglottic stenosis, tracheal, airway, cavity, tube, scarring, stenosis, Cardiovascular / Pulmonary Right pleural effusion and suspected malignant mesothelioma. Mesothelioma - Pleural Biopsy PREOPERATIVE DIAGNOSIS: , Right pleural effusion and suspected malignant mesothelioma.,POSTOPERATIVE DIAGNOSIS:, Right pleural effusion, suspected malignant mesothelioma.,PROCEDURE: , Right VATS pleurodesis and pleural biopsy.,ANESTHESIA:, General double-lumen endotracheal.,DESCRIPTION OF FINDINGS: , Right pleural effusion, firm nodules, diffuse scattered throughout the right pleura and diaphragmatic surface.,SPECIMEN: , Pleural biopsies for pathology and microbiology.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid 1.2 L and 1.9 L of pleural effusion drained.,INDICATIONS: , Briefly, this is a 66-year-old gentleman who has been transferred from an outside hospital after a pleural effusion had been drained and biopsies taken from the right chest that were thought to be consistent with mesothelioma. Upon transfer, he had a right pleural effusion demonstrated on x-ray as well as some shortness of breath and dyspnea on exertion. The risks, benefits, and alternatives to right VATS pleurodesis and pleural biopsy were discussed with the patient and his family and they wished to proceed.,PROCEDURE IN DETAIL: ,After informed consent was obtained, the patient was brought to the operating room and placed in supine position. A double-lumen endotracheal tube was placed. SCDs were also placed and he was given preoperative Kefzol. The patient was then brought into the right side up, left decubitus position, and the area was prepped and draped in the usual fashion. A needle was inserted in the axillary line to determine position of the effusion. At this time, a 10-mm port was placed using the knife and Bovie cautery. The effusion was drained by placing a sucker into this port site. Upon feeling the surface of the pleura, there were multiple firm nodules. An additional anterior port was then placed in similar fashion. The effusion was then drained with a sucker. Multiple pleural biopsies were taken with the biopsy device in all areas of the pleura. Of note, feeling the diaphragmatic surface, it appeared that it was quite nodular, but these nodules felt as though they were on the other side of the diaphragm and not on the pleural surface of the diaphragm concerning for a possibly metastatic disease. This will be worked up with further imaging study later in his hospitalization. After the effusion had been drained, 2 cans of talc pleurodesis aerosol were used to cover the lung and pleural surface with talc. The lungs were then inflated and noted to inflate well. A 32 curved chest tube chest tube was placed and secured with nylon. The other port site was closed at the level of the fascia with 2-0 Vicryl and then 4-0 Monocryl for the skin. The patient was then brought in the supine position and extubated and brought to recovery room in stable condition.,Dr. X was present for the entire procedure which was right VATS pleurodesis and pleural biopsies.,The counts were correct x2 at the end of the case. cardiovascular / pulmonary, double-lumen, endotracheal, pleural surface, chest tube, pleural biopsy, malignant mesothelioma, vats pleurodesis, pleural biopsies, pleural effusion, pleural, vats, pleurodesis, mesothelioma, Cardiovascular / Pulmonary Mesothelioma versus primary lung carcinoma, Chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, malignant pleural effusion, status post surgery as stated above, and anemia of chronic disease. Mesothelioma - Consult REASON FOR CONSULTATION: , Mesothelioma.,HISTORY OF PRESENT ILLNESS: , The patient is a 73-year-old pleasant Caucasian male who is known to me from his previous hospitalization. He has also been seen by me in the clinic in the last few weeks. He was admitted on January 18, 2008, with recurrent malignant pleural effusion. On the same day, he underwent VATS and thoracoscopic drainage of the pleural effusion with right pleural nodule biopsy, lysis of adhesions, and directed talc insufflation by Dr. X. He was found to have 2.5L of bloody pleural effusions, some loculated pleural effusion, adhesions, and carcinomatosis in the parenchyma. His hospital course here has been significant for dyspnea, requiring ICU stay. He also had a chest tube, which was taken out few days ago. He has also had paroxysmal atrial fibrillation, for which he has been on amiodarone by cardiologist. The biopsy from the pleural nodule done on the right on January 18, 2008, shows malignant epithelioid neoplasm consistent with mesothelioma. Immunohistochemical staining showed tumor cells positive for calretinin and focally positive for D2-40, MOC-31. Tumor cells are negative for CDX-2, and monoclonal CEA.,The patient at this time reports that overall he has been feeling better with decrease in shortness of breath and cough over the last few days. He does have edema in his lower extremities. He is currently on 4L of oxygen. He denies any nausea, vomiting, abdominal pain, recent change in bowel habit, melena, or hematochezia. No neurological or musculoskeletal signs or symptoms. He reports that he is able to ambulate to the bathroom, but gets short of breath on exertion. He denies any other complaints.,PAST MEDICAL HISTORY:, Left ventricular systolic dysfunction as per the previous echocardiogram done in December 2007, history of pneumonia in December 2007, admitted to XYZ Hospital. History of recurrent pleural effusions, status post pleurodesis and locally advanced non-small cell lung cancer as per the biopsy that was done in XYZ Hospital.,ALLERGIES:, No known drug allergies.,CURRENT MEDICATIONS: ,In the hospital are amiodarone, diltiazem, enoxaparin, furosemide, methylprednisolone, pantoprazole, Zosyn, p.r.n. acetaminophen, and hydrocodone.,SOCIAL HISTORY: , The patient is married and lives with his spouse. He has history of tobacco smoking and also reports history of alcohol abuse. No history of illicit drug abuse.,FAMILY HISTORY: ,Significant for history of ?cancer? in the mother and history of coronary artery disease in the father.,REVIEW OF SYSTEMS: , As stated above. He denies any obvious asbestos exposure, as far as he can remember.,PHYSICAL EXAMINATION,GENERAL: He is awake, alert, in no acute distress. He is currently on 4L of oxygen by nasal cannula.,VITAL SIGNS: Blood pressure 97/65 mmHg, respiration is 20 per minute, pulse is 72 per minute, and temperature 98.3 degrees Fahrenheit.,HEENT: No icterus or sinus tenderness. Oral mucosa is moist.,NECK: Supple. No lymphadenopathy.,LUNGS: Clear to auscultation except few diffuse wheezing present bilaterally.,CARDIOVASCULAR: S1 and S2 normal.,ABDOMEN: Soft, nondistended, and nontender. No hepatosplenomegaly. Bowel sounds are present in all four quadrants.,EXTREMITIES: Bilateral pedal edema is present in both the extremities. No signs of DVT.,NEUROLOGICAL: Grossly nonfocal.,INVESTIGATION:, Labs done on January 28, 2008, showed BUN of 23 and creatinine of 0.9. Liver enzymes checked on January 17, 2008, were unremarkable. CBC done on January 26, 2008, showed WBC of 19.8, hemoglobin of 10.7, hematocrit of 30.8, and platelet count of 515,000. Chest x-ray from yesterday shows right-sided Port-A-Cath, diffuse right lung parenchymal and pleural infiltration without change, mild pulmonary vascular congestion.,ASSESSMENT,1. Mesothelioma versus primary lung carcinoma, two separate reports as for the two separate biopsies done several weeks apart.,2. Chronic obstructive pulmonary disease.,3. Paroxysmal atrial fibrillation.,4. Malignant pleural effusion, status post surgery as stated above.,5. Anemia of chronic disease.,RECOMMENDATIONS,1. Compare the slides from the previous biopsy done in December at XYZ Hospital with recurrent pleural nodule biopsy slides. I have discussed regarding this with Dr. Y in Pathology here at Methodist XYZ Hospital. I will try to obtain the slides for comparison from XYZ Hospital for comparison and immunohistochemical staining.,2. I will also discuss with Dr. X and also with intervention radiologist at XYZ Hospital regarding the exact sites of the two biopsies.,3. Once the results of the above are available, I will make further recommendations regarding treatment. The patient has significantly decreased performance status with dyspnea on exertion and is being planned for transfer to Triumph Hospital for rehab, which I agree with.,4. Continue present care.,Discussed regarding the above in great details with the patient and his wife and daughter and answered the questions to their satisfaction. They clearly understand the above. They also understand his very poor performance status at this time, and the risks and benefits of delaying chemotherapy due to this. Cardiovascular / Pulmonary Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section). Left thoracotomy with resection of posterior mediastinal mass. Mediastinal Mass Resection PREOPERATIVE DIAGNOSIS:, Posterior mediastinal mass with possible neural foraminal involvement.,POSTOPERATIVE DIAGNOSIS: , Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).,OPERATION PERFORMED:, Left thoracotomy with resection of posterior mediastinal mass.,INDICATIONS FOR PROCEDURE: ,The patient is a 23-year-old woman who recently presented with a posterior mediastinal mass and on CT and MRI there were some evidence of potential widening of one of the neural foramina. For this reason, Dr. X and I agreed to operate on this patient together. Please note that two surgeons were required for this case due to the complexity of it. The indications and risks of the procedure were explained and the patient gave her informed consent.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating suite and placed in the supine position. General endotracheal anesthesia was given with a double lumen tube. The patient was positioned for a left thoracotomy. All pressure points were carefully padded. The patient was prepped and draped in usual sterile fashion. A muscle sparing incision was created several centimeters anterior to the tip of the scapula. The serratus and latissimus muscles were retracted. The intercostal space was opened. We then created a thoracoscopy port inferiorly through which we placed a camera for lighting and for visualization. Through our small anterior thoracotomy and with the video-assisted scope placed inferiorly we had good visualization of the posterior mediastinum mass. This was in the upper portion of the mediastinum just posterior to the subclavian artery and aorta. The lung was deflated and allowed to retract anteriorly. With a combination of blunt and sharp dissection and with attention paid to hemostasis, we were able to completely resect the posterior mediastinal mass. We began by opening the tumor and taking a very wide large biopsy. This was sent for frozen section, which revealed a benign nerve sheath tumor. Then, using the occluder device Dr. X was able to _____ the inferior portions of the mass. This left the external surface of the mass much more malleable and easier to retract. Using a bipolar cautery and endoscopic scissors we were then able to completely resect it. Once the tumor was resected, it was then sent for permanent sections. The entire hemithorax was copiously irrigated and hemostasis was complete. In order to prevent any lymph leak, we used 2 cc of Evicel and sprayed this directly on to the raw surface of the pleural space. A single chest tube was inserted through our thoracoscopy port and tunneled up one interspace. The wounds were then closed in multiple layers. A #2 Vicryl was used to approximate the ribs. The muscles of the chest wall were allowed to return to their normal anatomic position. A 19 Blake was placed in the subcutaneous tissues. Subcutaneous tissues and skin were closed with running absorbable sutures. The patient was then rolled in the supine position where she was awakened from general endotracheal anesthesia and taken to the recovery room in stable condition. cardiovascular / pulmonary, posterior mediastinal mass, neural foraminal, nerve sheath tumor, frozen section, thoracotomy, mediastinal mass, foraminal, neural, sheath, mediastinal, Cardiovascular / Pulmonary Myoview nuclear stress study. Angina, coronary artery disease. Large fixed defect, inferior and apical wall, related to old myocardial infarction. Mayoview - 1 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. cardiovascular / pulmonary, myoview, myoview interpretations, spect, gated spect protocol, myoview nuclear stress study, nuclear stress study, stress study, stress test, stress, lexiscan, ekg, inferoapical, angina, wall, resting, Cardiovascular / Pulmonary Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy. Metastasectomy & Bronchoscopy 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. Cardiovascular / Pulmonary Resting Myoview and adenosine Myoview SPECT Mayoview PROCEDURE DONE: ,Resting Myoview and adenosine Myoview SPECT.,INDICATIONS:, Chest pain.,PROCEDURE:, 13.3 mCi of Tc-99m tetrofosmin was injected and resting Myoview SPECT was obtained. Pharmacologic stress testing was done using adenosine infusion. Patient received 38 mg of adenosine infused at 140 mcg/kg/minute over a period of four minutes. Two minutes during adenosine infusion, 31.6 mCi of Tc-99m tetrofosmin was injected. Resting heart rate was 90 beats per minute. Resting blood pressure was 130/70. Peak heart rate obtained during adenosine infusion was 102 beats per minute. Blood pressure obtained during adenosine infusion was 112/70. During adenosine infusion, patient experienced dizziness and shortness of breath. No significant ST segment, T wave changes, or arrhythmias were seen.,Resting Myoview and adenosine Myoview SPECT showed uniform uptake of isotope throughout myocardium without any perfusion defect. Gated dynamic imaging showed normal wall motion and normal systolic thickening throughout left ventricular myocardium. Left ventricular ejection fraction obtained during adenosine Myoview SPECT was 77%. Lung heart ratio was 0.40. TID ratio was 0.88.,IMPRESSION:, Normal adenosine Myoview myocardial perfusion SPECT. Normal left ventricular regional and global function with left ventricular ejection fraction of 77%. cardiovascular / pulmonary, myoview, gated dynamic imaging, myoview spect, resting myoview, spect, tc-99m, adenosine myoview, adenosine infusion, ejection fraction, myocardium, systolic thickening, tetrofosmin, adenosine myoview spect, adenosine, Cardiovascular / Pulmonary Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI. The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion. Lung Cancer & MI - Hospice Cosult 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. Cardiovascular / Pulmonary Mediastinal exploration and delayed primary chest closure. The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification. Mediastinal Exploration 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. cardiovascular / pulmonary, mediastinal exploration, delayed primary chest closure, extracorporeal membrane oxygenation, stage i norwood procedure, sano modification, chest closure, infant, mediastinal, exploration, closure, endotracheal, chest Cardiovascular / Pulmonary Lexiscan myoview stress study. Chest discomfort. Normal stress/rest cardiac perfusion with no indication of ischemia. Normal LV function and low likelihood of significant epicardial coronary narrowing. Mayoview - 2 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., cardiovascular / pulmonary, chest discomfort, lexiscan myoview stress study, mci, spect, gated spect, myoview, lexiscan, stress test, ekg, lexiscan myoview, lv function, coronary narrowing, heart rate, blood pressure, myoview interpretation, cardiac perfusion, cardiac, ischemia, perfusion, stress, Cardiovascular / Pulmonary The patient had undergone mitral valve repair about seven days ago. Mediastinal Exploration & Right Atrium Repair PREOPERATIVE DIAGNOSES:,1. Cardiac tamponade.,2. Status post mitral valve repair.,POSTOPERATIVE DIAGNOSES:,1. Cardiac tamponade.,2. Status post mitral valve repair.,PROCEDURE PERFORMED: , Mediastinal exploration with repair of right atrium.,ANESTHESIA: , General endotracheal.,INDICATIONS: , The patient had undergone mitral valve repair about seven days ago. He had epicardial pacing wires removed at the bedside. Shortly afterwards, he began to feel lightheaded and became pale and diaphoretic. He was immediately rushed to the operating room for cardiac tamponade following removal of epicardial pacing wires. He was transported immediately and emergently and remained awake and alert throughout the time period inspite of hypotension with the systolic pressure in the 60s-70s.,DETAILS OF PROCEDURE: ,The patient was taken emergently to the operating room and placed supine on the operating room table. His chest was prepped and draped prior to induction under general anesthesia. Incision was made through the previous median sternotomy chest incision. Wires were removed in the usual manner and the sternum was retracted. There were large amounts of dark blood filling the mediastinal chest cavity. Large amounts of clot were also removed from the pericardial well and chest. Systematic exploration of the mediastinum and pericardial well revealed bleeding from the right atrial appendix at the site of the previous cannulation. This was repaired with two horizontal mattress pledgeted #5-0 Prolene sutures. An additional #0 silk tie was also placed around the base of the atrial appendage for further hemostasis. No other sites of bleeding were identified. The mediastinum was then irrigated with copious amounts of antibiotic saline solution. Two chest tubes were then placed including an angled chest tube into the pericardial well on the inferior border of the heart, as well as straight mediastinal chest tube. The sternum was then reapproximated with stainless steel wires in the usual manner and the subcutaneous tissue was closed in multiple layers with running Vicryl sutures. The skin was then closed with a running subcuticular stitch. The patient was then taken to the Intensive Care Unit in a critical but stable condition. cardiovascular / pulmonary, mitral valve repair, exploration, median sternotomy chest incision, pericardial, mediastinal exploration, pacing wires, cardiac tamponade, chest tubes, mitral valve, valve repair, mediastinal, mitral, wires, atrium, repair, Cardiovascular / Pulmonary Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan. Lung Biopsy Pathology Report CLINICAL HISTORY:, A 48-year-old smoker found to have a right upper lobe mass on chest x-ray and is being evaluated for chest pain. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan. The lower lobe mass was approximately 1 cm in diameter and the upper lobe mass was 4 cm to 5 cm in diameter. The patient was referred for surgical treatment.,SPECIMEN:,A. Lung, wedge biopsy right lower lobe,B. Lung, resection right upper lobe,C. Lymph node, biopsy level 2 and 4,D. Lymph node, biopsy level 7 subcarinal,FINAL DIAGNOSIS:,A. Wedge biopsy of right lower lobe showing: Adenocarcinoma, Grade 2, Measuring 1 cm in diameter with invasion of the overlying pleura and with free resection margin.,B. Right upper lobe lung resection showing: Adenocarcinoma, grade 2, measuring 4 cm in diameter with invasion of the overlying pleura and with free bronchial margin. Two (2) hilar lymph nodes with no metastatic tumor.,C. Lymph node biopsy at level 2 and 4 showing seven (7) lymph nodes with anthracosis and no metastatic tumor.,D. Lymph node biopsy, level 7 subcarinal showing (5) lymph nodes with anthracosis and no metastatic tumor.,COMMENT: ,The morphology of the tumor seen in both lobes is similar and we feel that the smaller tumor involving the right lower lobe is most likely secondary to transbronchial spread from the main tumor involving the right upper lobe. This suggestion is supported by the fact that no obvious vascular or lymphatic invasion is demonstrated and adjacent to the smaller tumor, there is isolated nests of tumor cells within the air spaces. Furthermore, immunoperoxidase stain for Ck-7, CK-20 and TTF are performed on both the right lower and right upper lobe nodule. The immunohistochemical results confirm the lung origin of both tumors and we feel that the tumor involving the right lower lobe is due to transbronchial spread from the larger tumor nodule involving the right upper lobe., cardiovascular / pulmonary, pet scan, wedge biopsy, morphology, lung wedge biopsy, lymph node biopsy, lymph node, lower lobe, tumor, biopsy, lobe, lung, mass, lymph, node Cardiovascular / Pulmonary Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter. Lymphoblastic Leukemia - Consult "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.," Cardiovascular / Pulmonary The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy. Lung Biopsy Pathology Report - 1 "GROSS DESCRIPTION:,A. Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an,8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line. There is a 0.8 x,0.7 x 0.5 cm sessile tumor with surrounding pleural puckering.,B. Received fresh, labeled with patient's name, designated ""lymph node', is a 1.7 cm possible lymph node with anthracotic pigment.,C. Received fresh labeled with patient's name, designated 'right upper lobe', is a 16.0 x,14.5 x 6.0 cm lobe of lung. The lung is inflated with formalin. There is a 12.0 cm staple line on the lateral surface, inked blue. There is a 1.3 x 1.1 x 0.8 cm subpleural firm ill-defined mass, 2.2 cm from the bronchial margin and 1.5 cm from the previously described staple line. The overlying pleura is puckered.,D. Received fresh, labeled with patient's name, designated '4 lymph nodes', is a 2.0 x 2.0 x 2.0 cm aggregate of lymphoid material with anthracotic pigment and adipose tissue.,E. Received fresh, labeled with patient's name, designated 'subcarinal lymph node', is a,2.0 x 1.7 x 0.8 cm aggregate of lymphoid material with anthracotic pigment .,FINAL DIAGNOSIS:,A. Right upper lobe wedge lung biopsy: Poorly differentiated non-small cell carcinoma. Tumor Size: 0.8 cm. Arterial (large vessel) invasion: Not seen. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.,B. Biopsy, 10R lymph node: Anthracotically pigmented lymphoid tissue, negative for malignancy.,C. Right upper lobe, lung: Moderately differentiated non-small cell carcinoma,(adenocarcinoma). Tumor Size: 1.3 cm. Arterial (large vessel) invasion: Present. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.,D. Biopsy, 4R lymph nodes: Lymphoid tissue, negative for malignancy.,E. Biopsy, subcarinal lymph node: Lymphoid tissue, negative for malignancy.,COMMENTS:, Pathologic examination reveals two separate tumors in the right upper lobe. They appear histologically distinct, suggesting they are separate primary tumors (pT1). The right upper lobe wedge biopsy (part A) shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy. The right upper lobe carcinoma identified in the resection (part C) is a moderately differentiated adenocarcinoma with obvious gland formation." cardiovascular / pulmonary, lung biopsy, wedge, lobe, pathologic, lymph node', node', lymphoid, malignancy, lung, lymph, biopsy Cardiovascular / Pulmonary Right upper lung lobectomy. Mediastinal lymph node dissection Lobectomy & Lymph Node Dissection OPERATION,1. Right upper lung lobectomy.,2. Mediastinal lymph node dissection.,ANESTHESIA,1. General endotracheal anesthesia with dual-lumen tube.,2. Thoracic epidural.,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 with a dual-lumen tube. Next, the patient was placed in the left lateral decubitus position, and his right chest was prepped and draped in the standard surgical fashion. We used a #10-blade scalpel to make an incision in the skin approximately 1 fingerbreadth below the angle of the scapula. Dissection was carried down in a muscle-sparing fashion using Bovie electrocautery. The 5th rib was counted, and the 6th interspace was entered. The lung was deflated. We identified the major fissure. We then began by freeing up the inferior pulmonary ligament, which was done with Bovie electrocautery. Next, we used Bovie electrocautery to dissect the pleura off the lung. The pulmonary artery branches to the right upper lobe of the lung were identified. Of note was the fact that there was a visible, approximately 4 x 4-cm mass in the right upper lobe of the lung without any other metastatic disease palpable. As mentioned, a combination of Bovie electrocautery and sharp dissection was used to identify the pulmonary artery branches to the right upper lobe of the lung. Next, we began by ligating the pulmonary artery branches of the right upper lobe of the lung. This was done with suture ligature in combination with clips. After taking the pulmonary artery branches of the right upper lobe of the lung, we used a combination of blunt dissection and sharp dissection with Metzenbaum scissors to separate out the pulmonary vein branch of the right upper lobe of the lung. This likewise was ligated with a 0 silk. It was stick-tied with a 2-0 silk. It was then divided. Next we dissected out the bronchial branch to the right upper lobe of the lung. A curved Glover was placed around the bronchus. Next a TA-30 stapler was fired across the bronchus. The bronchus was divided with a #10-blade scalpel. The specimen was handed off. We next performed a mediastinal lymph node dissection. Clips were applied to the base of the feeding vessels to the lymph nodes. We inspected for any signs of bleeding. There was minimal bleeding. We placed a #32-French anterior chest tube, and a #32-French posterior chest tube. The rib space was closed with #2 Vicryl in an interrupted figure-of-eight fashion. A flat Jackson-Pratt drain, #10 in size, was placed in the subcutaneous flap. The muscle layer was closed with a combination of 2-0 Vicryl followed by 2-0 Vicryl, followed by 4-0 Monocryl in a running subcuticular fashion. 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 transferred to the PACU in good condition. cardiovascular / pulmonary, mediastinal, thoracic, epidural, lymph node dissection, lymph node, artery branches, lobectomy, lung, anesthesia, bovie, electrocautery, lymph, pulmonary, branches Cardiovascular / Pulmonary VATS right middle lobectomy, fiberoptic bronchoscopy, mediastinal lymph node sampling, tube thoracostomy x2, multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor. Lobectomy - VATS PREOPERATIVE DIAGNOSIS:, Right middle lobe lung cancer.,POSTOPERATIVE DIAGNOSIS: , Right middle lobe lung cancer.,PROCEDURES PERFORMED:,1. VATS right middle lobectomy.,2. Fiberoptic bronchoscopy thus before and after the procedure.,3. Mediastinal lymph node sampling including levels 4R and 7.,4. Tube thoracostomy x2 including a 19-French Blake and a 32-French chest tube.,5. Multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.,ANESTHESIA: ,General endotracheal anesthesia with double-lumen endotracheal tube.,DISPOSITION OF SPECIMENS: , To pathology both for frozen and permanent analysis.,FINDINGS:, The right middle lobe tumor was adherent to the anterior chest wall. The adhesion was taken down, and the entire pleural surface along the edge of the adhesion was sent for pathologic analysis. The final frozen pathology on this entire area returned as negative for tumor. Additional chest wall abnormalities were biopsied and sent for pathologic analysis, and these all returned separately as negative for tumor and only fibrotic tissue. Several other biopsies were taken and sent for permanent analysis of the chest wall. All of the biopsy sites were additionally marked with Hemoclips. The right middle lobe lesion was accompanied with distal pneumonitis and otherwise no direct involvement of the right upper lobe or right lower lobe.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,CONDITION OF THE PATIENT AFTER SURGERY: , Stable.,HISTORY OF PROCEDURE:, This patient is well known to our service. He was admitted the night before surgery and given hemodialysis and had close blood sugar monitoring in control. The patient was subsequently taken to the operating room on April 4, 2007, was given general anesthesia and was endotracheally intubated without incident. Although, he had markedly difficult airway, the patient had fiberoptic bronchoscopy performed all the way down to the level of the subsegmental bronchi. No abnormalities were noted in the entire tracheobronchial tree, and based on this, the decision was made to proceed with the surgery. The patient was kept in the supine position, and the single-lumen endotracheal tube was removed and a double-lumen tube was placed. Following this, the patient was placed into the left lateral decubitus position with the right side up and all pressure points were padded. Sterile DuraPrep preparation on the right chest was placed. A sterile drape around that was also placed. The table was flexed to open up the intercostal spaces. A second bronchoscopy was performed to confirm placement of the double-lumen endotracheal tube. Marcaine was infused into all incision areas prior to making an incision. The incisions for the VATS right middle lobectomy included a small 1-cm incision for the auscultatory incision approximately 4 cm inferior to the inferior tip of the scapula. The camera port was in the posterior axillary line in the eighth intercostal space through which a 5-mm 30-degree scope was used. Third incision was an anterior port, which was approximately 2 cm inferior to the inframammary crease and the midclavicular line in the anterior sixth intercostal space, and the third incision was a utility port, which was a 4 cm long incision, which was approximately one rib space below the superior pulmonary vein. All of these incisions were eventually created during the procedure. The initial incision was the camera port through which, under direct visualization, an additional small 5-mm port was created just inferior to the anterior port. These two ports were used to identify the chest wall lesions, which were initially thought to be metastatic lesions. Multiple biopsies of the chest wall lesions were taken, and the decision was made to also insert the auscultatory incision port. Through these three incisions, the initial working of the diagnostic portion of the chest wall lesion was performed. Multiple biopsies were taken of the entire chest wall offers and specimens came back as negative. The right middle lobe was noted to be adherent to the anterior chest wall. This area was taken down and the entire pleural surface along this area was taken down and sent for frozen pathologic analysis. This also returned as negative with only fibrotic tissue and a few lymphocytes within the fibrotic tissue, but no tumor cells. Based on this, the decision was made to not proceed with chest wall resection and continue with right middle lobectomy. Following this, the anterior port was increased in size and the utility port was made and meticulous dissection from an anterior to posterior direction was performed. The middle lobe branch of the right superior pulmonary vein was initially dissected and stapled with vascular load 45-mm EndoGIA stapler. Following division of the right superior pulmonary vein, the right middle lobe bronchus was easily identified. Initially, this was thought to be the main right middle lobe bronchus, but in fact it was the medial branch of the right middle lobe bronchus. This was encircled and divided with a blue load stapler with a 45-mm EndoGIA. Following division of this, the pulmonary artery was easily identified. Two branches of the pulmonary artery were noted to be going into the right middle lobe. These were individually divided with a vascular load after encircling with a right angle clamp. The vascular staple load completely divided these arterial branches successfully from the main pulmonary artery trunk, and following this, an additional branch of the bronchus was noted to be going to the right middle lobe. A fiberoptic bronchoscopy was performed intraoperatively and confirmed that this was in fact the lateral branch of the right middle lobe bronchus. This was divided with a blue load stapler 45 mm EndoGIA. Following division of this, the minor and major fissures were completed along the edges of the right middle lobe separating the right upper lobe from the right middle lobe as well as the right middle lobe from the right lower lobe. Following complete division of the fissure, the lobe was put into an EndoGIA bag and taken out through the utility port. Following removal of the right middle lobe, a meticulous lymph node dissection sampling was performed excising the lymph node package in the 4R area as well as the 7 lymph node package. Node station 8 or 9 nodes were easily identified, therefore none were taken. The patient was allowed to ventilate under water on the right lung with no obvious air leaking noted. A 19-French Blake was placed into the posterior apical position and a 32-French chest tube was placed in the anteroapical position. Following this, the patient's lung was allowed to reexpand fully, and the patient was checked for air leaking once again. Following this, all the ports were closed with 2-0 Vicryl suture used for the deeper tissue, and 3-0 Vicryl suture was used to reapproximate the subcutaneous tissue and 4-0 Monocryl suture was used to close the skin in a running subcuticular fashion. The patient tolerated the procedure well, was extubated in the operating room and taken to the recovery room in stable condition. cardiovascular / pulmonary, middle lobe, endogia, fiberoptic, mediastinal lymph node, vats, bronchoscopy, chest tube, chest wall, endotracheal tube, endotracheally, lobectomy, lung cancer, pneumonitis, sampling, thoracostomy, utility port, lumen endotracheal tube, superior pulmonary vein, chest wall lesions, anterior chest wall, middle lobectomy, fiberoptic bronchoscopy, anterior chest, lymph node, node, port, chest, bronchus, tumor, pulmonary, incision, Cardiovascular / Pulmonary " Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung""." Lung adenocarcinoma Path Report "CLINICAL HISTORY: ,Probable right upper lobe lung adenocarcinoma.,SPECIMEN: , Lung, right upper lobe resection.,GROSS DESCRIPTION:, Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"". It consists of one lobectomy specimen measuring 16.1 x 10.6 x,4.5.cm. The specimen is covered by a smooth, pink-tan and gray pleural surface which is largely unremarkable. Sectioning reveals a round, ill-defined, firm, tan-gray mucoid mass. This mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest surgical margin and 3.9 cm from the hilum. There is no necrosis or hemorrhage evident. The tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying pleura is puckered.,FINAL DIAGNOSIS:, Right lung, upper lobe, lobectomy: Bronchioloalveolar carcinoma, mucinous type,COMMENT:, Right upper lobe, lobectomy.,Tumor type: Bronchioloalveolar carcinoma, mucinous type.,Histologic grade: Well differentiated.,Tumor size (greatest diameter): 3.6 cm.,Blood/lymphatic vessel invasion: Absent.,Perineural invasion: Absent.,Bronchial margin: Negative.,Vascular margin: Negative.,Inked surgical margin: Negative.,Visceral pleura: Not involved.,In situ carcinoma: Absent.,Non-neoplastic lung: Emphysema.,Hilar lymph nodes: Number of positive lymph nodes: 0; Total number of lymph nodes: 1.,P53 immunohistochemical stain is negative in the tumor." cardiovascular / pulmonary, bronchioloalveolar carcinoma, mucinous, mucoid mass, lymph nodes, upper lobe, visceral, bronchioloalveolar, carcinoma, lymph, pleural, margin, tumor, adenocarcinoma, specimen, lobe, lung, Cardiovascular / Pulmonary Right lower lobectomy, right thoracotomy, extensive lysis of adhesions, mediastinal lymphadenectomy. Lobectomy & Lymphadenectomy 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. cardiovascular / pulmonary, right lower lobe, gia stapler, mediastinal, non-small cell carcinoma, cancer, frozen section, hilum, lobectomy, lymphadenectomy, lysis of adhesions, pleura, thoracotomy, upper lobe, lower lobectomy, adhesions, chest Cardiovascular / Pulmonary Left lower extremity venous Doppler ultrasound Lower Extremity Venous Doppler 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. cardiovascular / pulmonary, popliteal veins, superficial femoral, common femoral, inguinal region, lymph nodes, venous doppler, lower extremity, lymph, inguinal, axis, doppler, extremity, venous, Cardiovascular / Pulmonary Lower Extremity Arterial Doppler Lower Extremity Arterial Doppler RIGHT LOWER EXTREMITY:, The arterial system was visualized showing triphasic waveform from the common femoral to popliteal and biphasic waveform at the posterior tibial artery with ankle brachial index of 0/8.,LEFT LOWER EXTREMITY:, The arterial system was visualized with triphasic waveform from the common femoral to the popliteal artery, with biphasic waveform at the posterior tibial artery. Ankle brachial index of 0.9.,IMPRESSION: , Mild bilateral lower extremity arterial obstructive disease., cardiovascular / pulmonary, lower extremity arterial doppler, posterior tibial artery, ankle brachial index, arterial doppler, triphasic waveform, common femoral, biphasic waveform, tibial artery, ankle brachial, brachial index, lower extremity, doppler, triphasic, femoral, popliteal, brachial, waveform, extremity, arterial, Cardiovascular / Pulmonary Left lower lobectomy. Lobectomy - Left Lower 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. cardiovascular / pulmonary, lower lobectomy, electrocautery, endo gia stapler, subcutaneous drain, endotracheal, subcutaneous, lobectomy, Cardiovascular / Pulmonary Patient is here to discuss possible open lung biopsy. Lung Biopsy Discussion CHART NOTE:, She is here to discuss possible open lung biopsy that she has actually scheduled for tomorrow. Dr. XYZ had seen her because of her complaints of shortness of breath. Then she had the pulmonary function test and CT scan and he felt that she probably had usual interstitial pneumonitis, but wanted her to have an open lung biopsy so he had her see Dr. XYZ Estep. He had concurred with Dr. XYZ that an open lung biopsy was appropriate and she was actually scheduled for this but both Dr. XYZ and I were unavailable before the procedure was originally scheduled so he had it delayed so that she could talk with us prior to having the biopsy. She was ready to go ahead with this and felt that it was important she find out why she is short of breath. She is very concerned about the findings on her CAT scan and pulmonary function test. She seemed alarmed to report that Dr. XYZ had found that her lung capacity was reduced to 60% of what should be normal. However, I told her that two years ago Dr. XYZ did pulmonary function studies which showed the same change in function. And that really her pulmonary function test, at least compared from two years ago, had not really changed over this period of time. After discussing the serious nature of an open lung biopsy, the fact that her pulmonary function studies have not changed in two years, the fact that she likely has a number of other things that are contributing to her being out of breath, which is deconditioning and obesity, she seemed comfortable with the thought of simply monitoring this a little bit longer before undergoing something as risky as an open lung biopsy. In fact when I called Dr. XYZ to talk to him about cancelling the procedure, he stated he would be very uncomfortable with doing an open lung biopsy on someone with pulmonary function studies which had not changed. I also explained to patient that I did not think Dr. XYZ was aware that she had had pulmonary function studies two years previously and certainly did not know that there results of those. And also I spoke with Dr. XYZ who agreed that although the two different tests may have some minor differences accounting for some of the similarity in results that may or may not be completely accurate, that generally a person with progressive interstitial lung disease without a fairly substantial change on pulmonary function tests even if they were done at different facilities.,I had a 30-minute discussion with patient about all of this and showed her the different test results and had a lengthy talk with her about the open lung biopsy and she ultimately felt very uncomfortable with going ahead and decided to cancel it. I also told her we could continue to monitor her breathing problems and continue to monitor her CAT scan, x-ray, and pulmonary function tests. And if there was some sign that this was a progressive problem, she could still go ahead with the lung biopsy. But she needed to understand that the treatment and likely diagnosis found from an open lung biopsy were not highly likely to be of any great help to her. She understands that the diagnoses made from open lung biopsy are not all that specific and that the treatment for the few specific things that can be detected are not often well tolerated or extremely helpful.,We are going to see her back in a month to see how her breathing is doing. We will cancel her open lung biopsy for tomorrow and decide whether she should follow up with a pulmonologist at that time. I told her I would try to talk to her sister sometime in the next day or two. cardiovascular / pulmonary, discuss, interstitial pneumonitis, lung biopsy, lung capacity, pulmonary function test, shortness of breath, pulmonary function studies, pulmonary function, function, biopsy, lung, interstitial, pulmonaryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., Cardiovascular / Pulmonary 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. The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago. Lobectomy - Followup 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. cardiovascular / pulmonary, non-small cell lung cancer, lobectomy, lung cancer, non-small cell, lung, cancer Cardiovascular / Pulmonary Lightheaded, dizziness, and palpitation. This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope. During the episode, the patient describes symptoms of palpitation and fluttering of chest. She relates the heart was racing. By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm. No evidence of arrhythmia. Lightheaded & Dizziness REASON FOR CONSULTATION: , Lightheaded, dizziness, and palpitation.,HISTORY OF PRESENT ILLNESS: , The patient is a 50-year-old female who came to the Emergency Room. This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope. During the episode, the patient describes symptoms of palpitation and fluttering of chest. She relates the heart was racing. By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm. No evidence of arrhythmia. The patient had some cardiac workup in the past, results are as mentioned below. Denies any specific chest pain. Activities fairly stable. She is actively employed. No other cardiac risk factor in terms of alcohol consumption or recreational drug use, caffeinated drink use or over-the-counter medication usage.,CORONARY RISK FACTORS: , No history of hypertension or diabetes mellitus. Nonsmoker. Cholesterol normal. No history of established coronary artery disease and family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: , Tubal ligation.,MEDICATIONS: , On pain medications, ibuprofen.,ALLERGIES:, SULFA.,PERSONAL HISTORY: , She is a nonsmoker. Does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY: , History of chest pain in the past. Had workup done including nuclear myocardial perfusion scan, which was reportedly abnormal. Subsequently, the patient underwent cardiac catheterization in 11/07, which was also normal. An echocardiogram at that time was also normal. At this time, presentation with lightheaded, dizziness, and palpitation.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No history of fever, rigors, or chills.,HEENT: No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR: As above.,RESPIRATORY: Shortness of breath. No pneumonia or valley fever.,GASTROINTESTINAL: No epigastric discomfort, hematemesis or melena.,UROLOGICAL: No frequency or urgency.,MUSCULOSKELETAL: Nonsignificant.,NEUROLOGICAL: No TIA. No CVA. No seizure disorder.,ENDOCRINE/HEMATOLOGIC: Nonsignificant.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 69, blood pressure 127/75, afebrile, and respiratory rate 16 per minute.,HEENT: Atraumatic and normocephalic.,NECK: Neck veins flat. No carotid bruits. No thyromegaly. No lympyhadenopathy.,LUNGS: Air entry bilaterally fair.,HEART: PMI normal. S1 and S2 regular.,ABDOMEN: Soft and nontender. Bowel sounds present.,EXTREMITIES: No edema. Pulses palpable. No clubbing or cyanosis.,CNS: Benign.,PSYCHOLOGICAL: Normal.,MUSCULOSKELETAL: Nonsignificant.,EKG: , Normal sinus rhythm, incomplete right bundle-branch block.,LABORATORY DATA:, H&H stable. BUN and creatinine within normal limits. Cardiac enzyme profile negative. Chest x-ray unremarkable.,IMPRESSION:,1. Lightheaded, dizziness in a 50-year-old female. No documented arrhythmia with the symptoms of palpitation.,2. Normal cardiac structure by echocardiogram a year and half ago.,3. Normal cardiac catheterization in 11/07.,4. Negative workup so far for acute cardiac event in terms of EKG, cardiac enzyme profile. Cardiovascular / Pulmonary Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis. Laryngoscopy PREOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,POSTOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,OPERATION PREFORMED,Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.,INDICATIONS FOR THE SURGERY,The patient is a 76-year-old white female with a history of subglottic upper tracheal stenosis. She has had undergone multiple previous endoscopic procedures in the past; last procedure was in January 2007. She returns with some increasing shortness of breath and dyspnea on exertion. Endoscopic reevaluation is offered to her. The patient has been considering laryngotracheal reconstruction; however, due to a recent death in the family, she has postponed this, but she has been having increasing symptoms. An endoscopic treatment was offered to her. Nature of the proposed procedure including risks and complications involving bleeding, infection, alteration of voice, speech, or swallowing, hoarseness changing permanently, recurrence of stenosis despite a surgical intervention, airway obstruction necessitating a tracheostomy now or in the future, cardiorespiratory, and anesthetic risks were all discussed in length. The patient states she understood and wished to proceed.,DESCRIPTION OF THE OPERATION,The patient was taken to the operating room, placed on table in supine position. Following adequate general anesthesia, the patient was prepared for endoscopy. The top sliding laryngoscope was then inserted in the oral cavity, pharynx, and larynx examined. In the oral cavity, she had good dentition. Tongue and buccal cavity mucosa were without ulcers, masses, or lesions. The oropharynx was clear. The larynx was then manually suspended. Epiglottis area, epiglottic folds, false cords, true vocal folds with some mild edema, but otherwise, without ulcers, masses, or lesions, and the supraglottic and glottic airway were widely patent. The larynx was manually suspended and a 5 x 30 pediatric rigid bronchoscope was passed through the vocal folds. At the base of the subglottis, there was a narrowing and in the upper trachea, restenosis had occurred. Moderate amount of mucoid secretions, these were suctioned, following which the area of stenosis was dilated. Remainder of the bronchi was then examined. The mid and distal trachea were widely patent. Pale pink mucosa takeoff from mainstem bronchi were widely patent without ulcers, lesions, or evidence of scarring. The scope was pulled back and removed and following this, a 6 x 30 pediatric rigid bronchoscope was passed through the larynx and further dilatation carried out. Once this had been completed, dramatic improvement in the subglottic upper tracheal airway accomplished. Instrumentation was removed and a #6 endotracheal tube, uncuffed, was placed to allow smooth emerge from anesthesia. The patient tolerated the procedure well without complication. cardiovascular / pulmonary, stenosis, epiglottis, subglottic, bronchoscope, bronchoscopy, endoscopic, laryngoscopy, laryngotracheal reconstruction, larynx, oral cavity, pharynx, tracheal, true vocal folds, vocal, upper tracheal stenosis, subglottic upper tracheal, subglottic upper, upper tracheal, airway, cavity, patent, Cardiovascular / Pulmonary Laparoscopic lysis of adhesions and Laparoscopic left adrenalectomy. Left adrenal mass, 5.5 cm and intraabdominal adhesions. Laparoscopic Adrenalectomy 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. Cardiovascular / Pulmonary Patient with a history of ischemic cardiac disease and hypercholesterolemia. Ischemic Cardiac Disease - Progress Note HISTORY OF PRESENT ILLNESS:, The patient is a 68-year-old man who returns for recheck. He has a history of ischemic cardiac disease, he did see Dr. XYZ in February 2004 and had a thallium treadmill test. He did walk for 8 minutes. The scan showed some mild inferior wall scar and ejection fraction was well preserved. He has not had difficulty with chest pain, palpitations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY/SURGERIES/HOSPITALIZATIONS: , He had tonsillectomy at the age of 8. He was hospitalized in 1996 with myocardial infarction and subsequently underwent cardiac catheterization and coronary artery bypass grafting procedure. He did have LIMA to the LAD and had three saphenous vein grafts performed otherwise.,MEDICATIONS:, Kerlone 10 mg 1/2 pill daily, gemfibrozil 600 mg twice daily, Crestor 80 mg 1/2 pill daily, aspirin 325 mg daily, vitamin E 400 units daily, and Citrucel one daily.,ALLERGIES: , None known.,FAMILY HISTORY: ,Father died at the age of 84. He had a prior history of cancer of the lung and ischemic cardiac disease. Mother died in her 80s from congestive heart failure. He has two brothers and six sisters living who remain in good health.,PERSONAL HISTORY: ,Quit smoking in 1996. He occasionally drinks alcoholic beverages.,REVIEW OF SYSTEMS:,Endocrine: He has hypercholesterolemia treated with diet and medication. He reports that he did lose 10 pounds this year.,Neurologic: Denies any TIA symptoms.,Genitourinary: He has occasional nocturia. Denies any difficulty emptying his bladder.,Gastrointestinal: He has a history of asymptomatic cholelithiasis.,PHYSICAL EXAMINATION:,Vital Signs: Weight: 225 pounds. Blood pressure: 130/82. Pulse: 83. Temperature: 96.4 degrees.,General Appearance: He is a middle-aged man who is not in any acute distress.,HEENT: Mouth: The posterior pharynx is clear.,Neck: Without adenopathy or thyromegaly.,Chest: Lungs are resonant to percussion. Auscultation reveals normal breath sounds.,Heart: Normal S1, S2, without gallops or rubs.,Abdomen: Without tenderness or masses.,Extremities: Without edema.,IMPRESSION/PLAN:,1. Ischemic cardiac disease. This remains stable. He will continue on the same medication. He reports he has had some laboratory studies today.,2. Hypercholesterolemia. He will continue on the same medication.,3. Facial tic. We also discussed having difficulty with the facial tic at the left orbital region. This occurs mainly when he is under stress. He has apparently had numerous studies in the past and has seen several doctors in Wichita about this. At one time was being considered for some type of operation. His description, however, suggests that they were considering an operation for tic douloureux. He does not have any pain with this tic and this is mainly a muscle spasm that causes his eye to close. Repeat neurology evaluation was advised. He will be scheduled to see Dr. XYZ in Newton on 09/15/2004.,4. Immunization. Addition of pneumococcal vaccination was discussed with him but had been decided by him at the end of the appointment. We will have this discussed with him further when his laboratory results are back. Cardiovascular / Pulmonary Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura. Immunohistochemical Study CLINICAL HISTORY: , Patient is a 37-year-old female with a history of colectomy for adenoma. During her preop evaluation it was noted that she had a lesion on her chest x-ray. CT scan of the chest confirmed a left lower mass.,SPECIMEN: , Lung, left lower lobe resection.,IMMUNOHISTOCHEMICAL STUDIES:, Tumor cells show no reactivity with cytokeratin AE1/AE3. No significant reactivity with CAM5.2 and no reactivity with cytokeratin-20 are seen. Tumor cells show partial reactivity with cytokeratin-7. PAS with diastase demonstrates no convincing intracytoplasmic mucin. No neuroendocrine differentiation is demonstrated with synaptophysin and chromogranin stains. Tumor cells show cytoplasmic and nuclear reactivity with S100 antibody. No significant reactivity is demonstrated with melanoma marker HMB-45 or Melan-A. Tumor cell nuclei (spindle cell and pleomorphic/giant cell carcinoma components) show nuclear reactivity with thyroid transcription factor marker (TTF-1). The immunohistochemical studies are consistent with primary lung sarcomatoid carcinoma with pleomorphic/giant cell carcinoma and spindle cell carcinoma components.,FINAL DIAGNOSIS:,Histologic Tumor Type: Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.,Tumor Size: 2.7 x 2.0 x 1.4 cm.,Visceral Pleura Involvement: The tumor closely approaches the pleural surface but does not invade the pleura.,Vascular Invasion: Present.,Margins: Bronchial resection margins and vascular margins are free of tumor.,Lymph Nodes: Metastatic sarcomatoid carcinoma into one of four hilar lymph nodes.,Pathologic Stage: pT1N1MX. cardiovascular / pulmonary, cytokeratin-20, hmb-45, melanoma, spindle cell carcinoma, tumor cells, carcinoma, immunohistochemical, lung, cytokeratin, sarcomatoid, spindle, pleural, cell, tumor, Cardiovascular / Pulmonary Comprehensive electrophysiology studies with attempted arrhythmia induction and IV Procainamide infusion for Brugada syndrome. IV Procainamide Infusion PREOPERATIVE DIAGNOSIS: , Syncopal episodes with injury. See electrophysiology consultation.,POSTOPERATIVE DIAGNOSES:,1. Normal electrophysiologic studies.,2. No inducible arrhythmia.,3. Procainamide infusion negative for Brugada syndrome.,PROCEDURES:,1. Comprehensive electrophysiology studies with attempted arrhythmia induction.,2. IV Procainamide infusion for Brugada syndrome.,DESCRIPTION OF PROCEDURE:, The patient gave informed consent for comprehensive electrophysiologic studies. She received small amounts of intravenous fentanyl and Versed for conscious sedation. Then 1% lidocaine local anesthesia was used. Three catheters were placed via the right femoral vein; 5-French catheters to the right ventricular apex and right atrial appendage; and a 6-French catheter to the His bundle. Later in the procedure, the RV apical catheter was moved to RV outflow tract.,ELECTROPHYSIOLOGICAL FINDINGS:, Conduction intervals in sinus rhythm were normal. Sinus cycle length 768 ms, PA interval 24 ms, AH interval 150 ms, HV interval 46 ms. Sinus node recovery times were also normal at 1114 ms. Corrected sinus node recovery time was normal at 330 ms. One-to-one AV conduction was present to cycle length 480 ms, AH interval 240 ms, HV interval 54 ms. AV nodal effective refractory period was normal, 440 ms at drive cycle length 600 ms. RA-ERP was 250 ms. With ventricular pacing, there was VA disassociation present.,Since there was no evidence for dual AV nodal pathways, and poor retrograde conduction, isoproterenol infusion was not performed to look for SVT.,Programmed ventricular stimulation was performed at both right ventricular apex and right ventricular outflow tracts. Drive cycle length 600, 500, and 400 ms was used with triple extrastimuli down to troubling intervals of 180 ms, or refractoriness. There was no inducible VT. Longest run was 5 beats of polymorphic VT, which is a nonspecific finding. From the apex 400-600 with 2 extrastimuli were delivered, again with no inducible VT.,Procainamide was then infused, 20 mg/kg over 10 minutes. There were no ST segment changes. HV interval after IV Procainamide remained normal at 50 ms.,ASSESSMENT: , Normal electrophysiologic studies. No evidence for sinus node dysfunction or atrioventricular block. No inducible supraventricular tachycardia or ventricular tachycardia, and no evidence for Brugada syndrome.,PLAN: , The patient will follow up with Dr. X. She recently had an ambulatory EEG. I will plan to see her again on a p.r.n. basis should she develop a recurrent syncopal episodes. Reveal event monitor was considered, but not placed since she has only had one single episode. cardiovascular / pulmonary, arrhythmia, attempted arrhythmia induction, conduction, sinus rhythm, electrophysiologic studies, sinus node, iv procainamide, brugada syndrome, electrophysiology, sinus, ventricular, Cardiovascular / Pulmonary Lexiscan Nuclear Myocardial Perfusion Scan. Chest pain. Patient unable to walk on a treadmill. Nondiagnostic Lexiscan. Normal nuclear myocardial perfusion scan. Lexiscan Nuclear Scan EXAM:, Lexiscan Nuclear Myocardial Perfusion Scan.,INDICATION:, Chest pain.,TYPE OF TEST: ,Lexiscan, unable to walk on a treadmill.,INTERPRETATION: , Resting heart rate of 96, blood pressure of 141/76. EKG, normal sinus rhythm, nonspecific ST-T changes, left bundle branch block. Post Lexiscan 0.4 mg injected intravenously by standard protocol. Peak heart rate was 105, blood pressure of 135/72. EKG remains the same. No symptoms are noted.,SUMMARY:,1. Nondiagnostic Lexiscan.,2. Nuclear interpretation as below.,NUCLEAR MYOCARDIAL PERFUSION SCAN WITH STANDARD PROTOCOL:, Resting and stress images were obtained with 10.4, 32.5 mCi of tetrofosmin injected intravenously by standard protocol. Myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake. There is no evidence of reversible or fixed defect. Gated SPECT revealed mild global hypokinesis, more pronounced in the septal wall possibly secondary to prior surgery. Ejection fraction calculated at 41%. End-diastolic volume of 115, end-systolic volume of 68.,IMPRESSION:,1. Normal nuclear myocardial perfusion scan.,2. Ejection fraction 41% by gated SPECT. cardiovascular / pulmonary, lexiscan nuclear myocardial perfusion scan, treadmill, bundle branch block, mci, tetrofosmin, nuclear myocardial perfusion scan, blood pressure, gated spect, ejection fraction, myocardial perfusion, ejection, fraction, myocardial, lexiscan, nuclear, Cardiovascular / Pulmonary Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C. Hypertension & Cardiomyopathy PROBLEMS LIST:,1. Nonischemic cardiomyopathy.,2. Branch vessel coronary artery disease.,3. Congestive heart failure, NYHA Class III.,4. History of nonsustained ventricular tachycardia.,5. Hypertension.,6. Hepatitis C.,INTERVAL HISTORY: , The patient was recently hospitalized for CHF exacerbation and was discharged with increased medications. However, he did not fill his prescriptions and came back with persistent shortness of breath on exertion and on rest. He has history of orthopnea and PND. He has gained a few pounds of weight but denied to have any palpitation, presyncope, or syncope.,REVIEW OF SYSTEMS: , Positive for right upper quadrant pain. He has occasional nausea, but no vomiting. His appetite has decreased. No joint pain, TIA, seizure or syncope. Other review of systems is unremarkable.,I reviewed his past medical history, past surgical history, and family history.,SOCIAL HISTORY: , He has quit smoking, but unfortunately was positive for cocaine during last hospital stay in 01/08.,ALLERGIES: , He has no known drug allergies.,MEDICATIONS:, I reviewed his medication list in the chart. He states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse 91 per minute and regular, blood pressure 151/102 in the right arm and 152/104 in the left arm, weight 172 pounds, which is about 6 pounds more than last visit in 11/07. HEENT: Atraumatic and normocephalic. No pallor, icterus or cyanosis. NECK: Supple. Jugular venous distention 5 cm above the clavicle present. No thyromegaly. LUNGS: Clear to auscultation. No rales or rhonchi. Pulse ox was 98% on room air. CVS: S1 and S2 present. S3 and S4 present. ABDOMEN: Soft and nontender. Liver is palpable 5 cm below the right subcostal margin. EXTREMITIES: No clubbing or cyanosis. A 1+ edema present.,ASSESSMENT AND PLAN:, The patient has hypertension, nonischemic cardiomyopathy, and branch vessel coronary artery disease. Clinically, he is in NYHA Class III. He has some volume overload and was not unfortunately taking Lasix as prescribed. I have advised him to take Lasix 40 mg p.o. b.i.d. I also increased the dose of hydralazine from 75 mg t.i.d. to 100 mg t.i.d. I advised him to continue to take Toprol and lisinopril. I have also added Aldactone 25 mg p.o. daily for survival advantage. I reinforced the idea of not using cocaine. He states that it was a mistake, may be somebody mixed in his drink, but he has not intentionally taken any cocaine. I encouraged him to find a primary care provider. He will come for a BMP check in one week. I asked him to check his blood pressure and weight. I discussed medication changes and gave him an updated list. I have asked him to see a gastroenterologist for hepatitis C. At this point, his Medicaid is pending. He has no insurance and finds hard to find a primary care provider. I will see him in one month. He will have his fasting lipid profile, AST, and ALT checked in one week. cardiovascular / pulmonary, congestive heart failure, hypertension, cardiomyopathy, coronary artery disease, ventricular tachycardia, nonischemic cardiomyopathy, branch vessel, nyha class, nonischemic, tachycardia, orthopnea, Cardiovascular / Pulmonary 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. Hypertension - Consult 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. cardiovascular / pulmonary, hypokalemia, shortness of breath, atrial tachycardia, sinus rhythm, hip fracture, atrial, tachycardia, rhythm, apcs, cardiac, regurgitation, aortic, hypertension, pulmonary, Cardiovascular / Pulmonary Patient with hypertension, syncope, and spinal stenosis - for recheck. Hypertension - Progress Note SUBJECTIVE:, The patient is a 78-year-old female who returns for recheck. She has hypertension. She denies difficulty with chest pain, palpations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY / SURGERY / HOSPITALIZATIONS:, Reviewed and unchanged from the dictation on 12/03/2003.,MEDICATIONS: ,Atenolol 50 mg daily, Premarin 0.625 mg daily, calcium with vitamin D two to three pills daily, multivitamin daily, aspirin as needed, and TriViFlor 25 mg two pills daily. She also has Elocon cream 0.1% and Synalar cream 0.01% that she uses as needed for rash.,ALLERGIES: ,Benadryl, phenobarbitone, morphine, Lasix, and latex.,FAMILY HISTORY / PERSONAL HISTORY: , Reviewed. Mother died from congestive heart failure. Father died from myocardial infarction at the age of 56. Family history is positive for ischemic cardiac disease. Brother died from lymphoma. She has one brother living who has had angioplasties x 2. She has one brother with asthma.,PERSONAL HISTORY:, Negative for use of alcohol or tobacco.,REVIEW OF SYSTEMS:,Bones and Joints: She has had continued difficulty with lower back pain particularly with standing which usually radiates down her right leg. She had been followed by Dr. Mills, but decided to see Dr. XYZ who referred to her Dr Isaac. She underwent several tests. She did have magnetic resonance angiography of the lower extremities and the aorta which were normal. She had nerve conduction study that showed several peripheral polyneuropathy. She reports that she has myelogram last week but has not got results of this. She reports that the rest of her tests have been normal, but it seems that vertebrae shift when she stands and then pinches the nerve. She is now seeing Dr. XYZ who comes to Hutchison from KU Medical Center, and she thinks that she probably will have surgery in the near future.,Genitourinary: She has occasional nocturia.,PHYSICAL EXAMINATION:,Vital Signs: Weight: 227.2 pounds. Blood pressure: 144/72. Pulse: 80. Temperature: 97.5 degrees.,General Appearance: She is an elderly female patient who is not in acute distress.,Mouth: Posterior pharynx is clear.,Neck: Without adenopathy or thyromegaly.,Chest: Lungs are resonant to percussion. Auscultation reveals normal breath sounds.,Heart: Normal S1 and S2 without gallops or rubs.,Abdomen: Without masses or tenderness to palpation.,Extremities: Without edema.,IMPRESSION/PLAN:,1. Hypertension. She is advised to continue with the same medication.,2. Syncope. She previously had an episode of syncope around Thanksgiving. She has not had a recurrence of this and her prior cardiac studies did not show arrhythmias.,3. Spinal stenosis. She still is being evaluated for this and possibly will have surgery in the near future. cardiovascular / pulmonary, progress note, hypertension, spinal stenosis, syncope, spinal, stenosis, infarction, orthopnea, Cardiovascular / Pulmonary Holter monitor report. Predominant rhythm is sinus. Triplet maximum rate of 178 beats per minute noted. Holter Monitor Report - 1 INDICATIONS: , Predominant rhythm is sinus. Heart rate varied between 56-128 beats per minute, average heart rate of 75 beats per minute. Minimum heart rate of 50 beats per minute.,640 ventricular ectopic isolated beats noted. Rare isolated APCs and supraventricular couplets.,One supraventricular triplet reported.,Triplet maximum rate of 178 beats per minute noted. cardiovascular / pulmonary, holter monitor, heart rate, supraventricular, triplet, heart, beatsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. Cardiovascular / Pulmonary Holter monitoring for syncope. Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds. Holter Monitor Report - 2 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. cardiovascular / pulmonary, artefact, ventricular contraction, holter monitor, premature contractions, mobitz type, holter, beatsNOTE Cardiovascular / Pulmonary Placement of a subclavian single-lumen tunneled Hickman central venous catheter. Surgeon-interpreted fluoroscopy. Hickman Central Venous Catheter Placement 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. cardiovascular / pulmonary, j wire, distal tip, stab incision, tunneled, hickman central venous catheter, subclavian, venous, fluoroscopy, hickman, catheterNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. Cardiovascular / Pulmonary Holter monitoring - For bradycardia and dizziness. Holter Monitoring 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. cardiovascular / pulmonary, holter monitoring, bradycardia, bigemini, dizziness, heart rate, interval, predominant, premature, premature ventricular contraction, rhythm, sinus, trigemini, ventricular, bradycardia and dizziness, premature ventricular, monitoring, Cardiovascular / Pulmonary Holter Monitor Report Holter Monitor Report INTERPRETATION:,1. Predominant rhythm is normal sinus rhythm.,2. No supraventricular arrhythmia.,3. Frequent premature ventricular contractions.,4. Trigemini and couplets.,5. No high-grade atrial ventricular block was noted.,6. Diary was not kept.,IMPRESSION:, Frequent premature atrial contractions, couplets, and trigemini., cardiovascular / pulmonary, atrial ventricular block, holter monitor report, holter monitor, frequent premature, holter, monitor, rhythm, ventricular, contractions, trigemini, atrial, Cardiovascular / Pulmonary Left heart catheterization, coronary angiography, and left ventriculogram. No angiographic evidence of coronary artery disease. Normal left ventricular systolic function. Normal left ventricular end diastolic pressure. Heart Catheterization, Ventriculography, & Angiography - 8 PROCEDURES,1. Left heart catheterization.,2. Coronary angiography.,3. Left ventriculogram.,PREPROCEDURE DIAGNOSIS:, Atypical chest pain.,POSTPROCEDURE DIAGNOSES,1. No angiographic evidence of coronary artery disease.,2. Normal left ventricular systolic function.,3. Normal left ventricular end diastolic pressure.,INDICATION: ,The patient is a 58-year-old male with past medical history significant for polysubstance abuse, chronic tobacco abuse, chronic alcohol dependence with withdrawal, atrial flutter, history of ventricular tachycardia with AICD placement, and hepatitis C. The patient was admitted for atypical chest pain and scheduled for cardiac catheterization.,PROCEDURE IN DETAIL:, After informed consent was signed by the patient, the patient was taken to the cardiac catheterization laboratory. He was prepped and draped in the usual sterile manner. The right inguinal area was anesthetized with 2% Xylocaine. A 4-French sheath was inserted into the right femoral artery using the modified Seldinger technique. JL4 and 3DRC catheters were used to cannulate the left and right coronary arteries respectively. Coronary angiographies were performed. These catheters were removed and exchanged for a 4-French pigtail catheter, which was positioned into the left ventricle. Left ventriculography was performed. The patient tolerated the procedure well. At the end of the procedure, all catheters and sheaths were removed. The patient was then transferred to telemetry in a stable condition.,HEMODYNAMIC DATA: , Hemodynamic data shows aortic pressures of 100/56 with mean of 70 mmHg and the LV 100/0 with LVEDP of 10 mmHg.,AORTIC VALVE: ,There is no significant gradient across this valve noted.,LV GRAM: , A 10 mL of contrast were delivered for 3 seconds for a total of 30 mL. Ejection fraction was calculated to be 69%. There were no wall motion abnormalities noted.,ANGIOGRAM,LEFT MAIN CORONARY ARTERY: , Left main coronary artery is a moderate-caliber vessel free of disease and trifurcates.,LAD: , LAD is a long, tortuous vessel which wraps around the apex. The LAD is small in caliber. In addition, there is a long bifurcating small-caliber diagonal branch noted. LAD and its branches are free of disease.,RAMUS INTERMEDIUS: , Ramus intermedius is a long small-caliber vessel free of disease.,LCX: , LCX is a nondominant small-caliber vessel with long bifurcating small-caliber distal OM branch. LCX and its branches are free of disease.,RCA:, RCA is a dominant small-caliber vessel with long small-caliber PDA branch. RCA and its branches are free of disease.,IMPRESSION,1. No angiographic evidence of coronary artery disease.,2. Normal left ventricular systolic function.,3. Normal left ventricular end diastolic pressure.,RECOMMENDATION: , Recommend to look for alternative causes of chest pain. Cardiovascular / Pulmonary Left heart catheterization, coronary angiography, left ventriculography. Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch. Heart Catheterization, Ventriculography, & Angiography - 7 PROCEDURE: , Left heart catheterization, coronary angiography, left ventriculography.,COMPLICATIONS: , None.,PROCEDURE DETAIL: , The right femoral area was draped and prepped in the usual fashion after Xylocaine infiltration. A 6-French arterial sheath was placed in the usual fashion. Left and right coronary angiograms were then performed in various projections after heparin was given 2000 units intraaortic. The right coronary artery was difficult to cannulate because of its high anterior takeoff. This was nondominant. Several catheters were used. Ultimately, an AL1 diagnostic catheter was used. A pigtail catheter was advanced across the aortic valve. Left ventriculogram was then done in the RAO view using 30 mL of contrast. Pullback gradient was obtained across the aortic valve. Femoral angiogram was performed through the sheath which was above the bifurcation, was removed with a Perclose device with good results. There were no complications. He tolerated this procedure well and returned to his room in good condition.,FINDINGS,1. Right coronary artery: This has an unusual high anterior takeoff. The vessel is nondominant, has diffuse mild-to-moderate disease.,2. Left main trunk: A 30% to 40% distal narrowing is present.,3. Left anterior descending: Just at the ostium of the vessel and up to and including the bifurcation of the first large diagonal branch, there is 80 to 90% narrowing. The diagonal is a large vessel about 3 mm in size.,4. Circumflex: Dominant vessel, 50% narrowing at the origin of the obtuse marginal. After this, there is 40% narrowing in the AV trunk. The small posterior lateral branch has diffuse mild disease and then the vessel gives rise to a fairly large posterior ventricular branch, which has 70% ostial narrowing, and then after this the posterior descending has 80% narrowing at its origin.,5. Left ventriculogram: Normal volume in diastole and systole. Normal systolic function is present. There is no mitral insufficiency or left ventricular outflow obstruction.,DIAGNOSES,1. Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch. Dominant circumflex system. Severe disease of the posterior descending. Mild left main trunk disease.,2. Normal left ventricular systolic function.,Given the complex anatomy of the predominant problem which is the left anterior descending; given its ostial stenosis and involvement of the bifurcation of the diagonal, would recommend coronary bypass surgery. The patient also has severe disease of the circumflex which is dominant. This anatomy is not appropriate for percutaneous intervention. The case will be reviewed with a cardiac surgeon. cardiovascular / pulmonary, heart catheterization, coronary angiography, left ventriculography, arterial sheath, coronary artery, obtuse marginal branch, angiography, catheterization, Cardiovascular / Pulmonary Very high PT-INR. she came in with pneumonia and CHF. She was noticed to be in atrial fibrillation, which is a chronic problem for her. High PT-INR - ER Visit REASON FOR THE VISIT:, Very high PT/INR.,HISTORY: , The patient is an 81-year-old lady whom I met last month when she came in with pneumonia and CHF. She was noticed to be in atrial fibrillation, which is a chronic problem for her. She did not want to have Coumadin started because she said that she has had it before and the INR has had been very difficult to regulate to the point that it was dangerous, but I convinced her to restart the Coumadin again. I gave her the Coumadin as an outpatient and then the INR was found to be 12. So, I told her to come to the emergency room to get vitamin K to reverse the anticoagulation.,PAST MEDICAL HISTORY:,1. Congestive heart failure.,2. Renal insufficiency.,3. Coronary artery disease.,4. Atrial fibrillation.,5. COPD.,6. Recent pneumonia.,7. Bladder cancer.,8. History of ruptured colon.,9. Myocardial infarction.,10. Hernia repair.,11. Colon resection.,12. Carpal tunnel repair.,13. Knee surgery.,MEDICATIONS:,1. Coumadin.,2. Simvastatin.,3. Nitrofurantoin.,4. Celebrex.,5. Digoxin.,6. Levothyroxine.,7. Vicodin.,8. Triamterene and hydrochlorothiazide.,9. Carvedilol.,SOCIAL HISTORY: ,She does not smoke and she does not drink.,PHYSICAL EXAMINATION:,GENERAL: Lady in no distress.,VITAL SIGNS: Blood pressure 100/46, pulse of 75, respirations 12, and temperature 98.2.,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.,ASSESSMENT:,1. Atrial fibrillation.,2. Coagulopathy, induced by Coumadin.,PLAN: , Her INR at the office was 12. I will repeat it, and if it is still elevated, I will give vitamin K 10 mg in 100 mL of D5W and then send her home and repeat the PT/INR next week. I believe at this time that it is too risky to use Coumadin in her case because of her age and comorbidities, the multiple medications that she takes and it is very difficult to keep an adequate level of anticoagulation that is safe for her. She is prone to a fall and this would be a big problem. We will use one aspirin a day instead of the anticoagulation. She is aware of the risk of stroke, but she is very scared of the anticoagulation with Coumadin and does not want to use the Coumadin at this time and I understand. We will see her as an outpatient. Cardiovascular / Pulmonary Left heart catheterization with left ventriculography and selective coronary angiography. A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function. Frequent PVCs. Metabolic syndrome. Heart Catheterization, Ventriculography, & Angiography - 6 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. cardiovascular / pulmonary, heart catheterization, ventriculography, coronary angiography, dyspnea, metabolic syndrome, two-vessel coronary artery disease, echocardiography, selective coronary angiography, anterior descending artery, branches, coronary, angiography, artery, catheterization, Cardiovascular / Pulmonary Left heart catheterization, left ventriculography, selective coronary angiography. Heart Catheterization, Ventriculography, & Angiography - 9 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. Cardiovascular / Pulmonary 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. Heart Catheterization, Ventriculography, & Angiography - 5 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. cardiovascular / pulmonary, ventricular arrhythmia, coronary artery syndrome, st segment elevation, heart catheterization, selective bilateral coronary angiography, ventriculography, catheterization, swan-ganz catheter, anterior descending artery, drug eluting stent, coronary artery, angioplasty, stent, coronary, anterior, angiography, artery, heart, Cardiovascular / Pulmonary Left heart catheterization, left ventriculography, selective coronary angiography, and right femoral artery approach. Heart Catheterization, Ventriculography, & Angiography - 12 PROCEDURE: , Cardiac catheterization by:,a. Left heart catheterization.,b. Left ventriculography.,c. Selective coronary angiography.,d. Right femoral artery approach.,COMPLICATIONS:, None.,MEDICATIONS,1. IV Versed.,2. IV fentanyl.,3. Intravenous fluid administration.,4. Heparin 3000 units IV.,INDICATIONS: , This 70-year-old Asian-American presents with chest pain syndrome, abnormal EKG suggesting an acute ST elevation, anterior myocardial infarction, being taken urgently to cardiac catheterization laboratory with possible coronary intervention.,NARRATIVE: , After detailed informed consent had been obtained. Usual benefits, alternatives, and risks of the procedure had been discussed with the patient, she was agreeable to proceed. The patient was prepped, draped, and anesthetized in the usual manner. Using modified Seldinger technique a 6 French introducer sheath inserted into the right femoral artery. Next, 6 French 3D right coronary catheter was inserted and right coronary angiogram was obtained in various projections. Next, a 6 French JL4.0 left coronary catheter was inserted and left coronary angiogram was obtained in various projections. Next, 4 French pigtail catheter was inserted into left ventricle under fluoroscopic guidance. Left ventricular angiogram was performed. Pre and post angiogram LVEDP, LV, and aortic pressures were obtained. At the end of the procedure catheters were removed and the introducer sheath was secured. The patient was admitted to the TCU in stable condition.,FINDINGS,HEMODYNAMICS,LEFT HEART PRESSURES:, LVEDP of 5, left ventricular systolic pressure of 81, central aortic pressure systolic 70, diastolic 20.,LEFT VENTRICULOGRAPHY: , Left ventricular chamber size is normal. The distal half of the anterior wall of the entire apex and the distal half of the inferior wall are completely akinetic with hypercontractility of the basilar segments of the anterior and inferior wall. Calculated ejection fraction of 51%, which probably overestimates the overall effective ejection fraction. No LV thrombus or mitral regurgitation present.,CORONARY ARTERIOGRAPHY,1. ,RIGHT CORONARY ARTERY: , The RCA gives rise to a posterior descending artery and a small posterolateral branch. Angiographically the right coronary artery is normal.,2. ,LEFT MAIN ARTERY:, The left main vessel is angiographically normal, bifurcates into left anterior descending artery and circumflex system.,3. ,LEFT ANTERIOR DESCENDING ARTERY: , The LAD gives rise to a normal complement of septal branches, diagonal branches, and extends around the apex. Angiographically the mid left anterior descending artery and distal left anterior descending artery demonstrates systolic compression of the vessel lumen, consistent with myocardial bridging. The degree of myocardial bridging appears moderate in the mid vessel and mild in the distal segment. Otherwise, there is no evidence of atherosclerotic obstruction.,4. ,CIRCUMFLEX ARTERY: , The circumflex gives rise to two large extremely tortuous marginal vessels that extend towards the apex. Angiographically, the circumflex artery is normal.,CONCLUSION: , This is a 70-year-old female with above clinical and cardiovascular history, who has angiographic evidence of a large anterior apical and inferior apical wall motion abnormality with angiographically patent coronary arteries with two segments of myocardial bridging involving the mid and distal left anterior descending artery. These angiographic findings are consistent with Takasubo syndrome, aka apical ballooning syndrome. The patient will be treated medically. Cardiovascular / Pulmonary Left heart catheterization with ventriculography, selective coronary angiography. Standard Judkins, right groin. Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4. Heart Catheterization, Ventriculography, & Angiography - 3 NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary angiography.,INDICATIONS: , Acute coronary syndrome.,TECHNIQUE OF PROCEDURE: , Standard Judkins, right groin. Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4. ,ANTICOAGULATION: ,The patient was on heparin at the time.,COMPLICATIONS: , None.,I reviewed with the patient the pros, cons, alternatives, risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of a cardiac chamber, dissection of an artery requiring countershock, infection, bleeding, ATN allergy, need for cardiac surgery. All questions were answered, and the patient desired to proceed.,HEMODYNAMIC DATA: ,Aortic pressure was in the physiologic range. No significant gradient across the aortic valve.,ANGIOGRAPHIC DATA,1. Ventriculogram: The left ventricle is of normal size and shape, normal wall motion, normal ejection fraction.,2. Right coronary artery: Dominant. There was insignificant disease in the system.,3. Left coronary: Left main, left anterior descending and circumflex systems showed no significant disease.,CONCLUSIONS,1. Normal left ventricular systolic function.,2. Insignificant coronary disease.,PLAN: , Based upon this study, medical therapy is warranted. Six-French Angio-Seal was used in the groin. cardiovascular / pulmonary, standard judkins, french pigtail, selective coronary angiography, heart catheterization, ventriculography, catheterization, angiography, Cardiovascular / Pulmonary Left heart catheterization with left ventriculography and selective coronary angiography. Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery. Heart Catheterization, Ventriculography, & Angiography - 4 NAME OF PROCEDURE,1. Left heart catheterization with left ventriculography and selective coronary angiography.,2. Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.,HISTORY: , This is a 58-year-old male who presented with atypical chest discomfort. The patient had elevated troponins which were suggestive of a myocardial infarction. The patient is suspected of having significant obstructive coronary artery disease, therefore he is undergoing cardiac catheterization.,PROCEDURE DETAILS: , Informed consent was given prior to the patient was brought to the catheterization laboratory. The patient was brought to the catheterization laboratory in postabsorptive state. The patient was prepped and draped in the usual sterile fashion, 2% Xylocaine solution was used to anesthetize the right femoral region. Using modified Seldinger technique, a 6-French arterial sheath was placed. Then, the patient had already been on heparin. Then, a Judkins left 4 catheter was intubated into the left main coronary artery. Several projections were obtained and the catheter was removed. A 3DRC catheter was intubated into the right coronary artery. Several projections were obtained and the catheter was removed. Then, a 3DRC guiding catheter was intubated into the right coronary artery. Then, a universal wire was advanced across the lesion into the distal right coronary artery. Integrilin was given. Then, a 3.0 x 12 Voyager balloon was inflated at 13 atmospheres for 30 seconds. Then, a projection was obtained. Then, a 3.0 x 15 Vision stent was placed into the distal right coronary artery. The stent was deployed at 15 atmospheres for 25 seconds. Post stent, the patient was given intracoronary nitroglycerin after one projection. Then, there was an attempt to place the intervention wire across the third posterolateral branch which was partially obstructed and this was not successful. Then, a pilot 150 wire was advanced across the lesion. Then, attempt to place the 2.0 x 8 power saver across the lesion was performed. However, it was felt that there was adequate flow and no further intervention needed to be performed. Then, the stent delivery system was removed. A pigtail catheter was placed into the left ventricle. Hemodynamics followed by left ventriculography was performed. Then, a pullback gradient was performed and the catheter was removed. Then, the right femoral artery was visualized and using angiography and then an Angio-Seal was applied. The patient was transferred back to his room in good condition.,FINDINGS,1. Hemodynamics: The opening aortic pressure was 116/61 with a mean of 64. The opening left ventricular pressure was 112 with end-diastolic pressure of 23. LV pressure on pullback was 106 with end-diastolic pressure of 21. Aortic pressure was 111/67 with a mean of 87. The closing pressure was 110/67.,2. Left ventriculography: The left ventricle was of normal cavity, size, and wall thickness. There is a mild anterolateral hypokinesis and moderate inferior and inferoapical hypokinesis. The overall systolic function appeared to be mildly reduced with ejection fraction between 40% and 45%. The mitral valve had no significant prolapse or regurgitation. The aortic valve appeared to be trileaflet and moved normally.,3. Coronary angiography: The left main is a normal-caliber vessel. This bifurcates into the left anterior descending and circumflex arteries. The left main is free of any significant obstructive coronary artery disease. The left anterior descending is a large vessel that extends to the apex. It gives off approximately 10 septal perforators and 5 diagonal branches. The first diagonal branch was large. The left anterior descending had mild irregularities, but no high-grade disease. The left circumflex is a nondominant vessel, which gives rise to two obtuse marginal branches. The two obtuse marginal branches are large. There is a relatively small left atrial branch. The left circumflex had a 50% stenosis after the first obtuse marginal branch. The rest of the vessel is moderately irregular, but no high-grade disease. The right coronary artery appears to be a dominant vessel, which gives rise to three right ventricular branches, four posterior lateral branches, two right atrial branches, and two small conus branches. The right coronary artery had moderate disease in its proximal segment with multiple areas of plaquing but no high-grade disease. However, distal between the second and third posterolateral branch, there is a 90% stenosis. The rest of the vessels had mild irregularities, but no high-grade disease. Then percutaneous transluminal coronary angioplasty of the right coronary artery resulted in a 20% residual stenosis. Then, after stent placement there was 0% residual stenosis; however, there was partial occlusion of the third posterolateral branch. Then, a wire was advanced through this and there was improvement of flow. There is improvement from TIMI grade 2 to TIMI grade 3 flow.,CLINICAL IMPRESSION,1. Successful percutaneous transluminal angioplasty and stent placement of the right coronary artery.,2. Two-vessel coronary artery disease.,3. Elevated left ventricular end-diastolic pressure.,4. Mild anterolateral and moderate inferoapical hypokinesis.,RECOMMENDATIONS,1. Integrilin.,2. Bed rest.,3. Risk factor modification.,4. Thallium scintigraphy in approximately six weeks. cardiovascular / pulmonary, heart catheterization, ventriculography, selective coronary angiography., angioplasty, stent placement, transluminal, percutaneous, coronary artery, coronary angiography, coronary angioplasty, diastolic pressure, obtuse marginal, percutaneous transluminal, catheterization, artery, coronary, angiography Cardiovascular / Pulmonary Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal. Heart Catheterization, Ventriculography, & Angiography - 2 NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.,INDICATION:, Recurrent angina. History of coronary disease.,TECHNICAL PROCEDURE: , Standard Judkins, right groin.,CATHETERS USED:, 6-French pigtail, 6-French JL4, 6-French JR4.,ANTICOAGULATION: , 2000 of heparin, 300 of Plavix, was begun on Integrilin.,COMPLICATIONS: , None.,STENT: , For stenting we used a 6-French left Judkins guide. Stent was a 275 x 13 Zeta.,DESCRIPTION OF PROCEDURE: , I reviewed with the patient the pros, cons, alternatives and risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of cardiac chamber, resection of an artery, arrhythmia requiring countershock, infection, bleeding, allergy, and need for vascular surgery. All questions were answered and the patient decided to proceed.,HEMODYNAMIC DATA: , Aortic pressure was within physiologic range. There was no significant gradient across the aortic valve.,ANGIOGRAPHIC DATA,1. Ventriculogram: Left ventricle was of normal size and shape with normal wall motion, normal ejection fraction.,2. Right coronary artery: Dominant. There was a lesion in the proximal portion in the 60% range, insignificant disease distally.,3. Left coronary artery: The left main coronary artery showed insignificant disease. The circumflex arose, showed about 30% proximally. Left anterior descending arose and the previously placed stent was perfectly patent. There was a large diagonal branch which showed 90% stenosis in its proximal portion. There was a lesion in the 30% to 40% range even more proximal.,I reviewed with the patient the options of medical therapy, intervention on the culprit versus bypass surgery. He desired that we intervene.,Successful stenting of the left anterior descending, diagonal. The guide was placed in the left main. We easily crossed the lesion in the diagonal branch of the left anterior descending. We advanced, applied and post-dilated the 275 x 13 stent. Final angiography showed 0% residual at the site of previous 90% stenosis. The more proximal 30% to 40% lesion was unchanged.,CONCLUSION,1. Successful stenting of the left anterior descending/diagonal. Initially there was 90% in the diagonal after stenting. There was 0% residual. There was a lesion a bit more proximal in the 40% range.,2. Left anterior descending stent remains patent.,3. 30% in the circumflex.,4. 60% in the right coronary.,5. Ejection fraction and wall motion are normal.,PLAN: , We have stented the culprit lesion. The patient will receive a course of aspirin, Plavix, Integrilin, and statin therapy. We used 6-French Angio-Seal in the groin. All questions have been answered. I have discussed the possibility of restenosis, need for further procedures. Cardiovascular / Pulmonary Selective coronary angiography, left heart catheterization, and left ventriculography. Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch. Heart Catheterization, Ventriculography, & Angiography - 11 NAME OF PROCEDURES,1. Selective coronary angiography.,2. Left heart catheterization.,3. Left ventriculography.,PROCEDURE IN DETAIL: ,The right groin was sterilely prepped and draped in the usual fashion. The area of the right coronary artery was anesthetized with 2% lidocaine and a 4-French sheath was placed. Conscious sedation was obtained using a combination of Versed 1 mg and fentanyl 50 mcg. A left #4, 4-French, Judkins catheter was placed and advanced through the ostium of the left main coronary artery. Because of difficulty positioning the catheter, the catheter was removed and a 6-French sheath was placed and a 6-French #4 left Judkins catheter was placed. This was advanced through the ostium of the left main coronary artery where selective angiograms were performed. Following this, the 4-French right Judkins catheter was placed and angiograms of the right coronary were performed. A pigtail catheter was placed and a left heart catheterization was performed, followed by a left ventriculogram. The left heart pullback was performed. The catheter was removed and a small injection of contrast was given to the sheath. The sheath was removed over a wire and an Angio-Seal was placed. There were no complications. Total contrast media was 200 mL of Optiray 350. Fluoroscopy time 5.3 minutes. Total x-ray dose is 1783 mGy.,HEMODYNAMICS: ,Rhythm is sinus throughout the procedure. LV pressure of 155/22 mmHg, aortic pressure of 160/80 mmHg. LV pullback demonstrates no gradient.,The right coronary artery is a nondominant vessel and free of disease. This also gives rise to the conus branch and two RV free wall branches. The left main has minor plaquing in the inferior aspect measuring no more than 10% to 15%. This vessel then bifurcates into the LAD and circumflex. The circumflex is a large caliber vessel and is dominant. This vessel gives rise to a large first marginal artery, a moderate sized second marginal branch, and additionally gives rise to a large third marginal artery and the PDA. There was a very eccentric and severe stenosis in the proximal circumflex measuring approximately 90% in severity. The origin of the first marginal artery has a severe stenosis measuring approximately 90% in severity. The distal circumflex has a 60% lesion just prior to the origin of the third marginal branch and PDA.,The proximal LAD is ectatic. The LAD gives rise to a large first diagonal artery that has a 90% lesion in its origin and a subtotal occlusion midway down the diagonal. Distal to the origin of this diagonal branch, there is another area of ectasia in the LAD, followed by an area of stenosis that in some views is approximately 50% in severity.,The left ventriculogram demonstrates hypokinesis of the distal half of the inferior wall. The overall ejection fraction is preserved. There is moderate dilatation of the aortic root. The calculated ejection fraction is 63%.,IMPRESSION,1. Left ventricular dysfunction as evidenced by increased left ventricular end diastolic pressure and hypokinesis of the distal inferior wall.,2. Coronary artery disease with high-grade and complex lesion in the proximal portion of the dominant large circumflex coronary artery. There is subtotal stenosis at the origin of the first obtuse marginal artery.,3. A 60% stenosis in the distal circumflex.,4. Ectasia of the proximal left anterior descending with 50% stenosis in the mid left anterior descending.,5. Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch. cardiovascular / pulmonary, coronary angiography, catheterization, ventriculography, heart catheterization, coronary artery, stenosis, artery, angiography Cardiovascular / Pulmonary Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery. Heart Catheterization, Ventriculography, & Angiography - 10 PROCEDURE: , Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.,PROCEDURE IN DETAIL: ,The patient was brought to the Catheterization Laboratory. After informed consent, he was medicated with Versed and fentanyl. The right groin was prepped and draped, and infiltrated with 2% Xylocaine. Percutaneously, #6-French arterial sheath was placed. Selective native left and right coronary angiography was performed followed by left ventricular angiography. The patient had a totally occluded right coronary. We initially started with a JR4 guide. We were able to a sport wire through the total occlusion and saw a very tight stenosis. We were able to get a 30 x 13 mm power saver balloon into the stenosis and dilated. We then attempted to put a 30 x 12 mm stent across the stenosis, but we had very little guide support, the guide kept coming out. We then switched to an AL1 guide and that too did not enable us to get anything to cross this lesion. We finally had to go an AL2 guide, we were concerned that this could cause some proximal dissection. That guided seated, we did have initial difficulty getting the wire back across the stenosis, and we did see a little staining suggesting we did have some tearing from the guide tip. The surgeons were put on notice in case we could not get this vessel open, but we were able to re-cross with a sport wire. We then re-dilated the area of stenosis and with good guide support, we were able to get a 30 x 23 mm Vision stent, where the lesion was and post-dilated it to 18 atmospheres. Routine angiography did show that the distal posterolateral branch seems to be occluded, whether this was from distal wire dissection or distal thrombosis was unclear, but we were able to re-wire that area and get a 25 x12 Vision balloon and dilate the area and re-establish flow to the small segment. We then came back because of the residual dissection proximal to the first stent and put a 30 x15 mm Vision stent at 18 atmospheres. Final angiography showed resolution of the dissection. We could see a little staining extrinsic to the stent. No perforation and excellent flow. During the intervention, we did give a bolus and drip of Angiomax. At the end of the procedure, we stopped the Angiomax and gave 600 mg of Plavix. We did a right femoral angiogram; however, the Angio-Seal plug could not take, so we used manual pressure and a Femostop. We transported the patient to his room in stable condition.,ANGIOGRAPHIC DATA:, Left main coronary is normal. Left anterior descending artery has a fair amount of wall disease proximally about 50 to 60% stenosis of the LAD before it bifurcates into diagonal. The diagonal does appear to have about 50% osteal stenosis. There is a lot of plaquing further down the diagonal, but good flow. The rest of the LAD looked good pass the proximal 60% stenosis and after the diagonal branch. Circumflex artery was nondominant vessel, consisting of an obtuse marginal vessel. The first obtuse marginal had a long 50% narrowing and then the AV groove branch was free of any disease. Some mild collaterals to the right were seen. Right coronary angiography revealed a total occlusion of the right coronary, just about 0.5 cm after its origin. After we got a wire across the area of occlusion, we could see some thrombosis and a 99% stenosis just at the curve. Following the balloon angioplasty, we established good flow down the distal vessel. We still had about residual 70% stenosis. When we had to go back with the AL2 guide, we could see a little bit of staining in the proximal portion of the vessel that we did not notice previously and we felt that the tip of the guide caused a little bit of intimal dissection. We re-dilated and then deployed. Repeat angiography now did show some hang up off dye distally. We never did have the wire that far down, so this was probably felt to be due to distal embolization of some thrombus. After deploying the stent, we had total resolution of the original lesion. We then directed our attention to the posterolateral branch, which the remainder of the vessel was patent giving off a large PDA. The posterolateral branch appeared to be occluded in its mid portion. We got a wire through and dilated this. We then came back and put a second stent in the proximal area of the right coronary proximal and abutting to the previous stent. Repeat angiography now showed no significant dissection, a little bit of contrast getting extrinsic to the stent probably in a little subintimal pouch, but this was excluded by the stent. There were no filling defects in the stent and excellent flow. The distal posterolateral branch did open up, although it was little under-filled and there may have been some mild residual disease there.,IMPRESSION: , Atherosclerotic heart disease with total occlusion of right coronary, successfully stented to zero residual with repair of a small proximal dissection. Minor distal disease of the posterolateral branch and 60% proximal left anterior descending coronary artery stenosis and 50% diagonal stenosis along with 50% stenosis of the first obtuse marginal branch. cardiovascular / pulmonary, heart catheterization, coronary angiography, ventricular angiography, intercoronary stenting, intercoronary, coronary, stenting, stenosis, angiography Cardiovascular / Pulmonary Left heart cath, selective coronary angiography, LV gram, right femoral arteriogram, and Mynx closure device. Normal stress test. Heart Catheterization & Angiography - 1 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., cardiovascular / pulmonary, selective coronary angiography, lv gram, femoral, mynx, heart cath, mynx closure device, heart catheterization, femoral arteriogram, stress test, coronary angiography, heart, arteriogram, catheterization, lad, coronary, angiography, Cardiovascular / Pulmonary Right and left heart catheterization, left ventriculogram, aortogram, and bilateral selective coronary angiography. 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. Heart Catheterization & Ventriculogram 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. Cardiovascular / Pulmonary Left heart catheterization, bilateral selective coronary angiography, saphenous vein graft angiography, left internal mammary artery angiography, and left ventriculography. Heart Catheterization, Ventriculography, & Angiography PROCEDURES PERFORMED:,1. Left heart catheterization.,2. Bilateral selective coronary angiography.,3. Saphenous vein graft angiography.,4. Left internal mammary artery angiography.,5. Left ventriculography.,INDICATIONS: , Persistent chest pain on maximum medical therapy with known history of coronary artery disease, status post coronary artery bypass grafting in year 2000.,PROCEDURE: , After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, an informed consent was obtained both verbally and in writing. The patient was taken to the Cardiac Catheterization Suite where the right femoral region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was then used to infiltrate the skin overlying the right femoral artery. Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery. A steel guidewire was then inserted through the needle into the vascular lumen without resistance. A small nick was then made in the skin and its pressure was held. The needle was removed over the guidewire. A #6 French 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. Next, angulated pigtail catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of the guidewire. The catheter was then advanced into the left ventricle. The guidewire was then removed. The catheter was connected to the manifold and flushed. LVEDP was then measured and found to be favorable for a left ventriculogram. The left ventriculogram was performed in the RAO position with a single power injection of non-ionic contrast material. LVEDP was then remeasured. Pullback was then performed, which failed to reveal an LVAO gradient. The catheter was then removed. Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. Using hand injections of non-ionic contrast material, the left coronary system was evaluated in several different views. Once adequate study has been performed, the catheter was removed. Next, a Judkins right #4 catheter was then 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 saphenous vein graft was engaged using hand injections of non-ionic contrast material. The saphenous vein graft was visualized in several different views. The Judkins right catheter was then advanced and the native coronary artery was engaged using hand injections of non-ionic contrast material. Right coronary system was evaluated in several different views. Once adequate study has been performed, the catheter was retracted. We were unable to engage the left subclavian artery thus the catheter was removed over an exchange wire. Next, a multipurpose catheter was advanced over the exchange wire. The wire was then easily passed into the left subclavian artery. The multipurpose catheter was then removed. LIMA catheter was then exchanged over the wire into the left subclavian artery. The guidewire was removed and the catheter was connected to the manifold and flushed. LIMA graft was then engaged using hand injections of non-ionic contrast material. The LIMA graft was evaluated in several different views. Once adequate study has been performed, the LIMA catheter was retracted under fluoroscopic guidance. The sheath was flushed for the final time. The patient was returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:,LEFT VENTRICULOGRAM: , There is no evidence of any wall motion abnormalities with an estimated ejection fraction of 60%. Left ventricular end-diastolic pressure was 24 mmHg preinjection and 26 mmHg postinjection. There is no mitral regurgitation. There is no LVAO or pullback.,LEFT MAIN CORONARY ARTERY: , The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries. There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING ARTERY: , The LAD is a small caliber vessel, which traverses through the intraventricular groove and wraps around the apex of the heart. There are luminal irregularities from the mid to distal portion. There is noted to be antegrade flow in the LIMA to LAD graft. There are very small diagonal branches, which are diffusely diseased.,CIRCUMFLEX ARTERY: , The circumflex is a small caliber vessel, which traverses through the atrioventricular groove. There are minor luminal irregularities throughout. There are very small obtuse marginal branches, which are diffusely diseased.,RIGHT CORONARY ARTERY:, The RCA is a small vessel with luminal irregularities throughout. The RCA is the dominant coronary artery.,Left internal mammary artery graft to the left anterior descending artery failed to demonstrate any hemodynamically significant stenosis. Saphenous vein graft to the obtuse marginal branches is a Y-graft, which bifurcates to the first obtuse marginal and the obtuse marginal branch. The saphenous vein graft to the obtuse marginal branches is widely patent without any evidence of hemodynamically significant disease.,IMPRESSION:,1. Diffusely diseased native vessels.,2. Saphenous vein graft to the obtuse marginal branch is widely patent.,3. Left internal mammary artery graft to the left anterior descending artery is patent.,4. Normal left ventricular function with ejection fraction of 60%.,5. Mildly elevated left-sided filling pressures.,PLAN:,1. The patient is to continue on her current medical regimen, which includes beta-blocker, aspirin, statin, and Plavix. The patient is unable to tolerate a long-acting nitrate, thus this will be discontinued.,2. We will add Norvasc 5 mg daily as well as hydrochlorothiazide 25 mg daily.,3. Risk factor modification was discussed with the patient including diet control as well as tobacco cessation.,4. The patient will need to be monitored closely for close lipid control as well as blood pressure control. Cardiovascular / Pulmonary Left heart catheterization and bilateral selective coronary angiography. Left ventriculogram was not performed. Heart Catheterization & Angiography - 2 PROCEDURES PERFORMED:,1. Left heart catheterization.,2. Bilateral selective coronary angiography.,3. Left ventriculogram was not performed.,INDICATION: , Non-ST elevation MI.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery. Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery. A steel guidewire was inserted through the needle into the vascular lumen without resistance. A small nick was then made in the skin. The pressure was held. The needle was removed over the guidewire. Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the left main coronary artery was engaged. Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views. Once an adequate study had been performed, the catheter was removed from the ostium of the left main coronary artery and a steel guidewire was inserted through the catheter. The catheter was then removed over the guidewire.,Next, a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to manifold and flushed. The catheter did slip into the left ventricle. During the rotation, the LVEDP was then measured. The ostium of the right coronary artery was then engaged. Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views. Once adequate study has been performed, the catheter was then removed. The sheath was lastly flushed for the final time.,FINDINGS:,LEFT MAIN CORONARY ARTERY: , The left main coronary artery is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries. There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING ARTERY: , The LAD is a moderate caliber vessel, which is subtotaled in its mid portion for approximately 1.5 cm to 1 cm with subsequent TIMI-I flow distally. The distal portion was diffusely diseased. The proximal portion otherwise shows minor luminal irregularities. The first diagonal branch demonstrated minor luminal irregularities throughout.,CIRCUMFLEX ARTERY: ,The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove. There is a 60% proximal lesion and a 90% mid lesion prior to the takeoff of the first obtuse marginal branch. The first obtuse marginal branch demonstrates minor luminal irregularities throughout.,RIGHT CORONARY ARTERY: , The RCA is a moderate caliber vessel, which demonstrates a 90% mid stenotic lesion. The dominant coronary artery gives off the posterior descending artery and posterolateral artery. The left ventricular end-diastolic pressure was approximately 22 mmHg. It should be noted that during injection of the contrast agent that there was ST elevation in the inferior leads, which resolved after the injection was complete.,IMPRESSION:,1. Three-vessel coronary artery disease involving a subtotaled left anterior descending artery with TIMI-I flow distally and 90% circumflex lesion and 90% right coronary artery lesion.,2. Mildly elevated left-sided filling pressures.,PLAN:,1. The patient will be transferred to Providence Hospital today for likely PCI of the mid LAD lesion with a surgical evaluation for a coronary artery bypass grafting. These findings and plan were discussed in detail with the patient and the patient's family. The patient is agreeable.,2. The patient will be continued on aggressive medical therapy including beta-blocker, aspirin, ACE inhibitor, and statin therapy. The patient will not be placed on Plavix secondary to the possibility for coronary bypass grafting. In light of the patient's history of cranial aneurysmal bleed, the patient will be held off of Lovenox and Integrilin. cardiovascular / pulmonary, non-st elevation, coronary angiography, ventriculogram, heart catheterization, bypass grafting, catheterization, coronary, artery, angiography, luminal, branch, descending, circumflex, vessel, guidewire, Cardiovascular / Pulmonary Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery. Heart Catheterization, Ventriculography, & Angiography - 1 PROCEDURE:, Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery. This gentleman has had a non-Q-wave, troponin-positive myocardial infarction, complicated by ventricular fibrillation.,PROCEDURE DETAILS:, The patient was brought to the catheterization lab, the chart was reviewed, and informed consent was obtained. Right groin was prepped and draped sterilely and infiltrated 2% Xylocaine. Using the Seldinger technique, a #6-French sheath was placed in the right femoral artery. ACT was checked and was low. Additional heparin was given. A #6-French pigtail catheter was passed. Left ventriculography was performed. The catheter was exchanged for a #6-French JL4 catheter. Nitroglycerin was given in the left main. Left coronary angiography was performed. The catheter was exchanged for a #6-French __________ coronary catheter. Nitroglycerin was given in the right main, and right coronary angiography was performed. Films were closely reviewed, and it was felt that he had a significant lesion in the RCA and the distal left circumflex is basically an OM. Considering his age and his course, it was elected to stent both these lesions. ReoPro was started, and the catheter was exchanged for a #6-French JR4 guide. ReoPro was given in the RCA to prevent no reflow. A 0.014 Universal wire was passed. The lesion was measured. A 4.5 x 18-mm stent was passed and deployed to moderate pressures with an excellent result. The catheter was removed and exchanged for a #6-French JL4 guide. The same wire was passed down the circumflex and the lesion measured. A 2.75 x 15-mm stent was deployed to a moderate pressure with an excellent result. Plavix was given. The catheter was removed and sheath was in place. The results were explained to the patient and his wife.,FINDINGS,1. Hemodynamics. Please see attached sheet for details. ED was 20. There is no gradient across the aortic valve.,2. Left ventriculography revealed septum upper limits of normal size with borderline normal LV systolic function with borderline normal wall motion, in which there is a question of diffuse, very minimal global hypokinesis. There is mild MR noted.,3. Coronary angiography.,a. Left main normal.,b. LAD. Some very minimal luminal irregularities. There is a 1st diagonal which has a branch that is 1.5 mm with a proximal 50% narrowing.,c. Left circumflex is basically a marginal branch, in which distally there was a long 98% lesion.,d. The RCA is large dominant and has a mid somewhat long 70% lesion.,4. Stenting.,a. The RCA revealed a lesion that went from 70% to a -5%.,B. The circumflex went from 95% to -5%.,CONCLUSION,1. Decreased left ventricular compliance.,2. Borderline normal overall ejection fraction with mild mitral regurgitation.,3. Triple-vessel coronary artery disease with a borderline lesion in a very small branch of the 1st diagonal and significant lesions in the mid dominant right coronary artery and the distal circumflex, which is basically old.,4. Successful stenting of the right coronary artery and the circumflex.,RECOMMENDATION: , ReoPro/stent protocol, Plavix for at least 9 months, aggressive control of risk factors. I have ordered Zocor and a fasting lipid panel.,AICD will be considered, realizing when this gentleman becomes ischemic he is at high risk for fibrillating. cardiovascular / pulmonary, heart catheterization, ventriculography, coronary angiography, stenting, distal circumflex, coronary artery, coronary, lesion, catheterization, cardiac, angiography, heart, rca, artery, circumflex, Cardiovascular / Pulmonary Right heart catheterization. Refractory CHF to maximum medical therapy. Heart Catheterization - 2 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. cardiovascular / pulmonary, chf, cardiac, catheterization, swan-ganz, heart catheterization, internal jugular, pulmonary artery, heart, jugular, cannulate, vascular, needle, pulmonary, therapy Cardiovascular / Pulmonary Left heart catheterization and bilateral selective coronary angiography. The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest. Heart Cath & Coronary Angiography PROCEDURE PERFORMED:,1. Left heart catheterization.,2. Bilateral selective coronary angiography.,ANESTHESIA: , 1% lidocaine and IV sedation, including fentanyl 25 mcg.,INDICATION: , The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest. It was accompanied by diaphoresis and shortness of breath. The patient was felt to be a candidate for mitral valve repair versus mitral valve replacement and underwent a stress test as part of his evaluation for chest pain. He underwent adenosine Cardiolite, which revealed 2 mm ST segment depression in leads II, III aVF, and V3, V4, and V5. Stress images revealed left ventricular dilatations suggestive of multivessel disease. He is undergoing evaluation today as a part of preoperative evaluation and because of the positive stress test.,PROCEDURE: , After risks, benefits, alternatives of the above mentioned procedure were explained to the patient in detail, informed consent was obtained both verbally and writing. The patient was taken to the Cardiac Catheterization Laboratory where the procedure was performed. The right inguinal area was sterilely cleansed with a 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 obtained, a thin-walled Argon needle was used to cannulate the right femoral artery.,The guidewire was then advanced through the lumen of the needle without resistance and a small nick was made in the skin. The needle was removed and a pressure was held. A #6 French arterial sheath was advanced over the guidewire without resistance. The dilator and guidewire were removed and the sheath was flushed. A Judkins left #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with the use of the guidewire. The guidewire was removed and the catheter was connected to the manifold and flushed. The ostium of the left main coronary artery was carefully engaged and limited evaluation was performed after noticing that the patient had a significant left main coronary artery stenosis. The catheter was withdrawn from the ostium of the left main coronary artery and the guidewire was inserted through the tip of the catheter. The catheter was removed over guidewire and a Judkins right #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with use of a guidewire. The guidewire was removed and the catheter was connected to the manifold and flushed. The ostium of the right coronary artery was carefully engaged and using hand injections of nonionic contrast material, the right coronary artery was evaluated in both diagonal views. This catheter was removed. The sheath was flushed the final time. The patient was taken to the postcatheterization holding area in stable condition.,FINDINGS:,LEFT MAIN CORONARY ARTERY:, This vessel is seen to be heavily calcified throughout its course. Begins as a moderate caliber vessel. There is a 60% stenosis in the distal portion with extension of the lesion to the ostium and proximal portions of the left anterior descending and left circumflex coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:, This vessel is heavily calcified in its proximal portion. It is of moderate caliber and seen post anteriorly in the intraventricular groove and wraps around the apex. There is a 90% stenosis in the proximal portion and 90% ostial stenosis in the first and second anterolateral branches. There is sequential 80% and 90% stenosis in the mid-portion of the vessel. Otherwise, the LAD is seen to be diffusely diseased.,LEFT CIRCUMFLEX CORONARY ARTERY: ,This vessel is also calcified in its proximal portion. There is a greater than 90% ostial stenosis, which appears to be an extension of the lesion in the left main coronary artery. There is a greater than 70% stenosis in the proximal portion of the first large obtuse marginal branch, otherwise, the circumflex system is seen to be diffusely diseased.,RIGHT CORONARY ARTERY: , This is a large caliber vessel and is the dominant system. There is diffuse luminal irregularities throughout the vessel and a 80% to 90% stenosis at the bifurcation above the posterior descending artery and posterolateral branch.,IMPRESSION:,1. Three-vessel coronary artery disease as described above.,2. Moderate mitral regurgitation per TEE.,3. Status post venous vein stripping of the left lower extremity and varicosities in both lower extremities.,4. Long-standing history of phlebitis.,PLAN: , Consultation will be obtained with Cardiovascular and Thoracic Surgery for CABG and mitral valve repair versus replacement. cardiovascular / pulmonary, left heart catheterization, bilateral selective coronary angiography, regurgitation, gallops, diaphoresis, shortness of breath, coronary angiography, proximal portions, catheterization, artery, coronary, bilateral, selective, angiography, mitral, stenosis, vessel, guidewire, Cardiovascular / Pulmonary A female for a complete physical and follow up on asthma with allergic rhinitis. Followup on Asthma 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. Cardiovascular / Pulmonary Left and right heart catheterization and selective coronary angiography. Coronary artery disease, severe aortic stenosis by echo. Heart Catheterization & Angiography 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. cardiovascular / pulmonary, lad proximal, femoral artery, sheath, catheter, selective coronary angiography, coronary artery disease, pulmonary capillary wedge, capillary wedge, coronary angiography, coronary artery, heart catheterization, catheterization, heart, artery, stenosis, angiography, pressure, coronary Cardiovascular / Pulmonary Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore-Tex graft. Chronic renal failure and thrombosed left forearm arteriovenous Gore-Tex bridge fistula. Fogarty Thrombectomy PREOPERATIVE DIAGNOSES:,1. Chronic renal failure.,2. Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,POSTOPERATIVE DIAGNOSIS:,1. Chronic renal failure.,2. Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,PROCEDURE PERFORMED:,1. Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula.,2. Revision of distal anastomosis with 7 mm interposition Gore-Tex graft.,ANESTHESIA:, General with controlled ventillation.,GROSS FINDINGS: , The patient is a 58-year-old black male with chronic renal failure. He undergoes dialysis through the left forearm bridge fistula and has small pseudoaneurysms at the needle puncture sites level. There is narrowing at the distal anastomosis due to intimal hypoplasia and the vein beyond it was of good quality.,OPERATIVE PROCEDURE: , The patient was taken to the OR suite, placed in supine position. General anesthetic was administered. Left arm was prepped and draped in appropriate manner. A Pfannenstiel skin incision was created just below the antecubital crease just deeper to the subcutaneous tissue. Utilizing both blunt and sharp dissections segment of the fistula was isolated ________ vessel loop. Transverse graftotomy was created. A #4 Fogarty catheter passed proximally and distally restoring inflow and meager inflow. A fistulogram was performed and the above findings were noted. In a retrograde fashion, the proximal anastomosis was patent. There was no narrowing within the forearm graft. Both veins were flushed with heparinized saline and controlled with a vascular clamp. A longitudinal incision was then created in the upper arm just deep into the subcutaneous tissue fascia. Utilizing both blunt and sharp dissection, the brachial vein as well as distal anastomosis was isolated. The distal anastomosis amputated off the fistula and oversewn with continuous running #6-0 Prolene suture tied upon itself. The vein was controlled with vascular clamps. Longitudinal venotomy created along the anteromedial wall. A 7 mm graft was brought on to the field and this was cut to shape and size. This was sewed to the graft in an end-to-side fashion with U-clips anchoring the graft at the heel and toe with interrupted #6-0 Prolene sutures. Good backflow bleeding was confirmed. The vein flushed with heparinized saline and graft was controlled with vascular clamp. The end of the insertion graft was cut to shape in length and sutured to the graft in an end-to-end fashion with continuous running #6-0 Prolene suture. Good backflow bleeding was confirmed. The graftotomy was then closed with interrupted #6-0 Prolene suture. Flow through the fistula was permitted, a good flow passed. The wound was copiously irrigated with antibiotic solution. Sponge, needles, instrument counts were correct. All surgical sites were inspected. Good hemostasis was noted. The incision was closed in layers with absorbable sutures. Sterile dressing was applied. The patient tolerated the procedure well and returned to the recovery room in apparent stable condition. cardiovascular / pulmonary, chronic renal failure, thrombosed, gore-tex bridge fistula, arteriovenous, fogarty, thrombectomy, anastomosis, gore tex bridge, fogarty thrombectomy, prolene suture, renal failure, distal anastomosis, bridge fistula, interposition, renal, prolene Cardiovascular / Pulmonary H&P for a female with Angina pectoris. H&P - Cardio (Angina) CHIEF COMPLAINT (1/1):, This 62 year old female presents today for evaluation of angina.,Associated signs and symptoms: Associated signs and symptoms include chest pain, nausea, pain radiating to the arm and pain radiating to the jaw.,Context: The patient has had no previous treatments for this condition.,Duration: Condition has existed for 5 hours.,Quality: Quality of the pain is described by the patient as crushing.,Severity: Severity of condition is severe and unchanged.,Timing (onset/frequency): Onset was sudden and with exercise. Patient has the following coronary risk factors: smoking 1 packs/day for 40 years and elevated cholesterol for 5 years. Patient's elevated cholesterol is not being treated with medication. Menopause occurred at age 53.,ALLERGIES:, No known medical allergies.,MEDICATION HISTORY:, Patient is currently taking Estraderm 0.05 mg/day transdermal patch.,PMH:, Past medical history unremarkable.,PSH:, No previous surgeries.,SOCIAL HISTORY:, Patient admits tobacco use She relates a smoking history of 40 pack years.,FAMILY HISTORY:, Patient admits a family history of heart attack associated with father (deceased).,ROS:, Unremarkable with exception of chief complaint.,PHYSICAL EXAMINATION:,General: Patient is a 62 year old female who appears pleasant, her given age, well developed,,oriented, well nourished, alert and moderately overweight.,Vital Signs: BP Sitting: 174/92 Resp: 28 HR: 88 Temp: 98.6 Height: 5 ft. 2 in. Weight: 150 lbs.,HEENT: Inspection of head and face shows head that is normocephalic, atraumatic, without any gross or neck masses. Ocular motility exam reveals muscles are intact. Pupil exam reveals round and equally reactive to light and accommodation. There is no conjunctival inflammation nor icterus. Inspection of nose reveals no abnormalities. Inspection of oral mucosa and tongue reveals no pallor or cyanosis. Inspection of the tongue reveals normal color, good motility and midline position. Examination of oropharynx reveals the uvula rises in the midline. Inspection of lips, teeth, gums, and palate reveals healthy teeth, healthy gums, no gingival,hypertrophy, no pyorrhea and no abnormalities.,Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable.,Thyroid examination reveals smooth and symmetric gland with no enlargement, tenderness or masses noted.,Carotid pulses are palpated bilaterally, are symmetric and no bruits auscultated over the carotid and vertebral arteries. Jugular veins examination reveals no distention or abnormal waves were noted. Neck lymph nodes are not noted.,Back: Examination of the back reveals no vertebral or costovertebral angle tenderness and no kyphosis or scoliosis noted.,Chest: Chest inspection reveals intercostal interspaces are not widened, no splinting, chest contours are normal and normal expansion. Chest palpation reveals no abnormal tactile fremitus.,Lungs: Chest percussion reveals resonance. Assessment of respiratory effort reveals even respirations without use of accessory muscles and diaphragmatic movement normal. Auscultation of lungs reveal diminished breath sounds bibasilar.,Heart: The apical impulse on heart palpation is located in the left border of cardiac dullness in the midclavicular line, in the left fourth intercostal space in the midclavicular line and no thrill noted. Heart auscultation reveals rhythm is regular, normal S1 and S2, no murmurs, gallop, rubs or clicks and no abnormal splitting of the second heart sound which moves normally with respiration. Right leg and left leg shows evidence of edema +6.,Abdomen: Abdomen soft, nontender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities with respect to size, tenderness or masses. Palpation of spleen reveals no abnormalities with respect to size, tenderness or masses. Examination of abdominal aorta shows normal size without presence of systolic bruit.,Extremities: Right thumb and left thumb reveals clubbing.,Pulses: The femoral, popliteal, dorsalis, pedis and posterior tibial pulses in the lower extremities are equal and normal. The brachial, radial and ulnar pulses in the upper extremities are equal and normal. Examination of peripheral vascular system reveals varicosities absent, extremities warm to touch, edema present - pitting and pulses are full to palpation. Femoral pulses are 2 /4, bilateral. Pedal pulses are 2 /4, bilateral.,Neurological: Testing of cranial nerves reveals nerves intact. Oriented to person, place and time. Mood and affect normal and appropriate to situation.Deep tendon reflexes normal. Touch, pin, vibratory and proprioception sensations are normal. Babinski reflex is absent. Coordination is normal. Speech is not aphasic. Musculoskeletal: Muscle strength is 5/5 for all groups tested. Gait and station examination reveals midposition without abnormalities.,Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. Skin is warm and dry with normal turgor and there is no icterus.,Lymphatics: No lymphadenopathy noted.,IMPRESSION:, Angina pectoris, other and unspecified.,PLAN:, ,DIAGNOSTIC & LAB ORDERS:, Ordered serum creatine kinase isoenzymes (CK isoenzymes). Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report. The following cardiac risk factor modifications are recommended: quit smoking and reduce LDL cholesterol to below 120 mg/dl.,PATIENT INSTRUCTIONS: Cardiovascular / Pulmonary Chest pain and non-Q-wave MI with elevation of troponin I only. Left heart catheterization, left ventriculography, and left and right coronary arteriography. Heart Catheterization - 1 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. cardiovascular / pulmonary, arteriography, coronary arteriography, heart catheterization, ventriculography, angiograms Cardiovascular / Pulmonary Flexible bronchoscopy to evaluate the airway (chronic wheezing). Flexible Bronchoscopy 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. cardiovascular / pulmonary, flexible bronchoscopy, airway, arytenoids, bronchomalacia, bronchoscopy, endoscopy suite, epiglottis, mainstem, subglottic, vocal cords, wheezing, chronic wheezing, tracheal, lobe, Cardiovascular / Pulmonary Flexible fiberoptic bronchoscopy with right lower lobe bronchoalveolar lavage and right upper lobe endobronchial biopsy. Severe tracheobronchitis, mild venous engorgement with question varicosities associated pulmonary hypertension, right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy. Flexible Fiberoptic Bronchoscopy 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. cardiovascular / pulmonary, bronchoalveolar lavage, endobronchial biopsy, cytology, microbiology, tracheobronchitis, venous engorgement, varicosities, pulmonary hypertension, flexible fiberoptic bronchoscopy, fiberoptic bronchoscopy, lobe, bronchoalveolar, lavage, endobronchial, hemorrhage, oropharynx, vascular, bronchoscopy, biopsy, submucosal, bronchoscope Cardiovascular / Pulmonary Right and left heart catheterization, coronary angiography, left ventriculography. Heart Catheterization PROCEDURES:,1. Right and left heart catheterization.,2. Coronary angiography.,3. Left ventriculography.,PROCEDURE IN DETAIL:, After informed consent was obtained, the patient was taken to the cardiac catheterization laboratory. Patient was prepped and draped in sterile fashion. Via modified Seldinger technique, the right femoral vein was punctured and a 6-French sheath was placed over a guide wire. Via modified Seldinger technique, right femoral artery was punctured and a 6-French sheath was placed over a guide wire. The diagnostic procedure was performed using the JL-4, JR-4, and a 6-French pigtail catheter along with a Swan-Ganz catheter. The patient tolerated the procedure well and there were immediate complications were noted. Angio-Seal was used at the end of the procedure to obtain hemostasis.,CORONARY ARTERIES:,LEFT MAIN CORONARY ARTERY: The left main coronary artery is of moderate size vessel with bifurcation into the left descending coronary artery and circumflex coronary artery. No significant stenotic lesions were identified in the left main coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY: The left descending artery is a moderate sized vessel, which gives rise to multiple diagonals and perforating branches. No significant stenotic lesions were identified in the left anterior descending coronary artery system.,CIRCUMFLEX ARTERY: The circumflex artery is a moderate sized vessel. The vessel is a stenotic lesion. After the right coronary artery, the RCA is a moderate size vessel with no focal stenotic lesions.,HEMODYNAMIC DATA: , Capital wedge pressure was 22. The aortic pressure was 52/24. Right ventricular pressure was 58/14. RA pressure was 14. The aortic pressure was 127/73. Left ventricular pressure was 127/15. Cardiac output of 9.2.,LEFT VENTRICULOGRAM: , The left ventriculogram was performed in the RAO projection only. In the RAO projection, the left ventriculogram revealed dilated left ventricle with mild global hypokinesis and estimated ejection fraction of 45 to 50%. Severe mitral regurgitation was also noted.,IMPRESSION:,1. Left ventricular dilatation with global hypokinesis and estimated ejection fraction of 45 to 50%.,2. Severe mitral regurgitation.,3. No significant coronary artery disease identified in the left main coronary artery, left anterior descending coronary artery, circumflex coronary artery or the right coronary artery., cardiovascular / pulmonary, ventriculography, catheterization, seldinger, hypokinesis, estimated ejection fraction, severe mitral regurgitation, descending coronary artery, coronary artery, aortic pressure, heart catheterization, stenotic lesions, coronary, artery, heart, angiography, anterior, ventricular, ventriculogram, lesions Cardiovascular / Pulmonary Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe. Right hyoid mass, rule out carcinomatosis. Chronic obstructive pulmonary disease. Changes consistent with acute and chronic bronchitis. Fiberoptic Flexible Bronchoscopy PREOPERATIVE DIAGNOSES:,1. Right hyoid mass, rule out carcinomatosis.,2. Weight loss.,3. Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1. Right hyoid mass, rule out carcinomatosis.,2. Weight loss.,3. Chronic obstructive pulmonary disease.,4. Changes consistent with acute and chronic bronchitis.,5. Severe mucosal irregularity with endobronchial narrowing of the right middle and lower lobes.,6. Left vocal cord irregularity.,PROCEDURE PERFORMED: ,Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.,ANESTHESIA: , Demerol 50 mg with Versed 3 mg as well as topical cocaine and lidocaine solution.,LOCATION OF PROCEDURE: , Endoscopy suite #4.,After informed consent was obtained and following the review of the procedure including procedure as well as possible risks and complications were explained and consent was previously obtained, the patient was sedated with the above stated medication and the patient was continuously monitored on pulse oximetry, noninvasive blood pressure, and EKG monitoring. Prior to starting the procedure, the patient was noted to have a baseline oxygen saturation of 86% on room air. Subsequently, she was given a bronchodilator treatment with Atrovent and albuterol and subsequent saturation increased to approximately 90% to 91% on room air.,The patient was placed on a supplemental oxygen as the patient was sedated with above-stated medication. As this occurred, the bronchoscope was inserted into the right naris with good visualization of the nasopharynx and oropharynx. The cords were noted to oppose bilaterally on phonation. There was some slight mucosal irregularity noted on the vocal cord on the left side. Additional topical lidocaine was instilled on the vocal cords, at which point the bronchoscope was introduced into the trachea, which was midline in nature. The bronchoscope was then advanced to the distal trachea and additional lidocaine was instilled. At this time, the bronchoscope was further advanced through the main stem and additional lidocaine was instilled. Bronchoscope was then further advanced into the right upper lobe, which revealed no evidence of any endobronchial lesion. The mucosa was diffusely friable throughout. Bronchoscope was then slowly withdrawn into the right main stem and additional lidocaine was instilled. At this point, the bronchoscope was then advanced to the right bronchus intermedius. At this time, it was noted that there was severe mucosal irregularities of nodular in appearance significantly narrowing the right lower lobe and right middle lobe opening. The mucosal area throughout this region was severely friable. Additional lidocaine was instilled as well as topical epinephrine. At this time, bronchoscope was maintained in this region and endobronchial biopsies were performed. At the initial attempt of inserting biopsy forceps, some resistance was noted within the proximal channel at this time making advancement of the biopsy forceps out of the proximal channel impossible. So the biopsy forceps was withdrawn and the bronchoscope was completely withdrawn and new bronchoscope was then utilized. At this time, bronchoscope was then reinserted into the right naris and subsequently advanced to the vocal cords into the right bronchus intermedius without difficulty. At this time, the biopsy forceps were easily passed and visualized in the right bronchus intermedius. At this time, multiple mucosal biopsies were performed with some mild oozing noted. Several aliquots of normal saline lavage followed. After completion of multiple biopsies there was good hemostasis. Cytology flushing was also performed in this region and subsequently several aliquots of additional normal saline lavage was followed. Bronchoscope was unable to be passed distally to the base of the segment of the right lower lobe or distal to the further visualized endobronchial anatomy of the right middle lobe subsegments. The bronchoscope was then withdrawn to the distal trachea.,At this time, bronchoscope was then advanced to the left main stem. Additional lidocaine was instilled. The bronchoscope was advanced to the left upper and lower lobe subsegments. There was no endobronchial lesion visualized. There is mild diffuse erythema and fibromucosa was noted throughout. No endobronchial lesion was visualized in the left bronchial system. The bronchoscope was then subsequently further withdrawn to the distal trachea and readvanced into the right bronchial system. At this time, bronchoscope was readvanced into the right bronchus intermedius and additional aliquots of normal saline lavage until cleared. There is no gross bleeding evidenced at this time or diffuse mucosal erythema and edema present throughout. The bronchoscope was subsequently withdrawn and the patient was sent to recovery room. During the bronchoscopy, the patient noted ________ have desaturation and required increasing FiO2 with subsequent increased saturation to 93% to 94%. The patient remained at this level of saturation or greater throughout the remaining of the procedure.,The patient postprocedure relates having some intermittent hemoptysis prior to the procedure as well as moderate exertional dyspnea. This was confirmed by her daughter and mother who were also present at the bedside postprocedure. The patient did receive a nebulizer bronchodilator treatment immediately prebronchoscopy and postprocedure as well. The patient also admitted to continued smoking in spite of all of the above. The patient was extensively counseled regarding the continued smoking especially with her present symptoms. She was advised regarding smoking cessation. The patient was also placed on a prescription of prednisone 2 mg tablets starting at 40 mg a day decreasing every three days to continue to wean off. The patient was also administered Solu-Medrol 60 mg IV x1 in recovery room. There was no significant bronchospastic component noted, although because of the severity of the mucosal edema, erythema, and her complaints, short course of steroids will be instituted. The patient was also advised to refrain from using any aspirin or other nonsteroidal anti-inflammatory medication because of her hemoptysis. At this time, the patient was also advised that if hemoptysis were to continue or worsen or develop progressive dyspnea, to either contact myself, , or return to ABCD Emergency Room for evaluation of possible admission. However, the above was reviewed with the patient in great detail as well as with her daughter and mother who were at the bedsite at this time as well. cardiovascular / pulmonary, carcinomatosis, chronic obstructive pulmonary disease, fiberoptic flexible bronchoscopy, lavage, brushings, endobronchial mucosal biopsies, mucosal, bronchoscope, atrovent, topical, fiberoptic, hemoptysis, bronchoscopy, endobronchial, oropharynx Cardiovascular / Pulmonary Flexible fiberoptic bronchoscopy diagnostic with right middle and upper lobe lavage and lower lobe transbronchial biopsies. Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB. Flexible Fiberoptic Bronchoscopy -1 POSTOPERATIVE DIAGNOSIS:, Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.,PROCEDURE PERFORMED:, Flexible fiberoptic bronchoscopy diagnostic with:,a. Right middle lobe bronchoalveolar lavage.,b. Right upper lobe bronchoalveolar lavage.,c. Right lower lobe transbronchial biopsies.,COMPLICATIONS:, None.,Samples include bronchoalveolar lavage of the right upper lobe and right middle lobe and transbronchial biopsies of the right lower lobe.,INDICATION: ,The patient with a history of TB and caseating granulomata on open lung biopsy with evidence of interstitial lung disease and question tuberculosis.,PROCEDURE:, After obtaining an informed consent, the patient was brought to the Bronchoscopy Suite with appropriate isolation related to ______ precautions. The patient had appropriate oxygen, blood pressure, heart rate, and respiratory rate monitoring applied and monitored continuously throughout the procedure. 2 liters of oxygen via nasal cannula was applied to the nasopharynx with 100% saturations achieved. Topical anesthesia with 10 cc of 4% Xylocaine was applied to the right nares and oropharynx. Subsequent to this, the patient was premedicated with 50 mg of Demerol and then Versed 1 mg sequentially for a total of 2 mg. With this, adequate consciousness sedation was achieved. 3 cc of 4% viscous Xylocaine was applied to the right nares. The bronchoscope was then advanced through the right nares into the nasopharynx and oropharynx.,The oropharynx and larynx were well visualized and showed mild erythema, mild edema, otherwise negative.,There was normal vocal cord motion without masses or lesions. Additional topical anesthesia with 2% Xylocaine was applied to the larynx and subsequently throughout the tracheobronchial tree for a total of 18 cc. The bronchoscope was then advanced through the larynx into the trachea. The trachea showed mild evidence of erythema and moderate amounts of clear frothy secretions. These were suctioned clear. The bronchoscope was then advanced through the carina, which was sharp. Then advanced into the left main stem and each segment, subsegement in the left upper lingula and lower lobe was visualized. There was mild tracheobronchitis with mild friability throughout. There was modest amounts of white secretion. There were no other findings including evidence of mass, anatomic distortions, or hemorrhage. The bronchoscope was subsequently withdrawn and advanced into the right mainstem. Again, each segment and subsegment was well visualized. The right upper lobe anatomy showed some segmental distortion with dilation and irregularities both at the apical region as well as in the subsegments of the anteroapical and posterior segments. No specific masses or other lesions were identified throughout the tracheobronchial tree on the right. There was mild tracheal bronchitis with friability. Upon coughing, there was punctate hemorrhage. The bronchoscope was then advanced through the bronchus intermedius and the right middle lobe and right lower lobe. These again had no other anatomic lesions identified. The bronchoscope was then wedged in the right middle lobe and bronchoalveolar samples were obtained. The bronchoscope was withdrawn and the area was suctioned clear. The bronchoscope was then advanced into the apical segment of the right upper lobe and the bronchioalveolar lavage again performed. Samples were taken and the bronchoscope was removed suctioned the area clear. The bronchoscope was then re-advanced into the right lower lobe and multiple transbronchial biopsies were taken under fluoroscopic guidance in the posterior and lateral segments of the right lower lobe. Minimal hemorrhage was identified and suctioned clear without difficulty. The bronchoscope was then withdrawn to the mainstem. The area was suctioned clear. Fluoroscopy revealed no evidence of pneumothorax. The bronchoscope was then withdrawn. The patient tolerated the procedure well without evidence of desaturation or complications. cardiovascular / pulmonary, bronchoalveolar, lavage, lobe, tracheobronchitis, granulomatous, miliary tb, tb, flexible fiberoptic bronchoscopy, bronchoscope, flexible, fiberoptic, transbronchial, biopsies, bronchoscopy, oropharynx, Cardiovascular / Pulmonary Left arm fistulogram. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein. Ultrasound-guided access of left upper arm brachiocephalic fistula. Fistulogram & Angioplasty PREPROCEDURE DIAGNOSIS: , End-stage renal disease.,POSTPROCEDURE DIAGNOSIS: , End-stage renal disease.,PROCEDURES PERFORMED,1. Left arm fistulogram.,2. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.,3. Ultrasound-guided access of left upper arm brachiocephalic fistula.,ANESTHESIA:, Sedation with local.,COMPLICATIONS:, None.,CONDITION:, Fair.,DISPOSITION:, PACU.,ACCESS SITE:, Left upper arm brachiocephalic fistula.,SHEATH SIZE: , 5 French.,CONTRAST TYPE: , JC PEG tube 70.,CONTRAST VOLUME: , 48 mL.,FLUOROSCOPY TIME: , 16 minutes.,INDICATION FOR PROCEDURE: , This is a 38-year-old female with a left upper arm brachiocephalic fistula which has been transposed. The patient recently underwent a fistulogram with angioplasty at the proximal upper arm cephalic vein due to a stenosis detected on Duplex ultrasound. The patient subsequently was noted to have poor flow to the fistula, and the fistula was difficult to palpate. A repeat ultrasound was performed which demonstrated a high-grade stenosis involving the distal upper arm cephalic vein just distal to the brachial anastomosis. The patient presents today for a left arm fistulogram with angioplasty. The risks, benefits, and alternatives of the procedure were discussed with the patient and understands and in agreement to proceed.,PROCEDURE DETAILS: ,The patient was brought to the angio suite and laid supine on the table. After sedation was administered, the left arm was then prepped and draped in a standard surgical fashion. Continuous pulse oximetry and cardiac monitoring were performed throughout the procedure. The patient was given 1 g of IV Ancef prior to incision.,The left brachiocephalic fistula was visualized with bevel ultrasound. The cephalic vein in the proximal upper arm region appeared to be of adequate caliber. There was an area of stenosis at the proximal cephalic vein just distal to the brachial artery anastomosis. The cephalic vein in the proximal forearm region was easily compressible. The skin overlying the vessel was injected with 1% lidocaine solution. A small incision was made with the #11 blade. The cephalic vein then was cannulated with a 5 French micropuncture introducer sheath. The sheath was advanced over the wire. A fistulogram was performed which demonstrated a high-grade stenosis just distal to the brachial artery anastomosis. The introducer sheath was then exchanged for a 5 French sheath over a 0.025 guide wire. The sheath was aspirated and flushed with heparinized saline solution. A 0.025 glidewire was then obtained and advanced, placed over the sheath and across the area of stenosis into the brachial artery. A 5 French short Kumpe catheter was used to guide the wire into the distal brachial and radial artery. After crossing the area of stenosis, a 5 x 20 mm standard angioplasty balloon was obtained and prepped from the back table. This was placed over the glidewire into the area of stenosis and inflated to 14 mmHg pressure and then deflated. The balloon was then removed over the wire and repeat fistulogram was performed which demonstrated significant improvement. However, there is still a remainder of residual stenosis. The 5-mm balloon was placed over the wire again and a repeat angioplasty was performed. The balloon was then removed over the wire and a repeat angiogram was performed which demonstrated again an area of stenosis right at the anastomosis. The glidewire was removed and a 0.014 guide wire was then obtained and placed through the sheath and across the brachial anastomosis and into the radial artery. A 4 x 20 mm cutting balloon was obtained and prepped on the back table. The 5 French sheath was then exchanged for a 6 French sheath. The balloon was then placed over the 0.014 guide wire into the area of stenosis and then inflated to normal pressures at 8 mmHg. The balloon was then deflated and removed over the wire. A 5 mm x 20 mm balloon was obtained and prepped and placed over the wire into the area of stenosis and inflated to pressures of 14 mmHg. A repeat fistulogram was performed after the removal of the balloon which demonstrated excellent results with no significant residual stenosis. The patient actually had a nice palpable thrill at this point. The fistulogram of the distal cephalic vein at the subclavian anastomosis was performed which demonstrated a mild area of stenosis. The sheath was removed and blood pressure was held over the puncture site for approximately 10 minutes.,After hemostasis was achieved, the cephalic vein again was visualized with bevel ultrasound. The proximal cephalic vein was then cannulated after injecting the skin overlying the vessel with a 1% lidocaine solution. A 5 French micropuncture introducer sheath was then placed over the wire into the proximal cephalic vein. A repeat fistulogram was performed which demonstrated an area of stenosis within the distal cephalic vein just prior to the subclavian vein confluence. The 5 French introducer sheath was then exchanged for a 5 French sheath. The 5 mm x 20 mm balloon was placed over a 0.035 glidewire across the area of stenosis. The balloon was inflated to 14 mmHg. The balloon was then deflated and a repeat fistulogram was performed through the sheath which demonstrated good results. The sheath was then removed and blood pressure was held over the puncture site for approximately 10 minutes. After adequate hemostasis was achieved, the area was cleansed in 2x2 and Tegaderm was applied. The patient tolerated the procedure without any complications. I was present for the entire case. The sponge, instrument, and needle counts are correct at the end of the case. The patient was subsequently taken to PACU in stable condition.,ANGIOGRAPHIC FINDINGS:, The initial left arm brachiocephalic fistulogram demonstrated a stenosis at the brachial artery anastomosis and distally within the cephalic vein. After standard balloon angioplasty, there was a mild improvement but some residual area of stenosis remained at the anastomosis. Then postcutting balloon angioplasty, venogram demonstrated a significant improvement without any evidence of significant stenosis.,Fistulogram of the proximal cephalic vein demonstrated a stenosis just prior to the confluence with the left subclavian vein. Postangioplasty demonstrated excellent results with the standard balloon. There was no evidence of any contrast extravasation.,IMPRESSION,1. High-grade stenosis involving the cephalic vein at the brachial artery anastomosis and distally. Postcutting balloon and standard balloon angioplasty demonstrated excellent results without any evidence of contrast extravasation.,2. A moderate grade stenosis within the distal cephalic vein just prior to the confluence to the left subclavian vein. Poststandard balloon angioplasty demonstrated excellent results. No evidence of contrast extravasation. Cardiovascular / Pulmonary Emergent fiberoptic bronchoscopy with lavage. Status post multiple trauma/motor vehicle accident. Acute respiratory failure. Acute respiratory distress/ventilator asynchrony. Hypoxemia. Complete atelectasis of left lung. Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system. Fiberoptic Bronchoscopy with Lavage PREOPERATIVE DIAGNOSES:,1. Status post multiple trauma/motor vehicle accident.,2. Acute respiratory failure.,3. Acute respiratory distress/ventilator asynchrony.,4. Hypoxemia.,5. Complete atelectasis of left lung.,POSTOPERATIVE DIAGNOSES:,1. Status post multiple trauma/motor vehicle accident.,2. Acute respiratory failure.,3. Acute respiratory distress/ventilator asynchrony.,4. Hypoxemia.,5. Complete atelectasis of left lung.,6. Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,PROCEDURE PERFORMED: ,Emergent fiberoptic plus bronchoscopy with lavage.,LOCATION OF PROCEDURE: ,ICU. Room #164.,ANESTHESIA/SEDATION:, Propofol drip, Brevital 75 mg, morphine 5 mg, and Versed 8 mg.,HISTORY,: The patient is a 44-year-old male who was admitted to ABCD Hospital on 09/04/03 status post MVA with multiple trauma and subsequently diagnosed with multiple spine fractures as well as bilateral pulmonary contusions, requiring ventilatory assistance. The patient was noted with acute respiratory distress on ventilator support with both ventilator asynchrony and progressive desaturation. Chest x-ray as noted above revealed complete atelectasis of the left lung. The patient was subsequently sedated and received one dose of paralytic as noted above followed by emergent fiberoptic flexible bronchoscopy.,PROCEDURE DETAIL,: A bronchoscope was inserted through the oroendotracheal tube, which was partially obstructed with blood clots. These were lavaged with several aliquots of normal saline until cleared. The bronchoscope required removal because the tissue/clots were obstructing the bronchoscope. The bronchoscope was reinserted on several occasions until cleared and advanced to the main carina. The endotracheal tube was noted to be in good position. The bronchoscope was advanced through the distal trachea. There was a white tissue completely obstructing the left main stem at the carina. The bronchoscope was advanced to this region and several aliquots of normal saline lavage were instilled and suctioned. Again this partially obstructed the bronchoscope requiring several times removing the bronchoscope to clear the lumen. The bronchoscope subsequently was advanced into the left mainstem and subsequently left upper and lower lobes. There was diffuse mucus impactions/tissue as well as intermittent clots. There was no evidence of any active bleeding noted. Bronchoscope was adjusted and the left lung lavaged until no evidence of any endobronchial obstruction is noted. Bronchoscope was then withdrawn to the main carina and advanced into the right bronchial system. There is no plugging or obstruction of the right bronchial system. The bronchoscope was then withdrawn to the main carina and slowly withdrawn as the position of endotracheal tube was verified, approximately 4 cm above the main carina. The bronchoscope was then completely withdrawn as the patient was maintained on ventilator support during and postprocedure. Throughout the procedure, pulse oximetry was greater than 95% throughout. There is no hemodynamic instability or variability noted during the procedure. Postprocedure chest x-ray is pending at this time. cardiovascular / pulmonary, multiple trauma, motor vehicle accident, acute respiratory failure, acute respiratory distress, ventilator asynchrony, hypoxemia, atelectasis, bronchoscopy, lavage, fiberoptic bronchoscopy, endotracheal tube, acute respiratory, asynchrony, bronchoscope, fiberoptic, endotracheal, bronchial, ventilatory, tube, respiratory, Cardiovascular / Pulmonary Right common femoral artery cannulation, cnscious sedation using IV Versed and IV fentanyl, retrograde bilateral coronary angiography, abdominal aortogram with pelvic runoff, left external iliac angiogram with runoff to the patient's left foot, left external iliac angiogram with runoff to the patient's right leg, right common femoral artery angiogram runoff to the patient's right leg. Femoral Artery Cannulation & Aortogram PREOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.,POSTOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD. Significant coronary artery disease, very severe PAD.,PROCEDURES PERFORMED:,1. Right common femoral artery cannulation.,2. Conscious sedation using IV Versed and IV fentanyl.,3. Retrograde bilateral coronary angiography.,4. Abdominal aortogram with pelvic runoff.,5. Left external iliac angiogram with runoff to the patient's left foot.,6. Left external iliac angiogram with runoff to the patient's right leg.,7. Right common femoral artery angiogram runoff to the patient's right leg.,PROCEDURE IN DETAIL:, The patient was taken to the cardiac catheterization laboratory after having a valid consent. He was prepped and draped in the usual sterile fashion.,After local infiltration with 2% Xylocaine, the right common femoral artery was entered percutaneously and a 4-French sheath was placed over the artery. The arterial sheath was flushed throughout the procedure.,Conscious sedation was obtained using IV Versed and IV fentanyl.,With the help of a Wholey wire, a 4-French 4-curve Judkins right coronary artery catheter was advanced into the ascending aorta. The wire was removed, the catheter was flushed. The catheter was engaged in the left main. Injections were performed at the left main in different views. The catheter was then exchanged for an RCA catheter, 4-French 4-curve which was advanced into the ascending aorta with the help of a J-wire. The wire was removed, the catheter was flushed. The catheter was engaged in the RCA. Injections were performed at the RCA in different views.,The catheter was then exchanged for a 5-French Omniflush catheter, which was advanced into the abdominal aorta with the help of a regular J-wire. The wire was removed. The catheter was flushed. Abdominal aortogram was then performed with runoff to the patient's pelvis.,The Omniflush catheter was then retracted into the aortic bifurcation. Through the Omniflush catheter, a Glidewire was then advanced distally into the left SFA. The Omniflush was then removed. Through the wire, a Royal Flush catheter was then advanced into the left external iliac. The wire was removed. Left external iliac angiogram was performed with runoff to the patient's left foot _______ was then performed. The catheter was then retracted into the left common iliac. Angiograms were performed of the left common iliac with runoff to the patient's left groin. The catheter was then positioned at the level of the right common iliac. Angiogram of the right common iliac with runoff to the patient's right leg was then performed. The catheter was then removed with the help of a J-wire. The J-wire was left in the abdominal aorta. Hand injection was performed of the right common femoral artery in 2 locations with runoff to the patient's right leg.,The wire was then removed. The arterial sheath was then removed after being flushed. Hemostasis was obtained using hand compression.,The patient tolerated the procedure well and had no complications. At the end of the procedure, palpable right common femoral pulses were noted as well as 1+ right PT pulse.,Hemodynamic Findings:, Aortic pressure 140/70.,ANGIOGRAPHIC FINDINGS: , Left main with calcification 25% to 40% lesion.,The left main is very short.,LAD with calcification 25% to 40% proximal lesion.,D1 has 25% lesion. No in-stent restenosis was noted in D1.,D2 and D3 are very small with luminal irregularities.,Circumflex artery was diseased throughout the vessel. The circumflex artery has an ostium of 60% to 75% lesion distally and the circumflex has a 75% lesion.,OM1 has 25% to 40% lesion. These OMs are small with luminal irregularities.,RCA has 25% to 50% lesion, distally, the RCA has luminal irregularities.,Left ventriculography was not done.,ABDOMINAL AORTOGRAM:, Right renal artery with luminal irregularities. Left renal artery with luminal irregularities. The abdominal aorta has 25% lesion.,Right common iliac has a 25% to 50% lesion as well as a distal 75% lesion.,The right external iliac has a proximal 75% lesion.,The distal part of the right external iliac as well as the right common femoral appears to be occlusive by the 5-French sheath.,The right SFA was visualized, although not very well.,Left common iliac with 25% to 50% lesion. Left external iliac with 25% to 40% lesion. Left common femoral with 25% to 40% lesion. Left SFA with 25% lesion. Left popliteal with wall luminal irregularities.,Three-vessel runoff is noted at the level of the left knee and at the level of the left ankle.,Conclusions: Severe coronary artery disease. Very severe peripheral arterial disease.,PLAN: , Because of the anatomic distribution of the coronary artery disease, for now we will continue medical treatment for CAD. We will proceed with revascularization of the right external iliac as well as right common femoral. Discontinue tobacco. Cardiovascular / Pulmonary Reduced exercise capacity for age, no chest pain with exercise, no significant ST segment changes with exercise, symptoms of left anterior chest pain were not provoked with exercise, and hypertensive response noted with exercise. Exercise Stress Test - 2 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. cardiovascular / pulmonary, regular rhythm, s1, s2, chest pain, hypertensive, bruce protocol, exercise stress test, blood pressure, resting electrocardiogram, anterior chest, heart rate, rhythm, electrocardiogram, stress, chest, heart Cardiovascular / Pulmonary Chest pain. Achieved optimum METs for the exercise done and this is a normal exercise treadmill stress test. Exercise Stress Test - 4 INDICATION: , Chest pain.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained from the patient, the patient was brought to the cardiology procedure room where he was hooked up to continuous hemodynamic monitoring. The patient's baseline heart rate was 85 beats per minute and blood pressure was 124/90. The patient was started on a Bruce protocol where he exercised for 11 minutes and 42 seconds achieving 12.8 METs. The patient's maximum blood pressure during this stress part was 148/80 and the patient achieved heart rate of 152 with no EKG changes, no chest pain.,FINDINGS:,1. Normal hemodynamic response to exercise.,2. No EKG changes suggestive of ischemia.,3. No chest pain during the stress test.,4. Achieved optimum METs for the exercise done and this is a normal exercise treadmill stress test. cardiovascular / pulmonary, treadmill stress test, heart rate, blood pressure, stress test, treadmill, hemodynamic, ekg, chest, Cardiovascular / Pulmonary Fiberoptic bronchoscopy, diagnostic. Hemoptysis and history of lung cancer. Tumor occluding right middle lobe with friability. Fiberoptic Bronchoscopy - 1 PREOPERATIVE DIAGNOSIS:,1. Hemoptysis.,2. History of lung cancer.,POSTOPERATIVE DIAGNOSIS:, Tumor occluding right middle lobe with friability.,PROCEDURE PERFORMED:, Fiberoptic bronchoscopy, diagnostic.,LOCATION: , Endoscopy suite #4.,ANESTHESIA:, General per Anesthesia Service.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient presented to ABCD Hospital with a known history of lung cancer and acute hemoptysis with associated chest pain. Due to her prior history, it was felt that she would benefit from diagnostic fiberoptic bronchoscopy to help determine the etiology of the hemoptysis. She was brought to endoscopy suite #4 and informed consent was obtained. ,PROCEDURE DETAILS: ,The patient was placed in the supine position and intubated by the Anesthesia Service. Intravenous sedation was given as per Anesthesia. The fiberoptic scope was passed through the #8 endotracheal tube into the main trachea. The right mainstem bronchus was examined. The right upper lobe and subsegments appeared grossly within normal limits with no endobronchial lesions noted. Upon examining the right middle lobe, there was a tumor noted occluding the lateral segment of the right middle lobe and a clot appreciated over the medial segment of the right middle lobe.,The clot was lavaged with normal saline and there was noted to be tumor behind this clot. Tumor completely occluded both segments of the right middle lobe. Scope was then passed to the subsegments of the right lower lobe, which were individually examined and noted to be grossly free of endobronchial lesions. Scope was pulled back to the level of the midtrachea, passed into the left mainstem bronchus. Left upper lobe and its subsegments were examined and noted to be grossly free of endobronchial lesions. The lingula and left lower subsegments were all each individually examined and noted to be grossly free of endobronchial lesions. There were some secretions noted throughout the left lung. The scope was retracted and passed again to the right mainstem bronchus. The area of the right middle lobe was reexamined. The tumor was noted to be grossly friable with oozing noted from the tumor with minimal manipulation. It did not appear as if a scope or cannula could be passed distal to the tumor. Due to continued oozing, 1 cc of epinephrine was applied topically with adequate hemostasis obtained. The area was examined for approximately one minute for assurance of adequate hemostasis. The scope was then retracted and the patient was sent to the recovery room in stable condition. She will be extubated as per the Anesthesia Service. Cytology and cultures were not sent due to the patient's known diagnosis. Further recommendations are pending at this time. cardiovascular / pulmonary, hemoptysis, lung cancer, tumor, fiberoptic, bronchoscopy, endoscopy suite, adequate hemostasis, fiberoptic bronchoscopy, endobronchial lesions, middle lobe, lobe, Cardiovascular / Pulmonary No chest pain with exercise and no significant ECG changes with exercise. Poor exercise capacity 6 weeks following an aortic valve replacement and single-vessel bypass procedure. Exercise Stress Test - 3 INDICATIONS: , An 82-year-old man entering the cardiac rehabilitation program 6 weeks after a porcine aortic valve replacement and single-vessel coronary bypass graft procedure. The patient has had a complicated postoperative course with rapid atrial fibrillation, pleural effusions, anemia and thrombocytopenia. He is currently stabilized and improving in strength. He is living in Nantucket with his daughter Debra Anderson while he recuperates and completes the cardiac rehabilitation program. He has a few other significant medical problems.,MEDICATIONS:,1. Toprol-XL 25 mg daily.,2. Simvastatin 80 mg daily.,3. Aspirin 81 mg daily.,4. Synthroid 0.5 mg daily.,5. Warfarin 1.5 mg daily.,PHYSICAL EXAMINATION: , The patient appears pale and fragile. He is comfortable at rest. His resting heart rate is 80. His resting blood pressure is 112/70. His conjunctivae are pale. His lungs have decreased breath sounds throughout and dullness at the bases bilaterally. Heart exam reveals a distant S1 and S2. There is a short 2/6 systolic ejection murmur. The extremities are normal without clubbing, cyanosis or edema.,The resting echocardiogram showed a sinus rhythm at 70 beats per minute. There is poor R wave progression across the pericardium and Q waves inferiorly.,DESCRIPTION: ,The patient exercised according to the modified Bruce protocol stopping at 3 minutes and 20 seconds with fatigue and shortness of breath. He did not experience chest pain with exercise. He did achieve a maximal heart rate of 100, which is 72% of his maximal predicted heart rate. His maximal blood pressure was 190/70 resulting in a double product of 19,000 and achieving 2.3 METS. As noted, the resting electrocardiogram had inferior Q waves and poor R wave progression. There were no significant ST segment changes with exercise. There were only rare ventricular premature beats with exercise.,CONCLUSION:,1. Poor exercise capacity 6 weeks following an aortic valve replacement and single-vessel bypass procedure.,2. No chest pain with exercise.,3. No significant ECG changes with exercise.,4. The patient is considered stable to enter our cardiac rehabilitation program. I recommend the patient have a complete blood count, basic metabolic profile, and TSH obtained prior to entering the rehab program. cardiovascular / pulmonary, bruce protocol, exercise stress test, cardiac rehabilitation program, blood pressure, cardiac rehabilitation, heart rate, stress, rehabilitation, heart, atrial, Cardiovascular / Pulmonary Exercise stress test with nuclear scan for chest pain. Chest pain resolved after termination of exercise. Good exercise duration, tolerance and double product. Normal nuclear myocardial perfusion scan. Exercise Stress Test INDICATION: ,Chest pain.,INTERPRETATION: , Resting heart rate of 71, blood pressure 100/60. EKG normal sinus rhythm. The patient exercised on Bruce for 8 minutes on stage III. Peak heart rate was 151, which is 87% of the target heart rate, blood pressure of 132/54. Total METs was 10.1. EKG revealed nonspecific ST depression in inferior and lateral leads. The test was terminated because of fatigue. The patient did have chest pain during exercise that resolved after termination of the exercise.,IN SUMMARY:,1. Positive exercise ischemia with ST depression 0.5 mm.,2. Chest pain resolved after termination of exercise.,3. Good exercise duration, tolerance and double product.,NUCLEAR INTERPRETATION:,Resting and stress images were obtained with 10.1 mCi and 34.1 mCi of tetraphosphate injected intravenously by standard protocol. Nuclear myocardial perfusion scan demonstrates homogenous and uniform distribution with tracer uptake without any evidence of reversible or fixed defect. Gated SPECT revealed normal wall motion, ejection fraction of 68%. End-diastolic volume of 77, end-systolic volume of 24.,IN SUMMARY:,1. Normal nuclear myocardial perfusion scan.,2. Ejection fraction of 68% by gated SPECT. cardiovascular / pulmonary, chest pain, ekg, sinus, st depression, mci, gated spect, nuclear myocardial perfusion scan, ejection fraction, myocardial perfusion, perfusion scan, heart rate, spect, stress, nuclear, chest Cardiovascular / Pulmonary Patient in ER complaining of shortness of breath (COPD) ER Report - COPD 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. Cardiovascular / Pulmonary Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage. Bilateral upper lobe cavitary lung masses. 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. Fiberoptic Bronchoscopy 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. cardiovascular / pulmonary, inflammation, lung masses, lobe cavitary, bronchoalveolar, biopsies, segmental bronchi, fiberoptic, bronchoscopy, lavage, cavitary, segmental, lobe, Cardiovascular / Pulmonary Patient complains of chest pain - possible esophageal reflux ER Report - Chest Pain CHIEF COMPLAINT:, The patient complains of chest pain. ,HISTORY OF PRESENT ILLNESS: ,The patient is a 20-year-old male who states that he has had two previous myocardial infarctions related to his use of amphetamines. The patient has not used amphetamines for at least four to five months, according to the patient; however, he had onset of chest pain this evening. ,The patient describes the pain as midsternal pain, a burning type sensation that lasted several seconds. The patient took one of his own nitroglycerin tablets without any relief. The patient became concerned and came into the emergency department. ,Here in the emergency department, the patient states that his pain is a 1 on a scale of 1 to 10. He feels much more comfortable. He denies any shortness of breath or dizziness, and states that the pain feels unlike the pain of his myocardial infarction. The patient has no other complaints at this time. ,PAST MEDICAL HISTORY:, The patient's past medical history is significant for status post myocardial infarction in February of 1995 and again in late February of 1995. Both were related to illegal use of amphetamines. ,ALLERGIES:, None. ,CURRENT MEDICATIONS:, Include nitroglycerin p.r.n. ,PHYSICAL EXAMINATION: ,VITAL SIGNS: Blood pressure 131/76, pulse 50, respirations 18, temperature 96.5. ,GENERAL: The patient is a well-developed, well-nourished white male in no acute distress. The patient is alert and oriented x 3 and lying comfortably on the bed. ,HEENT: Atraumatic, normocephalic. The pupils are equal, round, and reactive. Extraocular movements are intact. ,NECK: Supple with full range of motion. No rigidity or meningismus. ,CHEST: Nontender. ,LUNGS: Clear to auscultation. ,HEART: Regular rate and rhythm. No murmur, S3, or S4. ,ABDOMEN: Soft, nondistended, nontender with active bowel sounds. No masses or organomegaly. No costovertebral angle tenderness. ,EXTREMITIES: Unremarkable. ,NEUROLOGIC: Unremarkable. ,EMERGENCY DEPARTMENT LABS:, The patient had a CBC, minor chemistry, and cardiac enzymes, all within normal limits. Chest x-ray, as read by me, was normal. Electrocardiogram, as read by me, showed normal sinus rhythm with no acute ST or T-wave segment changes. There were no acute changes seen on the electrocardiogram. O2 saturation, as interpreted by me, is 99%. ,EMERGENCY DEPARTMENT COURSE: ,The patient had a stable, uncomplicated emergency department course. The patient received 45 cc of Mylanta and 10 cc of viscous lidocaine with complete relief of his chest pain. The patient had no further complaints and stated that he felt much better shortly thereafter. ,AFTERCARE AND DISPOSITION: ,The patient was discharged from the emergency department in stable, ambulatory, good condition with instructions to use Mylanta for his abdominal pain and to follow up with his regular doctor in the next one to two days. Otherwise, return to the emergency department as needed for any problem. The patient was given a copy of his labs and his electrocardiogram. The patient was advised to decrease his level of activity until then. The patient left with final diagnosis of: ,FINAL DIAGNOSIS: ,1. Evaluation of chest pain. ,2. Possible esophageal reflux. Cardiovascular / Pulmonary A 44-year-old woman with a history of rheumatoid arthritis admitted to the hospital with chest pain. MI has been ruled out. She has been referred for an exercise echocardiogram. Exercise Stress Test - 1 Informed written consent has been obtained from the patient. I explained the procedure to her prior to initiation of such. The appropriate time-out procedure as per Medical Center protocol was performed prior to the procedure being begun while the patient was actively participating with appropriate identification of the patient, procedure, physician, documentation, position. There were no safety concerns noted by staff nor myself.,REST ECHO:, EF 60%. No wall motion abnormalities. EKG shows normal sinus rhythm with mild ST depressions. The patient exercised for 7 minutes 30 seconds on a standard Bruce protocol, exceeding target heart rate; no angina nor significant ECG changes seen. Peak stress echo imaging shows EF of 75%, no regional wall motion abnormalities. There was resting hypertension noted, systolic of approximately 152 mmHg with appropriate response of blood pressure to exercise. No dysrhythmias noted.,IMPRESSION:,1. Negative exercise ECG/echocardiogram stress evaluation for inducible ischemia in excess of target heart rate.,2. Resting hypertension with appropriate response of blood pressure to exercise.,These results have been discussed with the patient. Other management as per the hospital-based internal medicine service.,To be clear, there were no complications of this procedure. cardiovascular / pulmonary, ecg/echocardiogram, exercise stress test, ecg, wall motion abnormalities, target heart rate, hypertension, echocardiogram Cardiovascular / Pulmonary Ivor-Lewis esophagogastrectomy, feeding jejunostomy, placement of two right-sided 28 French chest tubes, and right thoracotomy. Esophagogastrectomy, Jejunostomy, & Chest Tubes 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. cardiovascular / pulmonary, ivor-lewis, esophagogastrectomy, jejunostomy, thoracotomy, dual-lumen tube, chest tubes, bovie electrocautery, chest, endotracheal, electrocautery, abdomen, gastric, esophagus, tubes, vicryl, stomach, Cardiovascular / Pulmonary Elevated BNP. Diastolic heart failure, not contributing to his present problem. Chest x-ray and CAT scan shows possible pneumonia. The patient denies any prior history of coronary artery disease but has a history of hypertension. Elevated BNP - Consult REASON FOR REFERRAL: , Elevated BNP.,HISTORY OF PRESENT ILLNESS:, The patient is a 95-year-old Caucasian male visiting from out of state, admitted because of the fall and could not get up and has a cough with dark color sputum, now admitted with pneumonia and a fall and the patient's BNP level was high, for which Cardiology consult was requested. The patient denies any chest pain or shortness of breath. Chest x-ray and CAT scan shows possible pneumonia. The patient denies any prior history of coronary artery disease but has a history of hypertension.,ALLERGIES: , No known drug allergies.,MEDICATIONS:, At this time, he is on:,1. Atrovent and albuterol nebulizers.,2. Azithromycin.,3. Potassium chloride 10 mEq p.o. daily.,4. Furosemide 20 mg IV daily.,5. Enoxaparin 40 mg daily.,6. Lisinopril 10 mg p.o. daily.,7. Ceftriaxone.,PAST MEDICAL HISTORY: , History of hypertension.,PAST SURGICAL HISTORY:, History of abdominal surgery.,SOCIAL HISTORY: , He does not smoke. Drinks occasionally.,FAMILY HISTORY: ,Noncontributory.,REVIEW OF SYSTEMS: , Denies chest pain, PND, or orthopnea. He has cough. No fever. No abdominal pain. No syncope, near-syncope, or palpitation. All other systems were reviewed.,PHYSICAL EXAMINATION:,GENERAL: The patient is comfortable, not in distress.,VITAL SIGNS: His blood pressure is 118/50, pulse rate 76, respiratory rate 18, and temperature 98.1.,HEENT: Atraumatic, normocephalic. Eyes PERRLA.,NECK: Supple. No JVD. No carotid bruit.,CHEST: Clear.,HEART: S1 and S2, regular. No S3. No S4. No murmur.,ABDOMEN: Soft, nontender. Positive bowel sounds.,EXTREMITIES: No cyanosis, clubbing, or edema. Pulse 2+.,CNS: Alert, awake, and oriented x3.,DIAGNOSTIC DATA:, EKG shows sinus tachycardia, nonspecific ST-T changes, nonspecific intraventricular conduction delay. CT chest shows bilateral pleural effusion, compressive atelectasis, pneumonic infiltrate noted in the right lower lobe. Loculated pleural effusion in the left upper lobe. No PE. Chest x-ray shows bilateral lower lobe patchy opacities concerning for atelectasis or pneumonia.,LABORATORY DATA: , Sodium 139, potassium 4.1, BUN 26, creatinine 0.9, BNP 331, troponin less than 0.05. White cell count 7.1, hemoglobin 11.5, hematocrit 35.2, platelet 195,000.,ASSESSMENT:,1. Pneumonia.,2. Diastolic heart failure, not contributing to his present problem.,3. Hypertension, controlled.,4. History of falls.,PLAN: , We will continue IV low-dose diuretics, continue lisinopril, continue IV antibiotics. No further cardiac workup at this time. Cardiovascular / Pulmonary Endotracheal intubation. 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. Endotracheal Intubation - 1 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. cardiovascular / pulmonary, nonrebreather, respiratory distress, falling saturation, endotracheal intubation, lavage, breathingNOTE Cardiovascular / Pulmonary Exercise myocardial perfusion study. The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall and normal LV systolic function with LV ejection fraction of 59% Exercise Myocardial Perfusion Study 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%. cardiovascular / pulmonary, chest pain, cardiolite, ekg, spect, lv systolic function, lv ejection fraction, myocardial perfusion study, spect study, ejection fraction, myocardial, perfusion, ischemia, Cardiovascular / Pulmonary Echocardiographic examination. Borderline left ventricular hypertrophy with normal ejection fraction at 60%, mitral annular calcification with structurally normal mitral valve, no intracavitary thrombi is seen, interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained. Echocardiography 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. cardiovascular / pulmonary, ventricular hypertrophy, normal wall motion, ventricle, atrium, annular calcification, mitral valve, interatrial septum, hypertrophy, annular, thrombi, ventricular, structurally, septum, valve, mitral, Cardiovascular / Pulmonary Endovascular Brachytherapy (EBT) Endovascular Brachytherapy ENDOVASCULAR BRACHYTHERAPY (EBT),The patient is to undergo a course of angioplasty for in-stent restenosis. The radiotherapy will be planned using simulation films when the Novoste system catheter markers are placed on either side of the coronary artery injury site. After this, a calculation will take place to determine the length of time at which the strontium sources will be left in place to deliver an adequate dose given the reference vessel diameter. The rationale for this treatment is based on radiobiological principles that make this type of therapy more effective than blade atherectomy or laser atherectomy. The does per fraction is individualized for each patient according to radiobiological principles and reference vessel diameter. Given that this is a very high dose rate source and the chances of severe acute toxicity such as cardiac ischemia and machine malfunction are present, it is imperative that the patient be followed closely by myself and monitored for ST segment elevation and correct machine function. cardiovascular / pulmonary, endovascular brachytherapy, ebt, angioplasty, stent, vessel, atherectomy, endovascular, brachytherapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., Cardiovascular / Pulmonary Abnormal cardiac enzyme profile. 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. Elevated Cardiac Enzymes 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. Cardiovascular / Pulmonary Endotracheal intubation. Respiratory failure. The patient is a 52-year-old male with metastatic osteogenic sarcoma. He was admitted two days ago with small bowel obstruction. Endotracheal Intubation PROCEDURE: , Endotracheal intubation.,INDICATION: , Respiratory failure.,BRIEF HISTORY: , The patient is a 52-year-old male with metastatic osteogenic sarcoma. He was admitted two days ago with small bowel obstruction. He has been on Coumadin for previous PE and currently on heparin drip. He became altered and subsequently deteriorated quite rapidly to the point where he is no longer breathing on his own and has minimal responsiveness. A code blue was called. On my arrival, the patient's vital signs are stable. His blood pressure is systolically in 140s and heart rate 80s. He however has 0 respiratory effort and is unresponsive to even painful stimuli. The patient was given etomidate 20 mg.,DESCRIPTION OF PROCEDURE: ,The patient positioned appropriate equipment at the bedside, given 20 mg of etomidate and 100 mg of succinylcholine. Mac-4 blade was used. A 7.5 ET tube placed to 24th teeth. There is good color change on the capnographer with bilateral breath sounds. Following intubation, the patient's blood pressure began to drop. He was given 2 L of bolus. I started him on dopamine drip at 10 mcg. Dr. X was at the bedside, who is the primary caregiver, he assumed the care of the patient, will be transferred to the ICU. Chest x-ray will be reviewed and Pulmonary will be consulted. cardiovascular / pulmonary, metastatic osteogenic sarcoma, respiratory failure, bowel obstruction, blood pressure, endotracheal intubation, endotracheal, sarcoma Cardiovascular / Pulmonary Echocardiogram was performed including 2-D and M-mode imaging. Echocardiogram - 1 EXAM:, Echocardiogram.,INTERPRETATION: , Echocardiogram was performed including 2-D and M-mode imaging, Doppler analysis continuous wave and pulse echo outflow velocity mapping was all seen in M-mode. Cardiac chamber dimensions, left atrial enlargement 4.4 cm. Left ventricle, right ventricle, and right atrium are grossly normal. LV wall thickness and wall motion appeared normal. LV ejection fraction is estimated at 65%. Aortic root and cardiac valves appeared normal. No evidence of pericardial effusion. No evidence of intracardiac mass or thrombus. Doppler analysis outflow velocity through the aortic valve normal, inflow velocities through the mitral valve are normal. There is mild tricuspid regurgitation. Calculated pulmonary systolic pressure 42 mmHg.,ECHOCARDIOGRAPHIC DIAGNOSES:,1. LV Ejection fraction, estimated at 65%.,2. Mild left atrial enlargement.,3. Mild tricuspid regurgitation.,4. Mildly elevated pulmonary systolic pressure. cardiovascular / pulmonary, lv ejection fraction, ejection fraction, tricuspid regurgitation, systolic pressure, valves, atrial, echocardiogram, Cardiovascular / Pulmonary Echocardiographic Examination Report. Angina and coronary artery disease. Mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%, mild mitral regurgitation, diastolic dysfunction grade 2, mild pulmonary hypertension. Echocardiogram - 3 REASON FOR EXAM:,1. Angina.,2. Coronary artery disease.,INTERPRETATION: ,This is a technically acceptable study.,DIMENSIONS: ,Anterior septal wall 1.2, posterior wall 1.2, left ventricular end diastolic 6.0, end systolic 4.7. The left atrium is 3.9.,FINDINGS: , Left atrium was mildly to moderately dilated. No masses or thrombi were seen. The left ventricle was mildly dilated with mainly global hypokinesis, more prominent in the inferior septum and inferoposterior wall. The EF was moderately reduced with estimated EF of 40% with near normal thickening. The right atrium was mildly dilated. The right ventricle was normal in size.,Mitral valve showed to be structurally normal with no prolapse or vegetation. There was mild mitral regurgitation on color flow interrogation. The mitral inflow pattern was consistent with pseudonormalization or grade 2 diastolic dysfunction. The aortic valve appeared to be structurally normal. Normal peak velocity. No significant AI. Pulmonic valve showed mild PI. Tricuspid valve showed mild tricuspid regurgitation. Based on which, the right ventricular systolic pressure was estimated to be mildly elevated at 40 to 45 mmHg. Anterior septum appeared to be intact. No pericardial effusion was seen.,CONCLUSION:,1. Mild biatrial enlargement.,2. Normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%.,3. Mild mitral regurgitation.,4. Diastolic dysfunction grade 2.,5. Mild pulmonary hypertension. cardiovascular / pulmonary, angina, coronary artery disease, septal, ventricular, diastolic, systolic, pulmonary hypertension, mitral regurgitation, septum, tricuspid, thickening, dysfunction, wall, ef, regurgitation, atrium, valve, dilated, mitral, ventricle, mildly, Cardiovascular / Pulmonary Echocardiogram for aortic stenosis. Transthoracic echocardiogram was performed of adequate technical quality. Concentric hypertrophy of the left ventricle with normal function. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm Echocardiogram - 2 EXAM:, Echocardiogram.,INDICATION: , Aortic stenosis.,INTERPRETATION: , Transthoracic echocardiogram was performed of adequate technical quality. Left ventricle reveals concentric hypertrophy with normal size and dimensions and normal function. Ejection fraction is 60% without any obvious wall motion abnormality. Left atrium and right side chambers are of normal size and dimensions. Aortic root has normal diameter.,Mitral and tricuspid valves are structurally normal except for minimal annular calcification. Valvular leaflet excursion is adequate. Aortic valve reveals annular calcification. Fibrocalcific valve leaflets with decreased excursion. Atrial and ventricular septum are intact. Pericardium is intact without any effusion. No obvious intracardiac mass or thrombi noted.,Doppler reveals mild mitral regurgitation, mild-to-moderate tricuspid regurgitation. Estimated pulmonary pressure of 48. Systolic consistent with mild-to-moderate pulmonary hypertension. Peak velocity across the aortic valve is 3.0 with a peak gradient of 37, mean gradient of 19, valve area calculated at 1.1 sq. cm consistent with moderate aortic stenosis.,IN SUMMARY:,1. Concentric hypertrophy of the left ventricle with normal function.,2. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm. cardiovascular / pulmonary, moderate aortic stenosis, annular calcification, concentric hypertrophy, aortic stenosis, echocardiogram, stenosis, valve, aortic, Cardiovascular / Pulmonary Duplex ultrasound of legs Duplex Ultrasound - Legs DUPLEX ULTRASOUND OF LEGS,RIGHT LEG:, Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound. Deep veins were imaged at the level of the common femoral and popliteal veins. All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis. The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression. The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.,LEFT LEG:, Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound. Deep veins were imaged at the level of the common femoral and popliteal veins. All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis. The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression. The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression. cardiovascular / pulmonary, duplex ultrasound, b-mode ultrasound, duplex imaging, compression, echogenicity, femoral, intraluminal thrombus, popliteal, saphenous vein, thrombosis, release of distal compression, calf with reflux, distal compression, duplex, ultrasound, legs, saphenous, release, distal, veins, Cardiovascular / Pulmonary Dobutamine Stress Echocardiogram. Chest discomfort, evaluation for coronary artery disease. Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate. Negative EKG criteria for ischemia. Dobutamine Stress Test - 1 DOBUTAMINE STRESS ECHOCARDIOGRAM,REASON FOR EXAM: , Chest discomfort, evaluation for coronary artery disease.,PROCEDURE IN DETAIL: , The patient was brought to the cardiac center. Cardiac images at rest were obtained in the parasternal long and short axis, apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg/kg per minute for low dose, increased every 2 to 3 minutes by 10 mcg/kg per minute. The patient maximized at 30 mcg/kg per minute. Images were obtained at that level after adding 0.7 mg of atropine to reach maximal heart rate of 145. Maximal images were obtained in the same windows of parasternal long and short axis, apical four and apical two windows.,Wall motion assessed at all levels as well as at recovery.,The patient got nauseated, had some mild shortness of breath. No angina during the procedure and the maximal amount of dobutamine was 30 mcg/kg per minute.,The resting heart rate was 78 with the resting blood pressure 186/98. Heart rate reduced by the vasodilator effects of dobutamine to 130/80. Maximal heart rate achieved was 145, which is 85% of age-predicted heart rate.,The EKG at rest showed sinus rhythm with no ST-T wave depression suggestive of ischemia or injury. Incomplete right bundle-branch block was seen. The maximal stress test EKG showed sinus tachycardia. There was subtle upsloping ST depression in III and aVF, which is a normal response to the tachycardia with dobutamine, but no significant depression suggestive of ischemia and no ST elevation seen.,No ventricular tachycardia or ventricular ectopy seen during the test. The heart rate recovered in a normal fashion after using metoprolol 5 mg.,The heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise.,The EF at rest appeared to be normal at 55 to 60 with normal wall motion including anterior, anteroseptal, inferior, lateral, and septal walls at low dose. All walls mentioned were augmented in a normal fashion. At maximum dose, all walls were augmented on all views except for the short axis was foreshortened, was uncertain about the anterolateral wall at peak exercise; however, of the other views, the lateral wall was showing normal thickening and normal augmentation. EF improved to about 70%.,The wall motion score was unchanged.,IMPRESSION:,1. Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.,2. Negative EKG criteria for ischemia.,3. Normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view. This is considered the negative dobutamine stress echocardiogram test, medical management. cardiovascular / pulmonary, chest discomfort, coronary artery disease, predicted heart rate, dobutamine stress echocardiogram, anterolateral wall, echocardiogram test, wall motion, stress echocardiogram, short axis, dobutamine stress, heart rate, dobutamine, stress, ekg, echocardiogram, artery, ischemia, heart Cardiovascular / Pulmonary Echocardiogram with color flow and conventional Doppler interrogation. Echocardiogram REASON FOR EXAMINATION: , Cardiac arrhythmia.,INTERPRETATION: , No significant pericardial effusion was identified.,The aortic root dimensions are within normal limits. The four cardiac chambers dimensions are within normal limits. No discrete regional wall motion abnormalities are identified. The left ventricular systolic function is preserved with an estimated ejection fraction of 60%. The left ventricular wall thickness is within normal limits.,The aortic valve is trileaflet with adequate excursion of the leaflets. The mitral valve and tricuspid valve motion is unremarkable. The pulmonic valve is not well visualized.,Color flow and conventional Doppler interrogation of cardiac valvular structures revealed mild mitral regurgitation and mild tricuspid regurgitation with an RV systolic pressure calculated to be 28 mmHg. Doppler interrogation of the mitral in-flow pattern is within normal limits for age.,IMPRESSION:,1. Preserved left ventricular systolic function.,2. Mild mitral regurgitation.,3. Mild tricuspid regurgitation. cardiovascular / pulmonary, arrhythmia, wall motion, ventricular systolic function, color flow, conventional doppler, systolic function, mitral regurgitation, mild tricuspid, tricuspid regurgitation, echocardiogram, doppler, cardiac, ventricular, systolic, tricuspid, valve, mitral, regurgitation, Cardiovascular / Pulmonary Dual chamber generator replacement. The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement. Dual Chamber Generator Replacement REFERRAL INDICATIONS,1. Pacemaker at ERI.,2. History AV block.,PROCEDURES PLANNED AND PERFORMED:, Dual chamber generator replacement.,FLUOROSCOPY TIME: , 0 minutes.,MEDICATION AT THE TIME OF STUDY,1. Ancef 1 g.,2. Versed 2 mg.,3. Fentanyl 50 mcg.,CLINICAL HISTORY: ,The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement.,RISKS AND BENEFITS: , Risks, benefits, and alternatives to generator replacement have been discussed with the patient. Risks including but not limited to bleeding, infection, vascular injury, and the need for pacemaker upgrade were discussed with the patient. The patient agreed both verbally and via written consent.,DESCRIPTION OF OPERATION: , The patient was transported to the cardiac catheterization laboratory in a fasting state. The region of the left dorsal pectoral groove was prepped and draped in a usual sterile manner. Lidocaine 1% (20 mL) was administered to the area of the previous incision. A transverse incision was made through the skin and subcutaneous tissue. Hemostasis was achieved with electrocautery. Using blunt dissection, pacemaker, and leads were removed from the pocket. Leads were disconnected from the pulse generator and interrogated. The pocket was washed with antibiotic impregnated saline. The new pulse generator was obtained and connected securely to the leads and placed back in the pocket. The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using running stitch. Sponge and needle counts were correct at the end of the procedure. No acute complications were noted.,DEVICE DATA,1. Explanted pulse generator Medronic, product # KDR601, serial # ABCD1234.,2. New pulse generator Medronic, product # ADDR01, serial # ABCD1234.,3. Right atrial lead, product # 4068, serial # ABCD1234.,4. Right atrial lead, product # 4068, serial # ABCD1234.,MEASURED INTRAOPERATIVE DATA,1. Right atrial lead impedance 572 ohms. P wave measure 3.7 mV, pacing threshold 1.5 volts at 0.5 msec.,2. Right ventricular lead impedance 365 ohms. No R waves to measure, pacing threshold 0.9 volts at 0.5 msec.,CONCLUSIONS,1. Successful dual chamber generator replacement.,2. No acute complications.,PLAN,1. She will be monitored for 3 hours and then dismissed home.,2. Resume all medications. Ex-home dismissal instructions.,3. Doxycycline 100 mg one p.o. twice daily for 7 days.,4. Wound check in 7-10 days.,5. Continue followup in device clinic. Cardiovascular / Pulmonary Dual Chamber ICD Implantation, fluoroscopy, defibrillation threshold testing, venography. Dual Chamber ICD Implantation 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. cardiovascular / pulmonary, venography, defibrillation threshold testing, venogram, dual chamber icd implantation, dual chamber icd, superior vena cava, seldinger technique, pectoral muscle, steri strips, dual chamber, ethibond suture, superior vena, vena cava, dual, chamber, icd, implantation, fluoroscopy, atrium, pectoral, vein, fluoroscopically, vena, cava, lead, guidewire, Cardiovascular / Pulmonary Insertion of a double lumen port through the left femoral vein, radiological guidance. Open exploration of the left subclavian and axillary vein. Metastatic glossal carcinoma, needing chemotherapy and a port. Double Lumen Port Inserstion 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. cardiovascular / pulmonary, axillary, vein, subclavian, double lumen port, femoral vein, radiological guidance, glossal carcinoma, port, inserstion, femoral, radiological, metastatic, carcinoma, chemotherapy, anesthetic, catheter, Cardiovascular / Pulmonary The patient was admitted after undergoing a drawn out process with a small bowel obstruction. Discharge Summary - Respiratory Failure DISCHARGE DIAGNOSIS:,1. Respiratory failure improved.,2. Hypotension resolved.,3. Anemia of chronic disease stable.,4. Anasarca improving.,5. Protein malnourishment improving.,6. End-stage liver disease.,HISTORY AND HOSPITAL COURSE: ,The patient was admitted after undergoing a drawn out process with a small bowel obstruction. His bowel function started to improve. He was on TPN prior to coming to Hospital. He has remained on TPN throughout his time here, but his appetite and his p.o. intake have improved some. The patient had an episode while here where his blood pressure bottomed out requiring him to spend multiple days in the Intensive Care Unit on dopamine. At one point, we were unsuccessful at weaning him off the dopamine, but after approximately 11 days, he finally started to tolerate weaning parameters, was successfully removed from dopamine, and has maintained his blood pressure without difficulty. The patient also was requiring BiPAP to help with his oxygenation and it appeared that he developed a left-sided pneumonia. This has been treated successfully with Zyvox and Levaquin and Diflucan. He seems to be currently doing much better. He is only using BiPAP in the evening. As stated above, he is eating better. He had some evidence of redness and exquisite swelling around his genital and lower abdominal region. This may be mainly dependent edema versus anasarca. The patient has been diuresed aggressively over the last 4 to 5 days, and this seems to have made some improvement in his swelling. This morning, the patient denies any acute distress. He states he is feeling good and understands that he is being discharged to another facility for continued care and rehabilitation. He will be discharged to Garden Court skilled nursing facility.,DISCHARGE MEDICATIONS/INSTRUCTIONS:, He is going to be going with Protonix 40 mg daily, metoclopramide 10 mg every 6 hours, Zyvox 600 mg daily for 5 days, Diflucan 150 mg p.o. daily for 3 days, Bumex 2 mg p.o. daily, Megace 400 mg p.o. b.i.d., Ensure 1 can t.i.d. with meals, and MiraLax 17 gm p.o. daily. The patient is going to require physical therapy to help with assistance in strength training. He is also going to need respiratory care to work with his BiPAP. His initial settings are at a rate of 20, pressure support of 12, PEEP of 6, FIO2 of 40%. The patient will need a sleep study, which the nursing home will be able to set up.,PHYSICAL EXAMINATION:,VITAL SIGNS: On the day of discharge, heart rate 99, respiratory rate 20, blood pressure 102/59, temperature 98.2, O2 sat 97%.,GENERAL: A well-developed white male who appears in no apparent distress.,HEENT: Unremarkable.,CARDIOVASCULAR: Positive S1, S2 without murmur, rubs, or gallops.,LUNGS: Clear to auscultation bilaterally without wheezes or crackles.,ABDOMEN: Positive for bowel sounds. Soft, nondistended. He does have some generalized redness around his abdominal region and groin. This does appear improved compared to presentation last week. The swelling in this area also appears improved.,EXTREMITIES: Show no clubbing or cyanosis. He does have some lower extremity edema, 2+ distal pedal pulses are present.,NEUROLOGIC: The patient is alert and oriented to person and place. He is alert and aware of surroundings. We have not had any difficulties with confusion here lately.,MUSCULOSKELETAL: The patient moves all extremities without difficulty. He is just weak in general.,LABORATORY DATA: , Lab work done today shows the following: White count 4.2, hemoglobin 10.2, hematocrit 30.6, and platelet count 184,000. Electrolytes show sodium 139, potassium 4.1, chloride 98, CO2 26, glucose 79, BUN 56, and creatinine 1.4. Calcium 8.8, phosphorus is a little high at 5.5, magnesium 2.2, albumin 3.9.,PLAN: ,Discharge this gentleman from Hospital and admit him to Garden Court SNF where they can continue with his rehab and conditioning. Hopefully, long-term planning will be discharge home. He has a history of end-stage liver disease with cirrhosis, which may make him a candidate for hospice upon discharge. The family initially wanted to bring the patient home, but he is too weak and requires too much assistance to adequately consider this option at this time. cardiovascular / pulmonary, respiratory failure, hypotension, anemia, anasarca, end-stage liver disease, drawn out process, bowel obstruction, blood pressure, dopamine, discharge, Cardiovascular / Pulmonary Dobutamine stress test for chest pain, as the patient was unable to walk on a treadmill, and allergic to adenosine. Nondiagnostic dobutamine stress test. Normal nuclear myocardial perfusion scan. Dobutamine Stress Test EXAM: , Dobutamine Stress Test.,INDICATION: , Chest pain.,TYPE OF TEST: , Dobutamine stress test, as the patient was unable to walk on a treadmill, and allergic to adenosine.,INTERPRETATION: , Resting heart rate of 66 and blood pressure of 88/45. EKG, normal sinus rhythm. Post dobutamine increment dose, his peak heart rate achieved was 125, which is 87% of the target heart rate. Blood pressure 120/42. EKG remained the same. No symptoms were noted.,IMPRESSION:,1. Nondiagnostic dobutamine stress test.,2. Nuclear interpretation as below.,NUCLEAR INTERPRETATION: , Resting and stress images were obtained with 10.8, 30.2 mCi of tetrofosmin injected intravenously by standard protocol. Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect. Gated and SPECT revealed normal wall motion and ejection fraction of 75%. End-diastolic volume was 57 and end-systolic volume of 12.,IMPRESSION:,1. Normal nuclear myocardial perfusion scan.,2. Ejection fraction of 75% by gated SPECT. cardiovascular / pulmonary, nuclear myocardial perfusion scan, dobutamine stress test, ejection fraction, myocardial perfusion, perfusion scan, dobutamine stress, stress test, myocardial, perfusion, nuclear, dobutamine, stress, Cardiovascular / Pulmonary Patient had some cold symptoms, was treated as bronchitis with antibiotics. Discharge Summary 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. cardiovascular / pulmonary, acute respiratory failure, bronchitis, acute on chronic renal failure, severe hypertension, diastolic dysfunction, cold symptoms, iv steroids, nasal spray, nasal, steroids, Cardiovascular / Pulmonary A 3-year-old abrupt onset of cough and increased work of breathing. Discharge Summary - Respiratory Distress 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. Cardiovascular / Pulmonary The patient is 14 months old, comes in with a chief complaint of difficulty breathing. Difficulty Breathing - ER Visit 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. Cardiovascular / Pulmonary DDDR permanent pacemaker, insertion of a steroid-eluting screw in right atrial lead, insertion of a steroid-eluting screw in right ventricular apical lead, pulse generator insertion, model Sigma, DDDR Permanent Pacemaker PROCEDURES PERFORMED:,1. DDDR permanent pacemaker.,2. Insertion of a steroid-eluting screw in right atrial lead.,3. Insertion of a steroid-eluting screw in right ventricular apical lead.,4. Pulse generator insertion, model Sigma.,SITE: , Left subclavian vein access.,INDICATION: , The patient is a 73-year-old African-American female with symptomatic bradycardia and chronotropic incompetence with recurrent heart failure and symptoms of hypoperfusion, and for a Class 2a indication for a permanent pacemaker was ascertained.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,Risks, benefits, and alternatives of the procedure were all explained in detail to the patient and the patient's family at length. They all consented for the procedure, and the consent was signed and placed on the chart.,PROCEDURE: , The patient was taken to cardiac cath lab where she was monitored throughout all procedure. The area of the left pectoral deltoid and subclavian area was sterilely prepped and draped in the usual manner. We also scrubbed for approximately eight minutes. Using lidocaine with epinephrine, the area of the left pectoral deltoid region and subclavian area was then fully anesthetized. Using an #18 gauge Cook needle, the left subclavian vein was cannulated at two separate sites without difficulty, where two separate guidewires were inserted into the left subclavian vein. The Cook needles were removed. Then the guidewires were secured in place with hemostat. Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectodeltoid groove, where the skin was dissected and blunted on to the pectoralis major muscle. The skin was then undermined making a pocket for the generator. The guidewires were then tunneled through the performed pocket. Subsequently, the atrial and ventricular leads were inserted through each one of the Cordis separately and respectively. Initially, the ventricular lead was inserted, where a Cordis sheath was placed and the guidewire was removed. After the thresholds and appropriate position was obtained for the ventricular lead, the Cordis sheath was then inserted for the atrial lead. After the atrial lead was inserted and appropriately placed and thresholds were obtained, the Cordis was removed and then both leads were sutured in place with pectoralis major muscle with #1-0 silk suture. The leads were then connected to a pulse generator. The pocket was then irrigated and cleansed, where then the leads and the generators were inserted into that pocket. The subcutaneous tissue was then closed with gut sutures and the skin was then closed with #4-0 polychrome sutures using a subcuticular uninterrupted technique. The area was then cleansed and dry. Steri-Strips and pressure dressing were applied. The patient tolerated the procedure well. There were no complications.,Information on the pacemaker:,The implanted device are as follows:,PULSE GENERATOR,Model Name: Sigma.,Model #: SDR203.,Serial #: 123456.,ATRIAL LEAD,Model #: 4568-45 cm.,Serial #: 123456.,RIGHT VENTRICULAR APICAL STEROID-eluting SCREW IN LEAD:,Model #: 4068-52 cm.,Serial #: 123456.,STIMULATION THRESHOLDS ARE AS FOLLOWS:,The right atrial chamber polarity is bipolar, pulse width is 0.50 milliseconds, 1.5 volts of voltage, 3.7 milliamps of current, 557 ohms of impedance, and P-wave sensing of 3.3 millivolts.,The right ventricular polarity is bipolar, pulse width is 0.50 milliseconds, 0.7 volts of voltage, 1.4 milliamps of current, impedance of 700 ohms, and R-wave sensing of 14 millivolts.,The brady parameter settings were set as follows:,The atrial and ventricular appendages were set at 3.5 volts with 0.4 milliseconds of pulse width, atrial sensitivity of 0.5 with 180 milliseconds of blanking. Ventricular sensitivity was set at 2.8 with 28 milliseconds of blanking. The pacing mode was DDDR, mode switch was on lower rate of 70 and upper rate of 130.,The patient tolerated the procedure well. There were no complications. The patient went to Recovery in satisfactory condition. Family was updated. Orders are all in the chart. Please see orders.,Again, thank you for allowing to participate in this care. Cardiovascular / Pulmonary Chest x-ray on admission, no acute finding, no interval change. CT angiography, negative for pulmonary arterial embolism. Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators. Discharge Summary - COPD 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. Cardiovascular / Pulmonary A 63-year-old man with a dilated cardiomyopathy presents with a chief complaint of heart failure. He has noted shortness of breath with exertion and occasional shortness of breath at rest. Dilated Cardiomyopathy - Consult "REASON FOR VISIT: , I have been asked to see this 63-year-old man with a dilated cardiomyopathy by Dr. X at ABCD Hospital. He presents with a chief complaint of heart failure.,HISTORY OF PRESENT ILLNESS: , In retrospect, he has had symptoms for the past year of heart failure. He feels in general ""OK,"" but is stressed and fatigued. He works hard running 3 companies. He has noted shortness of breath with exertion and occasional shortness of breath at rest. There has been some PND, but he sleeps on 1 pillow. He has no edema now, but has had some mild leg swelling in the past. There has never been any angina and he denies any palpitations, syncope or near syncope. When he takes his pulse, he notes some irregularity. He follows no special diet. He gets no regular exercise, although he has recently started walking for half an hour a day. Over the course of the past year, these symptoms have been slowly getting worse. He gained about 20 pounds over the past year.,There is no prior history of either heart failure or other heart problems.,His past medical history is remarkable for a right inguinal hernia repair done in 1982. He had trauma to his right thumb. There is no history of high blood pressure, diabetes mellitus or heart murmur.,On social history, he lives in San Salvador with his wife. He has a lot of stress in his life. He does not smoke, but does drink. He has high school education.,On family history, mother is alive at age 89. Father died at 72 of heart attack. He has 2 brothers and 1 sister all of whom are healthy, although the oldest suffered a myocardial infarction. He has 3 healthy girls and 9 healthy grandchildren.,A complete review of systems was performed and is negative aside from what is mentioned in the history of present illness.,MEDICATIONS: , Aspirin 81 mg daily and chlordiazepoxide and clidinium - combination pill at 5 mg/2.5 mg 1 tablet daily for stress.,ALLERGIES: , Denied.,MAJOR FINDINGS:, On my comprehensive cardiovascular examination, he is 5 feet 8 inches and weighs 231 pounds. His blood pressure is 120/70 in each arm seated. His pulse is 80 beats per minute and regular. He is breathing 1two times per minute and that is unlabored. Eyelids are normal. Pupils are round and reactive to light. Conjunctivae are clear and sclerae are anicteric. There is no oral thrush or central cyanosis. Neck is supple and symmetrical without adenopathy or thyromegaly. Jugular venous pressure is normal. Carotids are brisk without bruits. Lungs are clear to auscultation and percussion. The precordium is quiet. The rhythm is regular. The first and second heart sounds are normal. He does have a fourth heart sound and a soft systolic murmur. The precordial impulse is enlarged. Abdomen is soft without hepatosplenomegaly or masses. He has no clubbing, cyanosis or peripheral edema. Distal pulses are normal throughout both arms and both legs. On neurologic examination, his mentation is normal. His mood and affect are normal. He is oriented to person, place, and time.,DATA: , His EKG shows sinus rhythm with left ventricular hypertrophy.,A metabolic stress test shows that he was able to exercise for 5 minutes and 20 seconds to 90% of his maximum predicted heart rate. His peak oxygen consumption was 19.7 mL/kg/min, which is consistent with mild cardiopulmonary disease.,Laboratory data shows his TSH to be 1.33. His glucose is 97 and creatinine 0.9. Potassium is 4.3. He is not anemic. Urinalysis was normal.,I reviewed his echocardiogram personally. This shows a dilated cardiomyopathy with EF of 15%. The left ventricular diastolic dimension is 6.8 cm. There are no significant valvular abnormalities.,He had a stress thallium. His heart rate response to stress was appropriate. The thallium images showed no scintigraphic evidence of stress-induced myocardial ischemia at 91% of his maximum age predicted heart rate. There is a fixed small sized mild-to-moderate intensity perfusion defect in the distal inferior wall and apex, which may be an old infarct, but certainly does not account for the degree of cardiomyopathy. We got his post-stress EF to be 33% and the left ventricular cavity appeared to be enlarged. The total calcium score will put him in the 56 percentile for subjects of the same age, gender, and race/ethnicity.,ASSESSMENTS: , This appears to be a newly diagnosed dilated cardiomyopathy, the etiology of which is uncertain.,PROBLEMS DIAGNOSES: ,1. Dilated cardiomyopathy.,2. Dyslipidemia.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I started him on an ACE inhibitor, lisinopril 2.5 mg daily, and a beta-blocker, carvedilol 3.125 mg twice daily. The dose of these drugs should be up-titrated every 2 weeks to a target dose of lisinopril of 20 mg daily and carvedilol 25 mg twice daily. In addition, he could benefit from a loop diuretic such as furosemide. I did not start this as he is planning to go back home to San Salvador tomorrow. I will leave that up to his local physicians to up-titrate the medications and get him started on some furosemide.,In terms of the dilated cardiomyopathy, there is not much further that needs to be done, except for family screening. All of his siblings and his children should have an EKG and an echocardiogram to make sure they have not developed the same thing. There is a strong genetic component of this.,I will see him again in 3 to 6 months, whenever he can make it back here. He does not need a defibrillator right now and my plan would be to get him on the right doses of the right medications and then recheck an echocardiogram 3 months later. If his LV function has not improved, he does have New York Heart Association Class II symptoms and so he would benefit from a prophylactic ICD.,Thank you for asking me to participate in his care.,MEDICATION CHANGES:, See the above." Cardiovascular / Pulmonary Direct laryngoscopy and bronchoscopy. Direct Laryngoscopy PREOPERATIVE DIAGNOSIS:, Subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: , Subglottic stenosis.,OPERATIVE PROCEDURES: , Direct laryngoscopy and bronchoscopy.,ANESTHESIA:, General inhalation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operative table. General inhalational anesthesia was administered through the patient's tracheotomy tube. The small Parsons laryngoscope was inserted and the 2.9-mm telescope was used to inspect the airway. There was an estimated 60-70% circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds. The stoma showed some suprastomal fibroma. The remaining tracheobronchial passages were clear. The patient's 3.5 neonatal tracheostomy tube was repositioned and secured with Velcro ties. Bleeding was negligible. There were no untoward complications. The patient tolerated the procedure well and was transferred to recovery room in stable condition. cardiovascular / pulmonary, laryngoscopy and bronchoscopy, direct laryngoscopy, subglottic stenosis, bronchoscopy, laryngoscopy, subglottic, stenosis, Cardiovascular / Pulmonary The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer. CyberKnife treatment was completed one month ago. She is now being seen for her first post-CyberKnife treatment visit. CyberKnife Treatment - Followup HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer. CyberKnife treatment was completed one month ago. She is now being seen for her first post-CyberKnife treatment visit.,Since undergoing CyberKnife treatment, she has had low-level nausea without vomiting. She continues to have pain with deep inspiration and resolving dysphagia. She has no heartburn, cough, hemoptysis, rash, or palpable rib pain.,MEDICATIONS: , Dilantin 100 mg four times a day, phenobarbital 30 mg three times per day, levothyroxine 0.025 mg p.o. q. day, Tylenol with Codeine b.i.d., prednisone 5 mg p.r.n., citalopram 10 mg p.o. q. day, Spiriva q. day, Combivent inhaler p.r.n., omeprazole 20 mg p.o. q. day, Lidoderm patch every 12 hours, Naprosyn 375 mg p.o. b.i.d., oxaprozin 600 mg p.o. b.i.d., Megace 40 mg p.o. b.i.d., and Asacol p.r.n.,PHYSICAL EXAMINATION: , BP: 122/86. Temp: 96.8. HR: 79. RR: 26. RAS: 100%.,HEENT: Normocephalic. Pupils are equal and reactive to light and accommodation. EOMs intact.,NECK: Supple without masses or lymphadenopathy.,LUNGS: Clear to auscultation bilaterally,CARDIAC: Regular rate and rhythm without rubs, murmurs, or gallops.,EXTREMITIES: No cyanosis, clubbing or edema.,ASSESSMENT: , The patient has done well with CyberKnife treatment of a stage IA non-small cell lung cancer, right upper lobe, one month ago.,PLAN: , She is to return to clinic in three months with a PET CT. cardiovascular / pulmonary, non-small cell lung cancer, cyberknife therapy, lung cancer, cell, lung, cancer, cyberknife, Cardiovascular / Pulmonary A 10 years of age carries a diagnosis of cystic fibrosis Cystic Fibrosis INTERVAL HISTORY:, ABC who is 10 years of age and carries a diagnosis of cystic fibrosis, seen in the clinic today for routine follow-up visit. He was accompanied by his adopted mother. He is attending the fourth grade and has not missed significant days for illness. He has a chronic cough that has been slightly increased for the prior 4 days. Sputum is not produced. Sinuses are described as clear. He is an eager eater, eating a regular diet of increased calorie and protein. He also was taking Resource just for kid juice boxes as well as chocolate milkmaid with half-and-half. Belly complaints are denied. He has 2 to 3 bowel movements per day. He does need a flu vaccine.,MEDICATIONS: , Albuterol premix via nebulizer as needed, albuterol MDI 2 puffs b.i.d., therapy Vest daily, Creon 20 two with meals and snacks, A-dec 2 tablets daily, Prevacid 15 mg daily, Advair 100/50 one inhalation twice daily, and MiraLax p.r.n.,PHYSICAL EXAMINATION:,VITAL SIGNS: Respiratory rate 20 and pulse 91. Temperature is 100.0 per tympanic membrane. Oximetry is 98% on room air. Height is 128 cm, which is an increase of 1.0 cm from prior visit. Weight is 24.5 kg, which is an increase of 500 grams from prior visit.,GENERAL: He is a cooperative school-aged boy in no apparent distress.,HEENT: Tympanic membranes clear, throat with minimal postnasal drip.,CHEST: Significant for 1+ hyperinflation. Lungs are auscultated with good air entry and clear breath sounds.,CARDIAC: Regular sinus rhythm without murmur.,ABDOMEN: Palpated as soft, without hepatosplenomegaly.,EXTREMITIES: Not clubbed.,CHART REVIEW: , This chart was thoroughly reviewed prior to this conference by X, RN, BSN. Review of chart indicates that mother has good adherence to treatment plan indicated by medications being refilled in a timely fashion as well as clinic contact documented with appropriate concerns.,DISCUSSION: PHYSICIAN: , X did note that mother reported that the patient had discontinued the Pulmozyme due to CCS reasons. He is not sure what this would be since CCS Pulmozyme is a covered benefit on CCS for children with cystic fibrosis. This situation will be looked into with the hope of restarting soon. Other than that the patient seems to be doing well. A flu shot was given.,NURSE: , X, RN, BSN, did note that the patient was doing quite well. Reinforcement of current medication regime was supplied. No other needs identified at this time.,RESPIRATORY CARE: , X, RCP, did review appropriate sequencing of medications with the patient and family. Once again, she was concerned the lack of Pulmozyme due to mom stating CCS issues. At this time, they have increased the Vest use to twice daily and are doing 30-minute treatments.,DIETICIAN: , X, RD, CDE, notes that the patient is 89% of his ideal body weight, which is a nutritional failure per cystic fibrosis guidelines. This is despite the fact that he has an excellent appetite. Mom reports he is taking his enzymes consistently as well as vitamins. He does have problems meeting his goal for resource drinks per day. Since the patient has been struggling to gain weight this past year, we will need to monitor his nutritional status and weight trend very closely. A variety of additional high calorie items were discussed with mom.,SOCIAL WORK: , X, LCSW, notes that mom has recently gradually from respiratory therapy school and has accepted a position here at Children's Hospital. The patient is doing well in school. With the exception of issues with CCS authorization, there appears to be no pressing social needs at this time.,IMPRESSION: , ,1. Cystic fibrosis.,2. Poor nutritional status.,PLAN: ,1. Give flu vaccine 0.5 mg IM now, this was done.,2. Continue all other medications and treatment.,3. Evaluate/investigate rationale for no authorization of Pulmozyme with CCS.,4. Needs to augment current high-calorie diet to give more nutrition. To follow advice by a dietician.,5. Continue all the medication treatments before.,6. To continue off and ongoing psychosocial nutritional counseling as necessary. Cardiovascular / Pulmonary CT of chest with contrast. Abnormal chest x-ray demonstrating a region of consolidation versus mass in the right upper lobe. CT of Chest with Contrast EXAM: , CT chest with contrast.,HISTORY: , Abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.,TECHNIQUE: ,Post contrast-enhanced spiral images were obtained through the chest.,FINDINGS: ,There are several, discrete, patchy air-space opacities in the right upper lobe, which have the appearance most compatible with infiltrates. The remainder of the lung parenchyma is clear. There is no pneumothorax or effusion. The heart size and pulmonary vessels appear unremarkable. There was no axillary, hilar or mediastinal lymphadenopathy.,Images of the upper abdomen are unremarkable.,Osseous windows are without acute pathology.,IMPRESSION: , Several discrete patchy air-space opacities in the right upper lobe, compatible with pneumonia. cardiovascular / pulmonary, ct chest, air-space, axillary, chest x-ray, consolidation, contrast, contrast-enhanced, effusion, hilar, infiltrates, lung, lymphadenopathy, mass, mediastinal, parenchyma, patchy air-space, pneumonia, pneumothorax, right upper lobe, spiral images, with contrast, air space opacities, upper lobe, opacities, ct, lobe, chest Cardiovascular / Pulmonary Cerebrovascular accident (CVA) 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. Acute bronchitis with reactive airway disease. CVA - Discharge Summary 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. cardiovascular / pulmonary, subacute infarct, atherosclerotic cardiovascular disease, cerebrovascular accident, coronary infarct, external capsule, cva, cerebrovascular, mri, bronchitis, cardiovascular, xopenex, atherosclerotic, accident Cardiovascular / Pulmonary A 51-year-old male with chest pain and history of coronary artery disease. Coronary CT Angiography (CCTA) - 4 COMPARISON:, None.,MEDICATIONS:, Lopressor 5mg IV at 0920 hours.,HEART RATE: ,Recorded heart rate 55 to 57bpm.,EXAM:,Initial unenhanced axial CT imaging of the heart was obtained with ECG gating for the purpose of coronary artery calcium scoring (Agatston Method) and calcium volume determination.,18 gauge IV Intracath was inserted into the right antecubital vein.,A 20cc saline bolus was injected intravenously to confirm vein patency and adequacy of venous access.,Multi-detector CT imaging was performed with a 64 slice MDCT scanner with images obtained from the mid ascending aorta to the diaphragm at 0.5mm slice thickness during breath-holding.,95 cc of Isovue was administered followed by a 90cc saline “bolus chaser”. Image reconstruction was performed using retrospective cardiac gating. Calcium scoring analysis (Agatston Method and volume determination) was performed.,FINDINGS:,CALCIUM SCORE: The patient's total Agatston calcium score is: 115. The Agatston score for the individual vessels are: LM: 49. RCA: 1. LAD: 2. CX: 2. Other: 62. The Agatston calcium score places the patient in the 90th percentile, which means 10 percent of the male population in this age group would have a higher calcium score.,QUALITY ASSESSMENT:, Examination is of good quality with good bolus timing and good demonstration of coronary arteries.,LEFT MAIN CORONARY ARTERY:, The left main coronary artery has a posteriorly positioned take-off from the valve cusp, with a patent ostium, and it has an extramural (non-malignant) course. The vessel is of moderate size. There is an apparent second ostium, in a more normal anatomic location, but quite small. This has an extramural (non-malignant) course. There is mixed calcific/atheromatous plaque within the distal vessel, as well as positive remodeling. There is no high grade stenosis but a flow-limiting lesion can not be excluded. The vessel trifurcates into a left anterior descending artery, a ramus intermedius and a left circumflex artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:, The left anterior descending artery is a moderate-size vessel, with ostial calcific plaque and soft plaque without a high-grade stenosis, but there may be a flow-limiting lesion here. There is a moderate size bifurcating first diagonal branch with ostial calcification, but no flow-limiting lesion. LAD continues as a moderate-size vessel to the posterior apex of the left ventricle.,Ramus intermedius branch is a moderate to large-size vessel with extensive calcific plaque, but no ostial stenosis. The dense calcific plaque limits evaluation of the vessel lumen, and a flow-limiting lesion within the proximal vessel cannot be excluded. The vessel continues as a small vessel on the left lateral ventricular wall.,LEFT CIRCUMFLEX CORONARY ARTERY:, The left circumflex artery is a moderate-size vessel with a normal ostium giving rise to a small OM1 branch and a large OM2 branch supplying much of the posterolateral wall of the left ventricular. The AV-groove branch tapers at the base of the heart. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting stenosis.,RIGHT CORONARY ARTERY:, The right coronary artery is a large vessel with a normal ostium giving rise to a moderate-size acute marginal branch and continuing as a large vessel to the crux of the heart supplying a left posterior descending artery and small posterolateral ventricular branches. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting lesion.,Coronary circulation is right dominant.,FUNCTIONAL ANALYSIS:, End diastolic volume: 106ml End systolic volume: 44ml Ejection fraction: 58 percent,ANATOMIC ANALYSIS:,Normal heart size with no demonstrated ventricular wall abnormalities. There are no demonstrated myocardial,bridges. Normal left atrial appendage with no evidence of thrombosis.,Cardiac valves are normal.,The aortic diameter measures 33mm just distal to the sino-tubular junction. The visualized thoracic aorta appears normal in size.,Normal pericardium without pericardial thickening or effusion.,There is no demonstrated mediastinal or hilar adenopathy. The visualized lung parenchyma is unremarkable.,There are two left and two right pulmonary veins.,IMPRESSION:,Ventricular function: Normal.,Single vessel coronary artery analysis:,LM: There is a posterior origin from the valve cusp. There is mixed calcific/atheromatous plaque and positive remodeling plaque within the LM, and although there is no high grade stenosis, a flow-limiting lesion can not be excluded. In addition, there is an apparent second ostium of indeterminate significance, but both ostia have extramural (non-malignant) courses.,LAD: Dense calcific plaque within the proximal vessel with ostial calcification and possible flow-limiting proximal lesion. There is a ramus branch with dense calcific plaque limiting evaluation of the vessel lumen, but a flow-limiting lesion cannot be excluded here.,CX: Minimal calcific plaque with no flow-limiting lesion.,RCA: Minimal calcific plaque with no flow-limiting lesion.,Coronary artery dominance: Right. Cardiovascular / Pulmonary Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300. CT Angiography CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM: , Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism.,TECHNIQUE: ,Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS: ,There is no evidence for pulmonary arterial embolism.,The lungs are clear of any abnormal airspace consolidation, pleural effusion, or pneumothorax. No abnormal mediastinal or hilar lymphadenopathy is seen.,Limited images of the upper abdomen are unremarkable. No destructive osseous lesion is detected.,IMPRESSION: , Negative for pulmonary arterial embolism. cardiovascular / pulmonary, airspace consolidation, pleural effusion, pneumothorax, lymphadenopathy, hilar, ct angiography, pulmonary arterial, arterial embolism, angiography, ct, chest, arterial, pulmonary, embolism, isovue, Cardiovascular / Pulmonary Shortness of breath for two weeks and a history of pneumonia. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300. CT Angiography - 1 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. cardiovascular / pulmonary, shortness of breath, pneumonia, pulmonary embolism, isovue-300, axial ct images, ct angiography, lower lobe, pulmonary, lobectomy, isovue, angiography, arterial, atelectasis, pleural, ct, embolism, Cardiovascular / Pulmonary A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology. An abnormal chest radiograph shows right middle lobe infiltrate and collapse. Patient needs staging CT of chest with contrast. CT Chest - 2 CLINICAL HISTORY: , A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology. An abnormal chest radiograph shows right middle lobe infiltrate and collapse. Patient needs staging CT of chest with contrast. Right sided supraclavicular and lower anterior cervical adenopathy noted on physical exam.,TECHNIQUE: , Multiple transaxial images utilized in 10 mm sections were obtained through the chest. Intravenous contrast was administered.,FINDINGS: , There is a large 3 x 4 cm lymph node seen in the right supraclavicular region. There is a large right paratracheal lymph node best appreciated on image #16 which measures 3 x 2 cm. A subcarinal lymph node is enlarged also. It measures 6 x 2 cm. Multiple pulmonary nodules are seen along the posterior border of the visceral as well as parietal pleura. There is a pleural mass seen within the anterior sulcus of the right hemithorax as well as the right crus of the diaphragm. There is also a soft tissue density best appreciated on image #36 adjacent to the inferior aspect of the right lobe of the liver which most likely also represents metastatic deposit. The liver parenchyma is normal without evidence of any dominant masses. The right kidney demonstrates a solitary cyst in the mid pole of the right kidney.,IMPRESSION:,1. Greater than twenty pulmonary nodules demonstrated on the right side to include pulmonary nodules within the parietal as well as various visceral pleura with adjacent consolidation most likely representing pulmonary neoplasm.,2. Extensive mediastinal adenopathy as described above.,3. No lesion seen within the left lung at this time.,4. Supraclavicular adenopathy. cardiovascular / pulmonary, supraclavicular, cervical adenopathy, pulmonary nodules, lymph node, adenopathy, pulmonary, chest, Cardiovascular / Pulmonary Coronary Artery CTA with Calcium Scoring and Cardiac Function Coronary CT Angiography (CCTA) - 3 EXAM: , Coronary artery CTA with calcium scoring and cardiac function.,HISTORY: , Chest pain.,TECHNIQUE AND FINDINGS: , Coronary artery CTA was performed on a Siemens dual-source CT scanner. Post-processing on a Vitrea workstation. 150 mL Ultravist 370 was utilized as the intravenous contrast agent. Patient did receive nitroglycerin sublingually prior to the contrast.,HISTORY: , Significant for high cholesterol, overweight, chest pain, family history,Patient's total calcium score (Agatston) is 10. his places the patient just below the 75th percentile for age.,The LAD has a moderate area of stenosis in its midportion due to a focal calcified plaque. The distal LAD was unreadable while the proximal was normal. The mid and distal right coronary artery are not well delineated due to beam-hardening artifact. The circumflex is diminutive in size along its proximal portion. Distal is not readable.,Cardiac wall motion within normal limits. No gross pulmonary artery abnormality however they are not well delineated. A full report was placed on the patient's chart. Report was saved to PACS. cardiovascular / pulmonary, coronary artery cta, calcium scoring, cardiac function, coronary artery, ct, scoring, lad, midportion, cta, calcium, cardiac, coronary, artery, angiography, Cardiovascular / Pulmonary CCTA with Cardiac Function/Calcium Scoring Coronary CT Angiography (CCTA) - 2 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. cardiovascular / pulmonary, coronary ct angiography, ventricular ejection fraction, anterior descending artery, coronary artery disease, coronary ct, ct angiography, cardiac ct, obtuse marginal, ventricular ejection, ejection fraction, coronary artery, artery, angiography, coronary, ccta, atherosclerosis, ventricular, beats/min, anterior, vessel, stenosis, ct, cardiac, disease, Cardiovascular / Pulmonary CT chest with contrast. CT Chest - 1 EXAM: , CT chest with contrast.,REASON FOR EXAM: , Pneumonia, chest pain, short of breath, and coughing up blood.,TECHNIQUE: , Postcontrast CT chest 100 mL of Isovue-300 contrast.,FINDINGS: , This study demonstrates a small region of coalescent infiltrates/consolidation in the anterior right upper lobe. There are linear fibrotic or atelectatic changes associated with this. Recommend followup to ensure resolution. There is left apical scarring. There is no pleural effusion or pneumothorax. There is lingular and right middle lobe mild atelectasis or fibrosis.,Examination of the mediastinal windows disclosed normal inferior thyroid. Cardiac and aortic contours are unremarkable aside from mild atherosclerosis. The heart is not enlarged. There is no pathologic adenopathy identified in the chest including the bilateral axillary and hilar regions.,Very limited assessment of the upper abdomen demonstrates no definite abnormalities.,There are mild degenerative changes in the thoracic spine.,IMPRESSION:,1.Anterior small right upper lobe infiltrate/consolidation. Recommend followup to ensure resolution given its consolidated appearance.,2.Bilateral atelectasis versus fibrosis. cardiovascular / pulmonary, pneumonia, chest pain, short of breath, coughing up blood, upper lobe infiltrate, ct chest, ct, chest, isovue, Cardiovascular / Pulmonary Selective coronary angiography, left heart catheterization with hemodynamics, LV gram with power injection, right femoral artery angiogram, closure of the right femoral artery using 6-French AngioSeal. Coronary Angiography 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. Cardiovascular / Pulmonary Acute on chronic COPD exacerbation and community acquired pneumonia both resolving. However, she may need home O2 for a short period of time. COPD & Pneumonia - SOAP 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. cardiovascular / pulmonary, community acquired pneumonia, copd exacerbation, home o2, acute on chronic, pneumonia, exacerbation, copd Cardiovascular / Pulmonary Common CT Chest template CT Chest TECHNIQUE: , Sequential axial CT images were obtained from the base of the brain to the upper abdomen following the uneventful administration of 100cc Optiray 350 intravenous contrast.,FINDINGS: , The heart size is normal and there is no pericardial effusion. The aorta and great vessels are normal in caliber. The central pulmonary arteries are patent with no evidence of embolus. There is no significant mediastinal, hilar, or axillary lymphadenopathy. The trachea and mainstem bronchi are patent. The esophagus is normal in course and caliber. The lungs are clear with no infiltrates, effusions, or masses. There is no pneumothorax. Scans through the upper abdomen are unremarkable. The osseous structures in the chest are intact. ,IMPRESSION: , No acute abnormalities. cardiovascular / pulmonary, sequential axial ct images, optiray, pericardial effusion, mediastinal, hilar, axillary, lymphadenopathy, ct chest, upper abdomenNOTE Cardiovascular / Pulmonary A 62-year-old male with a history of ischemic cardiomyopathy and implanted defibrillator. Coronary CT Angiography (CCTA) - 5 COMPARISON STUDIES:, None.,MEDICATION: , Lopressor 5 mg IV.,HEART RATE AFTER MEDICATION:, 64bpm,EXAM:,TECHNIQUE: Tomographic images were obtained of the heart and chest with a 64 detector row scanner using slice thicknesses of less than 1 mm. 80cc’s of Isovue 370 was injected in the right arm.,TECHNICAL QUALITY:,Examination is limited secondary to extensive artifact from defibrillator wires.,There is good demonstration of the coronary arteries and there is good bolus timing.,FINDINGS:,LEFT MAIN CORONARY ARTERY:,The left main coronary artery is a moderate-sized vessel with a normal ostium. There is no calcific or non-calcific plaque. The vessel bifurcates into a left anterior descending artery and a left circumflex artery.,LEFT ANTERIOR DESCENDING ARTERY:,The left anterior descending artery is a moderate-sized vessel, with a small first diagonal branch and a large second diagonal branch. The vessel continues as a small vessel, tapering at the apex of the left ventricle. There is calcific plaque within the mid vessel, with dense calcific plaque at the bifurcation of the second diagonal branch. This limits evaluation of the vessel lumen, and although a flow-limiting lesion cannot be excluded, there is no evidence of a high-grade stenosis. There is ostial calcification within the second diagonal branch as well. The LAD distal to the second diagonal branch is small relative to the more proximal vessel, and this is worrisome for a proximal flow-limiting lesion.,In addition, there is marked tapering of the D2 branch distal to the proximal and ostial calcific plaque. This is worrisome for either occlusion or a high-grade stenosis. There is only minimal contrast that is identified in the distal vessel.,LEFT CIRCUMFLEX ARTERY:,The left circumflex artery is a moderate-sized vessel with a patent ostium. There is calcific plaque within the proximal vessel. There is dense calcific plaque at the bifurcation of the OM1, and the AV groove branch. The AV groove branch tapers as a small vessel at the base of the heart. The dense calcific plaque within the bifurcation of the OM1 and the AV groove branch limits evaluation of the vessel lumen. There is no demonstrated high-grade stenosis, but a flow-limiting lesion cannot be excluded here.,RIGHT CORONARY ARTERY:,The right coronary artery is a moderate-sized vessel with a patent ostium. There is proximal mixed calcific and non-calcific plaque, but there is no flow-limiting lesion. The vessel continues as a moderate-sized vessel to the crux of the heart, supplying a small posterior descending artery and moderate to large posterolateral ventricular branches.,There is scattered calcific plaque within the mid vessel and there is also calcific plaque within the distal vessel at the origin of the posterior descending artery. There is no flow-limited lesion demonstrated.,The right coronary artery is dominant.,NONCORONARY CARDIAC STRUCTURE:,CARDIAC CHAMBERS:, There is diffuse myocardial thinning within the left ventricle, particularly within the apex where there is subendocardial calcification, consistent with chronic infarction. There is ventricular enlargement. There is no demonstrated aneurysm or pseudoaneurysm.,CARDIAC VALVES: ,There is calcification within the left aortic valve cusp. The aortic valve is tri-leaflet. Normal mitral valve.,PERICARDIUM:, Normal.,GREAT VESSELS: ,There are atherosclerotic changes within the aorta.,VISUALIZED LUNG PARENCHYMA, MEDIASTINUM AND CHEST WALL: ,Normal.,IMPRESSION:,Limited examination secondary to extensive artifact from the pacemaker wires.,There is extensive calcific plaque within the left anterior descending artery as well as within the proximal second diagonal branch. There is marked tapering of the LAD distal to the bifurcation of the D1 and this is worrisome for a flow-limiting lesion, but there is no evidence of occlusion.,There is marked tapering of the D1 branch distal to the calcific plaque and occlusion cannot be excluded.,There is dense calcific plaque within the left circumflex artery, and although a flow-limiting lesion cannot be excluded here, there is no evidence of an occlusion or high-grade stenosis.,There is mixed soft and calcific plaque within the proximal RCA, but there is no flow limiting lesion demonstrated.,There is diffuse thinning of the left ventricular wall, most focal at the apex where there is also dense calcification, consistent with chronic infarction. There is no demonstrated aneurysm or pseudoaneurysm. Cardiovascular / Pulmonary Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis. COPD & Bronchitis - Discharge Summary DIAGNOSIS AT ADMISSION:, Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,DIAGNOSES AT DISCHARGE,1. Chronic obstructive pulmonary disease exacerbation and acute bronchitis.,2. Congestive heart failure.,3. Atherosclerotic cardiovascular disease.,4. Mild senile-type dementia.,5. Hypothyroidism.,6. Chronic oxygen dependent.,7. Do not resuscitate/do not intubate.,HOSPITAL COURSE: , The patient was admitted from the office by Dr. X. She was placed on the usual medications that included Synthroid 0.05 mg a day, enalapril 5 mg a day, Imdur 30 mg a day, Lanoxin 0.125 mg a day, aspirin 81 mg a day, albuterol and Atrovent nebulizers q.4 h., potassium chloride 10 mEq 2 tablets per day, Lasix 40 mg a day, Humibid L.A. 600 mg b.i.d. She was placed on oral Levaquin after a load of 500 mg and 250 mg a day. She was given oxygen, encouraged to eat, and suctioned as needed.,Laboratory data included a urinalysis that had 0-2 WBCs per high power field and urine culture was negative, blood cultures x2 were negative, TSH was 1.7, and chem-7, sodium 134, potassium 4.4, chloride 93, CO2 34, glucose 105, BUN 17, creatinine 0.9, and calcium 9.1. Digoxin was 1.3. White blood cell count was 6100 with a normal differential, H&H 37.4/12.1, platelets 335,000. Chest x-ray was thought to have prominent interstitial lung changes without acute infiltrate. There is a question if there is mild fluid overload.,The patient improved with the above regimen. By discharge, her lungs fell back to her baseline. She had no significant shortness of breath. Her O2 saturations were stable. Her vital signs were stable.,She is discharged home to follow up with me in a week and a half.,Her daughter has been spoken to by phone and she will notify me if she worsens or has problems.,PROGNOSIS: ,Guarded. cardiovascular / pulmonary, chronic obstructive pulmonary disease exacerbation, chronic obstructive pulmonary disease, pulmonary, copd, discharge, bronchitis, Cardiovascular / Pulmonary Selective coronary angiography. Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery. Abdominal aortography. Coronary Angiography & Abdominal Aortography NAME OF PROCEDURE,1. Selective coronary angiography.,2. Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery.,3. Abdominal aortography.,INDICATIONS: ,The patient is a 65-year-old gentleman with a history of exertional dyspnea and a cramping-like chest pain. Thallium scan has been negative. He is undergoing angiography to determine if his symptoms are due to coronary artery disease.,NARRATIVE: ,The right groin was sterilely prepped and draped in the usual fashion and the area of the right coronary artery anesthetized with 2% lidocaine. Constant sedation was obtained using Versed 1 mg and fentanyl 50 mcg. Received additional Versed and fentanyl during the procedure. Please refer to the nurses' notes for dosages and timing.,The right femoral artery was entered and a 4-French sheath was placed. Advancement of the guidewire demonstrated some obstruction at the level of abdominal aorta. Via the right Judkins catheter, the guidewire was easily infiltrated to the thoracic aorta and over aortic arch. The right Judkins catheter was advanced to the origin of the right coronary artery where selective angiograms were performed. This revealed a very high-grade lesion at the proximal right coronary artery. This catheter was exchanged for a left #4 Judkins catheter which was advanced to the ostium of the left main coronary artery where selective angiograms were performed.,The patient was found to have the above mentioned high-grade lesion in the right coronary artery and a coronary intervention was performed. A 6-French sheath and a right Judkins guide was placed. The patient was started on bivalarudin. A BMW wire was easily placed across the lesion and into the distal right coronary artery. A 3.0 x 15 mm Voyager balloon was placed and deployed at 10 atmospheres. The intermediate result was improved with TIMI-3 flow to the terminus of the vessel. Following this, a 3.0 x 18 mm Xience stent was placed across the lesion and deployed at 17 atmospheres. This revealed excellent result however at the very distal of the stent there was an area of haziness but no definite dissection. This was stented with a 3.0 x 8 mm Xience stent deployed again at 17 atmospheres. Final angiograms revealed excellent result with TIMI-3 flow at the terminus of the right coronary artery and approximately 10% residual stenosis at the worst point of the narrowing. The guiding catheter was withdrawn over wire and a pigtail was placed. This was advanced to the abdominal aorta at the area of obstruction and small injection of contrast was given demonstrating that there was a small aneurysm versus a small retrograde dissection in that area with some dye hang up after injection. The catheter was removed. The bivalarudin was stopped at the termination of procedure. A small injection of contrast given through arterial sheath and Angio-Seal was placed without incident.,It should also be noted that an 8-French sheath was placed in the right femoral vein. This was placed initially as the patient was going to have a right heart catheterization as well because of the dyspnea.,Total contrast media, 205 mL, total fluoroscopy time was 7.5 minutes, X-ray dose, 2666 milligray.,HEMODYNAMICS: , Rhythm was sinus throughout the procedure. Aortic pressure was 170/81 mmHg.,The right coronary artery is a dominant vessel. This vessel gives rise to conus branch and two small RV free wall branches and PDA and a small left ventricular branch. It should be noted that there was competitive flow in the posterior left ventricular branch and that the distal right coronary artery fills via left sided collaterals. In the proximal right coronary artery, there is a large ulcerative plaque followed immediately by a severe stenosis that is subtotal in severity. After intervention, there is TIMI-3 flow to the terminus of the right coronary with better fill into the distal right coronary artery and loss of competitive flow. There was approximately 10% residual stenosis at the worst part of the previous stenosis.,The left main is without disease and trifurcates into a moderate-sized ramus intermedius, the LAD and the circumflex. The ramus intermedius is free of disease. The LAD terminates at the LV apex and has elongated area of mild stenosis at its mid segment. This measures 25% to 30% at its worst point. The circumflex is a large caliber vessel. There is a proximal 15% to 20% stenosis and an area of ectasia in the proximal circumflex. Distally, this circumflex gives rise to a large bifurcating marginal artery and beyond that point, the circumflex is a small vessel within the AV groove.,The aortogram demonstrates eccentric aneurysm formation. This may represent a small retrograde dissection as well. There was some dye hang up in the wall.,IMPRESSION,1. Successful stenting of subtotal stenosis of the proximal coronary artery.,2. Non-obstructive coronary artery disease in the mid left anterior descending as described above and ectasia of the proximal circumflex coronary artery.,3. Left to right collateral filling noted prior to coronary intervention.,4. Small area of eccentric aneurysm formation in the abdominal aorta. cardiovascular / pulmonary, xience stents, thallium scan, coronary artery, coronary angiography, abdominal aortography, artery, coronary, angiography, stents, flow, vessel, abdominal, catheter, circumflex, stenosis, proximal, Cardiovascular / Pulmonary A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath. COPD - Discharge Summary HISTORY OF PRESENT ILLNESS: ,A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath. He was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was admitted for acute asthmatic bronchitis, superimposed upon longstanding COPD. Unfortunately over the past few months he has returned to pipe smoking. At the time of admission, he denied fever, diaphoresis, nausea, chest pain or other systemic symptoms.,PAST MEDICAL HISTORY: , Status post artificial aortic valve implantation in summer of 2002 and is on chronic Coumadin therapy. COPD as described above, history of hypertension, and history of elevated cholesterol.,PHYSICAL EXAMINATION: , Heart tones regular with an easily audible mechanical click. Breath sounds are greatly diminished with rales and rhonchi over all lung fields.,LABORATORY STUDIES: ,Sodium 139, potassium 4.5, BUN 42, and creatinine 1.7. Hemoglobin 10.7 and hematocrit 31.7.,HOSPITAL COURSE: , He was started on intravenous antibiotics, vigorous respiratory therapy, intravenous Solu-Medrol. The patient improved on this regimen. Chest x-ray did not show any CHF. The cortisone was tapered. The patient's oxygenation improved and he was able to be discharged home.,DISCHARGE DIAGNOSES: ,Chronic obstructive pulmonary disease and acute asthmatic bronchitis.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN: , Prednisone 20 mg 3 times a day for 2 days, 2 times a day for 5 days and then one daily, Keflex 500 mg 3 times a day and to resume his other preadmission medication, can be given a pneumococcal vaccination before discharge. To follow up with me in the office in 4-5 days. cardiovascular / pulmonary, increased cough, respiratory secretions, wheezings, shortness of breath, acute asthmatic bronchitis, asthmatic bronchitis, respiratory, breath, asthmatic, copd, Cardiovascular / Pulmonary CCTA with cardiac function and calcium scoring. Coronary CT Angiography (CCTA) - 1 HISTORY: , Coronary artery disease.,TECHNIQUE AND FINDINGS: ,Calcium scoring and coronary artery CTA with cardiac function was performed on Siemens dual-source CT scanner with postprocessing on Vitrea workstation. Patient received oral Metoprolol 100 milligrams. 100 ml Ultravist 370 was utilized as the contrast agent. 0.4 milligrams of nitroglycerin was given.,Patient's calcium score 164, volume 205; this places the patient between the 75th and 90th percentile for age. There is at least moderate atherosclerotic plaque with mild coronary artery disease and significant narrowings possible.,Cardiac wall motion was within normal limits. Left ventricular ejection fraction calculated to be 82%. End-diastolic volume 98 mL, end-systolic volume calculated to be 18 mL.,There is normal coronary artery origins. There is codominance between the right coronary artery and the circumflex artery. There is mild to moderate stenosis of the proximal LAD with mixed plaque. Mild stenosis mid LAD with mixed plaque. No stenosis. Distal LAD with the distal vessel becoming diminutive in size. Right coronary artery shows mild stenosis proximally and in the midportion due to calcified focal plaque. Once again the distal vessel becomes diminutive in size. Circumflex shows mild stenosis due to focal calcified plaque proximally. No stenosis is seen involving the mid or distal circumflex. The distal circumflex also becomes diminutive in size. The left main shows small amount of focal calcified plaque without stenosis. Myocardium, pericardium and wall motion was unremarkable as seen.,IMPRESSION:,1. Atherosclerotic coronary artery disease with values as above. There are areas of stenosis most pronounced in the LAD with mild to moderate change and mild stenosis involving the circumflex and right coronary artery.,2. Consider cardiology consult and further evaluation if clinically indicated.,3. Full report was sent to the PACS. Report will be mailed to Dr. ABC. cardiovascular / pulmonary, coronary ct angiography, vitrea workstation, cardiac wall motion, proximal lad, distal lad, focal calcified plaque, coronary artery disease, cardiac function, calcium scoring, wall motion, distal vessel, calcified plaque, distal circumflex, artery disease, mild stenosis, coronary artery, ccta, scoring, atherosclerotic, vessel, calcium, calcified, lad, circumflex, distal, plaque, coronary, artery, stenosis, Cardiovascular / Pulmonary The patient admitted with palpitations and presyncope. Consult - Palpitations & Presyncope HISTORY OF PRESENT ILLNESS: , The patient is a charming and delightful 46-year-old woman admitted with palpitations and presyncope.,The patient is active and a previously healthy young woman, who has had nine years of occasional palpitations. Symptoms occur three to four times per year and follow no identifiable pattern. She has put thought and effort in trying to identify precipitating factors or circumstances but has been unable to do so. Symptoms can last for an hour or more and she feels as if her heart is going very rapidly but has never measured her heart rate. The last two episodes, the most recent of which was yesterday, were associated with feeling of darkness descending as if a shade was being pulled down in front of her vision. On neither occasion did she lose consciousness.,Yesterday, she had a modestly active morning taking a walk with her dogs and performing her normal routines. While working on a computer, she had a spell. Palpitations persisted for a short time thereafter as outlined in the hospital's admission note prompting her to seek evaluation at the hospital. She was in sinus rhythm on arrival and has been asymptomatic since.,No history of exogenous substance abuse, alcohol abuse, or caffeine abuse. She does have a couple of sodas and at least one to two coffees daily. She is a nonsmoker. She is a mother of two. There is no family history of congenital heart disease. She has had no history of thoracic trauma. No symptoms to suggest thyroid disease.,No known history of diabetes, hypertension, or dyslipidemia. Family history is negative for ischemic heart disease.,Remote history is significant for an ACL repair, complicated by contact urticaria from a neoprene cast.,No regular medications prior to admission.,The only allergy is the neoprene reaction outlined above.,PHYSICAL EXAMINATION: , Vital signs as charted. Pupils are reactive. Sclerae nonicteric. Mucous membranes are moist. Neck veins not distended. No bruits. Lungs are clear. Cardiac exam is regular without murmurs, gallops, or rubs. Abdomen is soft without guarding, rebound masses, or bruits. Extremities well perfused. No edema. Strong and symmetrical distal pulses.,A 12-lead EKG shows sinus rhythm with normal axis and intervals. No evidence of preexcitation.,LABORATORY STUDIES: , Unremarkable. No evidence of myocardial injury. Thyroid function is pending.,Two-dimensional echocardiogram shows no evidence of clinically significant structural or functional heart disease.,IMPRESSION/PLAN: , Episodic palpitations over a nine-year period. Outpatient workup would be appropriate. Event recorder should be obtained and the patient can be seen again in the office upon completion of that study. Suppressive medication (beta-blocker or Cardizem) was discussed with the patient for symptomatic improvement, though this would be unlikely to be a curative therapy. The patient expresses a preference to avoid medical therapy if possible.,Thank you for this consultation. We will be happy to follow her both during this hospitalization and following discharge. Caffeine avoidance was discussed as well.,ADDENDUM: , During her initial evaluation, a D-dimer was mildly elevated to 5. CT scan showed no evidence of pulmonary embolus. Lower extremity venous ultrasound is pending; however, in the absence of embolization to the pulmonary vasculature, this would be an unlikely cause of palpitations. In addition, no progression over the nine-year period that she has been symptomatic suggests that this is an unlikely cause., cardiovascular / pulmonary, presyncope, palpitations, episodic palpitations, beta-blocker, ultrasound, palpitations and presyncope, sinus rhythm, heart disease, heart Cardiovascular / Pulmonary Atrial fibrillation and shortness of breath. The patient is an 81-year-old gentleman with shortness of breath, progressively worsening, of recent onset. History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive. Consult - Atrial Fibrillation - 1 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: Cardiovascular / Pulmonary Patient with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia. Consult - Atrial Fibrillation REASON FOR CONSULTATION:, Atrial fibrillation.,HISTORY OF PRESENT ILLNESS:, The patient is a 78-year-old, Hispanic woman with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia. Apparently, the patient is a resident of Lake Harris Port Square long-term facility after her stroke. She was found to have confusion while in her facility. She then came to the emergency room and found to have a right sided acute stroke. 12-lead EKG performed on August 10, 2009, found to have atrial fibrillation. Telemetry also revealed atrial fibrillation with rapid ventricular response. Currently, the telemetry is normal sinus rhythm. Because of the finding of atrial fibrillation, cardiology was consulted.,The patient is a poor historian. She did not recall why she is in the hospital, she said she had a stroke. She reported no chest discomfort, no shortness of breath, no palpitations.,The following information was obtained from the patient's chart:,PAST MEDICAL HISTORY:,1. Coronary artery disease status post bypass grafting surgery. Unable to obtain the place, location, anatomy, and the year it was performed.,2. Carotid artery stenosis status post right carotid artery stenting. Again, the time was unknown.,3. Diabetes.,4. Hypertension.,5. Hyperlipidemia.,6. History of stroke with left side hemiplegia.,ALLERGIES: , No known drug allergies.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:, The patient is a resident of Lake Harris Port Square. She has no history of alcohol use.,CURRENT MEDICATIONS: , Please see attached list including hydralazine, Celebrex, Colace, metformin, aspirin, potassium, Lasix, Levaquin, Norvasc, insulin, Plavix, lisinopril, and Zocor.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 133/44, pulse 98, O2 saturation is 98% on room air. Temperature 99, respiratory rate 16.,GENERAL: The patient is sitting in the chair at bedside. Appears comfortable. Left facial droop. Left side hemiplegia.,HEAD AND NECK: No JVP seen. Right side carotid bruit heard.,CHEST: Clear to auscultation bilaterally.,CARDIOVASCULAR: PMI not displaced, regular rhythm. Normal S1 and S2. Positive S4. There is a 2/6 systolic murmur best heard at the left lower sternal border.,ABDOMEN: Soft.,EXTREMITIES: Not edematous.,DATA:, A 12-lead EKG performed on August 9, 2009, revealed atrial fibrillation with a ventricular rate of 96 beats per minute, nonspecific ST wave abnormality.,Review of telemetry done the last few days, currently the patient is in normal sinus rhythm at the rate of 60 beats per minute. Atrial fibrillation was noted on admission noted August 8 and August 10; however, there was normal sinus rhythm on August 10.,LABORATORY DATA: , WBC 7.2, hemoglobin 11.7. The patient's hemoglobin was 8.2 a few days ago before blood transfusion. Chemistry-7 within normal limits. Lipid profile: Triglycerides 64, total cholesterol 106, HDL 26, LDL 17. Liver function tests are within normal limits. INR was 1.1.,A 2D echo was performed on August 11, 2009, and revealed left ventricle normal in size with EF of 50%. Mild apical hypokinesis. Mild dilated left atrium. Mild aortic regurgitation, mitral regurgitation, and tricuspid regurgitation. No intracardiac masses or thrombus were noted. The aortic root was normal in size.,ASSESSMENT AND RECOMMENDATIONS:,1. Paroxysmal atrial fibrillation. It is unknown if this is a new onset versus a paroxysmal atrial fibrillation. Given the patient has a recurrent stroke, anticoagulation with Coumadin to prevent further stroke is indicated. However, given the patient's current neurologic status, the safety of falling is unclear. We need to further discuss with the patient's primary care physician, probably rehab physician. If the patient's risk of falling is low, then Coumadin is indicated. However, if the patient's risk for falling is high, then a course using aspirin and Plavix will be recommended. Transesophageal echocardiogram probably will delineate possible intracardiac thrombus better, however will not change our current management. Therefore, I will not recommend transesophageal echocardiogram at this point. Currently, the patient's heart rate is well controlled, antiarrhythmic agent is not recommended at this point.,2. Carotid artery stenosis. The patient underwent a carotid Doppler ultrasound on this admission and found to have a high-grade increased velocity of the right internal carotid artery. It is difficult to assess the severity of the stenosis given the history of possible right carotid stenting. If clinically indicated, CT angio of the carotid will be indicated to assess for stent patency. However, given the patient's current acute stroke, revascularization is not indicated at this time.,3. Coronary artery disease. Clinically stable. No further test is indicated at this time. Cardiovascular / Pulmonary Congestive heart failure (CHF). 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. Consult - Congestive Heart Failure 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: Cardiovascular / Pulmonary 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. Complex Cyanotic Congenital Heart Disease 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. Cardiovascular / Pulmonary Coronary artery disease, prior bypass surgery. 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. Consult - Coronary Artery Disease 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: Cardiovascular / Pulmonary " Left and right coronary system cineangiography. Left ventriculogram. 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. " Cineangiography - 1 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. cardiovascular / pulmonary, ventriculogram, circumflex, bare-metal stents, myocardial infarction, st-elevation, coronary system cineangiography, infarction, stents, cineangiography, stenosis, Cardiovascular / Pulmonary Juxtaductal coarctation of the aorta, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale. Coarctation of Aorta HISTORY: , The patient is a 4-month-old who presented with respiratory distress and absent femoral pulses with subsequent evaluation including echocardiogram that demonstrated severe coarctation of the aorta with a peak gradient of 29 mmHg and associated dilated cardiomyopathy with fractional shortening of 16%. A bicuspid aortic valve was also seen without insufficiency or stenosis. The patient underwent cardiac catheterization for balloon angioplasty for coarctation of the aorta.,PROCEDURE: ,After sedation and general endotracheal 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 percutaneous technique a 4-French 8 cm long double lumen central venous catheter was inserted in the left femoral vein and sutured into place. There was good blood return from both the ports.,Using a 4-French sheath a 4-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch of pulmonary arteries. The atrial septum was not probe patent.,Using a 4-French sheath a 4-French marker pigtail catheter was inserted into the left femoral artery and advanced retrograde to the descending aorta ,ascending aorta and left ventricle. A descending aortogram demonstrated discrete coarctation of the aorta approximately 8 mm distal to the origin of the left subclavian artery. The transverse arch measured 5 mm. Isthmus measured 4.7 mm and coarctation measured 2.9 x 1.8 mm at the descending aorta level. The diaphragm measured 5.6 mm. The pigtail catheter was exchanged for a wedge catheter, which was then directed into the right innominate artery. This catheter was exchanged over a wire for a Tyshak mini 6 x 2 cm balloon catheter which was advanced across the coarctation and inflated with complete disappearance of discrete waist. Pressure pull-back following angioplasty, however, demonstrated a residual of 15-20 mmHg gradient. Repeat angiogram showed mild improvement in degree of aortic narrowing. The angioplasty was then performed using a Tyshak mini 7 x 2 cm balloon catheter with complete disappearance of mild waist. The pigtail catheter was then reintroduced for a pressure pull-back measurement and final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption.,Cineangiograms were obtained with injection in the descending aorta.,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 pediatric intensive care unit in satisfactory condition. There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal. Mixed venous saturation was low due to mild systemic arterial desaturation and anemia. There is no evidence of significant intracardiac shunt. Further the heart was desaturated due to VQ mismatch.,Phasic right-sided pressures were normal as was the right pulmonary artery capillary wedge pressure with the A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg. Left ventricular systolic pressure was mildly increased with a 60 mmHg systolic gradient into the ascending aorta and a 29 mmHg systolic gradient on pressure pull-back to the descending aorta. The calculated flows were mildly increased. Vascular resistances were normal. A cineangiogram with contrast injection in the descending aorta showed a normal left aortic arch with normal origins of the brachiocephalic vessels. There is discrete juxtaductal coarctation of the aorta. Flow within the intercostal arteries was retrograde. Following balloon angioplasty of coarctation of the aorta, there was slight fall in the mixed venous saturation and an increase in systemic arterial saturation as the fall in left ventricular systolic pressure from 99 mmHg to 92 mmHg. There remained a 4 mmHg systolic gradient into the ascending aorta and 9 mmHg systolic gradient pressure pull-back to the descending aorta. The calculated systemic flow fell to normal values. Final angiogram with injection in the descending aorta demonstrated improved caliber of coarctation of the aorta with mild intimal irregularity and a small left lateral filling defect consistent with a small intimal tear in the region of the ductus arteriosus. There is brisk flow in the descending aorta and appropriate flow in the intercostal arteries. The narrowest diameter of the aorta measured 4.9 x 4.2 mm.,DIAGNOSES: ,1. Juxtaductal coarctation of the aorta.,2. Dilated cardiomyopathy.,3. Bicuspid aortic valve.,4. Patent foramen ovale.,INTERVENTION: , Balloon dilation of coarctation of the aorta.,MANAGEMENT: , The case will be discussed at combined Cardiology and Cardiothoracic Surgery Case Conference. The patient will be allowed to recover from the current intervention with the hopes of complete left ventricular function recovery. The patient will undoubtedly require formal coarctation of the aorta repair surgically in 4-6 months. The further cardiologic care will be directed by Dr. X. cardiovascular / pulmonary, coarctation, juxtaductal, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale, catheter was inserted, mmhg systolic gradient, mmhg systolic, systolic gradient, descending aorta, catheterization, mmhg, ventricular, aorta, aortic, foramen, Cardiovascular / Pulmonary Abnormal EKG and rapid heart rate. The patient came to the emergency room. Initially showed atrial fibrillation with rapid ventricular response. It appears that the patient has chronic atrial fibrillation. She denies any specific chest pain. Her main complaint is shortness of breath and symptoms as above. Consult - Abnormal EKG REASON FOR CONSULTATION: , Abnormal EKG and rapid heart rate.,HISTORY OF PRESENT ILLNESS: , The patient is an 86-year-old female. From the last few days, she is not feeling well, fatigue, tiredness, weakness, nausea, no vomiting, no hematemesis or melena. The patient relates to have some low-grade fever. The patient came to the emergency room. Initially showed atrial fibrillation with rapid ventricular response. It appears that the patient has chronic atrial fibrillation. As per the medications, they are not very clear. Husband has gone out to brief her medications. She denies any specific chest pain. Her main complaint is shortness of breath and symptoms as above.,CORONARY RISK FACTORS: , No hypertension or diabetes mellitus. Nonsmoker. Cholesterol status is normal. Questionable history of coronary artery disease. Family history noncontributory.,FAMILY HISTORY:, Nonsignificant.,PAST SURGICAL HISTORY: , Questionable coronary artery bypass surgery versus valve replacement.,MEDICATIONS: , Unclear at this time, but she does take Coumadin.,ALLERGIES: , ASPIRIN.,PERSONAL HISTORY: , She is married, nonsmoker. Does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY: , Symptoms as above, atrial fibrillation, history of open heart surgery, possible bypass surgery; however, after further query, husband relates that she may had just a valve surgery.,REVIEW OF SYSTEMS,CONSTITUTIONAL: Weakness, fatigue, and tiredness.,HEENT: No history of cataract, history of blurry vision and hearing impairment.,CARDIOVASCULAR: Irregular heart rhythm with congestive heart failure, questionable coronary artery disease.,RESPIRATORY: Shortness of breath, questionable pneumonia. No valley fever.,GASTROINTESTINAL: No nausea, no vomiting, hematemesis or melena.,UROLOGICAL: No frequency or urgency.,MUSCULOSKELETAL: Arthritis, muscle weakness.,CNS: No TIA. No CVA. No seizure disorder.,SKIN: Nonsignificant.,PSYCHOLOGIC: Anxiety and depression.,ALLERGIES: Nonsignificant except as mentioned above for medications.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse of 122, blood pressure 148/78, afebrile, and respiratory rate 18 per minute.,HEENT AND NECK: Neck is supple. Atraumatic and normocephalic. Neck veins are flat. No thyromegaly.,LUNGS: Air entry bilaterally fair. Decreased breath sounds especially in the right basilar areas. Few crackles.,HEART: Normal S1 and S2, irregular.,ABDOMEN: Soft and nontender.,EXTREMITIES: No edema. Pulse is palpable. No clubbing or cyanosis.,CNS: Grossly intact.,MUSCULOSKELETAL: Arthritic changes.,PSYCHOLOGICAL: None significant.,DIAGNOSTIC DATA: , EKG, atrial fibrillation with rapid ventricular response, and nonspecific ST-T changes. INR of 4.5, H and H 10 and 30. BUN and creatinine are within normal limits. Chest x-ray confirmed right lower lobe patchy infiltrate, and trace of pneumonia.,IMPRESSION:,1. The patient is an 86-year-old female who has questionable bypass surgery, questionable valve surgery with a rapid atrial heart rate, chronic atrial fibrillation with rapid ventricular response, exacerbated by most likely underlying pneumonia by chest x-ray findings.,2. Symptoms as above.,RECOMMENDATIONS:,1. We will start her on a low dose of beta-blocker for rate control and antibiotic for pneumonia. Once, if she is stable, we will consider further cardiac workup.,2. We will also obtain an echocardiogram to assess valves such as whether she had a prior valve surgery versus coronary artery bypass surgery. Cardiovascular / Pulmonary Left and right coronary system cineangiography, cineangiography of SVG to OM and LIMA to LAD. Left ventriculogram and aortogram. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent. Cineangiography PROCEDURES UNDERTAKEN,1. Left coronary system cineangiography.,2. Right coronary system cineangiography.,3. Cineangiography of SVG to OM.,4. Cineangiography of LIMA to LAD.,5. Left ventriculogram.,6. Aortogram.,7. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.,NARRATIVE:, After all risks and benefits were explained to the patient, informed consent was obtained. The patient was brought to the cardiac catheterization suite. The right groin was prepped in the usual sterile fashion. Right common femoral artery was cannulated using a modified Seldinger technique and a long 6-French AO sheath was introduced secondary to tortuous aorta. Next, Judkins left catheter was used to engage the left coronary system. Cineangiography was recorded in multiple views. Next, Judkins right catheter was used to engage the right coronary system. Cineangiography was recorded in multiple views. Next, the Judkins right catheter was used to engage the SVG to OM. Cineangiography was recorded. Next, the Judkins right was advanced into the left subclavian and exchanged over a long exchange length J-wire for a 4-French left internal mammary artery which was used to engage the LIMA graft to LAD and cineangiography was recorded in multiple views. Next, an angled pigtail catheter was advanced into the left ventricular cavity. LV pressures were measured. LV gram was done and a pullback gradient across the aortic valve was done and recorded. Next, an aortogram was done and recorded. At this point, I decided to proceed with percutaneous intervention of the left circumflex. Therefore, AVA 3.5 guide was used to engage the left coronary artery. Angiomax bolus and drip was started. Universal wire was advanced past the lesion and a 2.5-balloon was advanced first to the proximal lesions and predilations were done at 14 atmospheres and then to the distal lesion and predilatation was done at 12 atmospheres. Next, we attempted to advance a 3.0 x 12 stent to the distal lesion; however, we were unable to pass the stent. Next, second dilatations were done again with the 2.5 balloon at 18 atmospheres; however, we are unable to break the lesion. We next attempted a cutting balloon. Again, we are unable to cross the lesion, therefore a buddy wire technique was used with a PT choice support wire. Again, we were unable to cross the lesion with the stent. We then try to cross with a noncompliant balloon, which we were unsuccessful. We also try to cutting balloon again, we were unsuccessful. Despite multiple dilatations, we were unable to cross anything beyond the noncompliant balloon across the lesion; therefore, finally the procedure was aborted. Final images showed no evidence of dissection, perforation, or further complication. The right groin was filled after taking an image to confirm sheath placement above the bifurcation with excellent results. The patient tolerated the procedure very well without complications, was taken off the operating table and transferred back to cardiac telemetry floor.,DIAGNOSTIC FINDINGS,1. The LV. LVEDP was 4. LVES is approximately 50%-55% with inferobasal hypokinesis. No significant MR. No gradient across the aortic valve.,2. Aortogram. The ascending aorta shows no significant dilatation or evidence of dissection. The valve shows no significant aortic insufficiencies. The abdominal aorta and distal aorta shows significant tortuosities.,3. The left main. The left main coronary artery is a large caliber vessel, bifurcating the LAD and left circumflex with some mild distal disease of about 10%-20%.,4. Left circumflex. The left circumflex vessel is a large caliber vessel gives off a distal branching obtuse marginal branch. The upper pole of the OM shows retrograde filling of the distal graft and also at that point approximately a 70%-80% stenosis. The mid left circumflex is a high-grade 80% diffuse tortuous stenosis.,5. LAD. The LAD is a totally 100% occluded vessel. The LIMA to LAD is patent with only a small-to-moderate caliber LAD. There is a large diagonal branch coming off the proximal portion of the LAD and that proximal LAD showed some diffuse disease upwards of 60%-70%. The diagonal shows proximal 80% stenosis.,6. The right coronary artery: The right coronary artery is 100% occluded. There are retrograde collaterals from left to right to the distal PDA and PLV branches. The SVG to OM is 100% occluded at its take off. The SVG to PDA is not found; however, presumed 100% occluded given that there is collateral flow to the distal right.,7. LIMA to LAD is widely patent.,ASSESSMENT AND PLAN: , Attempted intervention to the left circumflex system, only able to perform plano balloon angioplasty, unable to pass stents, noncompliant balloons or cutting balloon. Final images showed some improvement, however, continued residual stenosis. At this point, the patient will be transferred back to telemetry floor and monitored. We can attempt future intervention or continue aggressive medical management. The patient continues to have residual stenosis in the diagonal; however, due to the length of this procedure, I did not attempt intervention to that diagonal branch. Possible consideration would be a stress test as an outpatient depending on where patient shows ischemia, focus on treatment to that lesion. cardiovascular / pulmonary, coronary system cineangiography, svg to om, lima to lad, ventriculogram, aortogram, percutaneous intervention, circumflex, obtuse marginal branch, balloon angioplasty, coronary artery, balloon, cineangiography, lad, Cardiovascular / Pulmonary Left pleural effusion, parapneumonic, loculated. Left chest tube placement. Chest Tube Placement PREOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,POSTOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,OPERATION: , Left chest tube placement.,IV SEDATION: , 5 mg of Versed total given under pulse ox monitoring, 1% lidocaine local infiltration.,PROCEDURE: , With the patient semi recumbent and supine the left anterolateral chest was prepped and draped in the usual sterile fashion. A 1% lidocaine was liberally infiltrated into the skin, subcutaneous tissue, deep fascia and the anterior axillary line just below the level of the nipple. The incision was made and deepened through the different layers to reach the intercostal space. The pleura was entered on top of the underlying rib and finger digital palpation was performed. Multiple loculations were encountered. Break up of loculations was performed posteriorly and a chest tube was directed posteriorly. Only a small amount of fluid was noted to come out initially. This was sent for various studies. Soft adhesions were encountered. The plan was to obtain a chest x-ray and start Activase installation. cardiovascular / pulmonary, activase, chest tube placement, pleural effusion, chest tube, lidocaine, infiltration, parapneumonic, loculated, pleural, chest, Cardiovascular / Pulmonary A routine return appointment for a 71-year-old woman with chronic atrial fibrillation. Chief complaint today is shortness of breath. Chronic Atrial Fibrillation 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. Cardiovascular / Pulmonary 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. Chest Wall Tumor Resection 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., cardiovascular / pulmonary, chest wall tumor resection, diaphragm, left lower lobe, lung wedge resection, chest wall reconstruction, chest wall segment, gore tex mesh, chest wall tumor, chest wall, pleural cavity, lower lobe, wedge resection, resection, tumor, wall, chest, anesthesia, electrocautery, wedge, mesh, lung, Cardiovascular / Pulmonary Bilateral pleural effusion. Removal of bilateral #32 French chest tubes with closure of wound. Chest Tube Removal 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., cardiovascular / pulmonary, serous drainage, bilateral pleural effusion, pleural effusion, chest tubes, effusion, pleural, chest Cardiovascular / Pulmonary Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized. Chest Pulmonary Angio EXAM: , CTA chest pulmonary angio.,REASON FOR EXAM: , Evaluate for pulmonary embolism.,TECHNIQUE: , Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.,FINDINGS: , There are no filling defects in the main or main right or left pulmonary arteries. No central embolism. The proximal subsegmental pulmonary arteries are free of embolus, but the distal subsegmental and segmental arteries especially on the right are limited by extensive pulmonary parenchymal, findings would be discussed in more detail below. There is no evidence of a central embolism.,As seen on the prior examination, there is a very large heterogeneous right chest wall mass, which measures at least 10 x 12 cm based on axial image #35. Just superior to the mass is a second heterogeneous focus of neoplasm measuring about 5 x 3.3 cm. Given the short interval time course from the prior exam, dated 01/23/09, this finding has not significantly changed. However, there is considerable change in the appearance of the lung fields. There are now bilateral pleural effusions, small on the right and moderate on the left with associated atelectasis. There are also extensive right lung consolidations, all new or increased significantly from the prior examination. Again identified is a somewhat spiculated region of increased density at the right lung apex, which may indicate fibrosis or scarring, but the possibility of primary or metastatic disease cannot be excluded. There is no pneumothorax in the interval.,On the mediastinal windows, there is presumed subcarinal adenopathy, with one lymph node measuring roughly 12 mm suggestive of metastatic disease here. There is aortic root and arch and descending thoracic aortic calcification. There are scattered regions of soft plaque intermixed with this. The heart is not enlarged. The left axilla is intact in regards to adenopathy. The inferior thyroid appears unremarkable.,Limited assessment of the upper abdomen discloses a region of lower density within the right hepatic lobe, this finding is indeterminate, and if there is need for additional imaging in regards to hepatic metastatic disease, follow up ultrasound. Spleen, adrenal glands, and upper kidneys appear unremarkable. Visualized portions of the pancreas are unremarkable.,There is extensive rib destruction in the region of the chest wall mass. There are changes suggesting prior trauma to the right clavicle.,IMPRESSION:,1. Again demonstrated is a large right chest wall mass.,2. No central embolus, distal subsegmental and segmental pulmonary artery branches are in part obscured by the pulmonary parenchymal findings, are not well assessed.,3. New bilateral pleural effusions and extensive increasing consolidations and infiltrates in the right lung.,4. See above regarding other findings. cardiovascular / pulmonary, chest pulmonary embolism, chest pulmonary embolism protocol, bilateral pleural effusions, chest wall mass, metastatic disease, pulmonary, isovue, subsegmental, metastatic, disease, mass, lung, embolism, chest, angio Cardiovascular / Pulmonary A lady was admitted to the hospital with chest pain and respiratory insufficiency. She has chronic lung disease with bronchospastic angina. Chest Pain & Respiratory Insufficiency We discovered new T-wave abnormalities on her EKG. There was of course a four-vessel bypass surgery in 2001. We did a coronary angiogram. This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.,She may continue in the future to have angina and she will have nitroglycerin available for that if needed.,Her blood pressure has been elevated and so instead of metoprolol, we have started her on Coreg 6.25 mg b.i.d. This should be increased up to 25 mg b.i.d. as preferred antihypertensive in this lady's case. She also is on an ACE inhibitor.,So her discharge meds are as follows:,1. Coreg 6.25 mg b.i.d.,2. Simvastatin 40 mg nightly.,3. Lisinopril 5 mg b.i.d.,4. Protonix 40 mg a.m.,5. Aspirin 160 mg a day.,6. Lasix 20 mg b.i.d.,7. Spiriva puff daily.,8. Albuterol p.r.n. q.i.d.,9. Advair 500/50 puff b.i.d.,10. Xopenex q.i.d. and p.r.n.,I will see her in a month to six weeks. She is to follow up with Dr. X before that. cardiovascular / pulmonary, chest pain, respiratory insufficiency, chronic lung disease, bronchospastic angina, insufficiency, chest, angina, respiratory, bronchospastic Cardiovascular / Pulmonary Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma. Chest Tube Insertion in ER 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. cardiovascular / pulmonary, spontaneous pneumothorax, barometric trauma, respiratory failure, sepsis, pneumonia, blunt dissection, chest wall, thoracic cavity, chest x-ray, chest tube insertion, chest tube, pneumothorax, tube, chest, insertion, Cardiovascular / Pulmonary Chest PA & Lateral to evaluate shortness of breath and pneumothorax versus left-sided effusion. Chest PA & Lateral EXAM: , Chest PA & Lateral.,REASON FOR EXAM: , Shortness of breath, evaluate for pneumothorax versus left-sided effusion.,INTERPRETATION: ,There has been interval development of a moderate left-sided pneumothorax with near complete collapse of the left upper lobe. The lower lobe appears aerated. There is stable, diffuse, bilateral interstitial thickening with no definite acute air space consolidation. The heart and pulmonary vascularity are within normal limits. Left-sided port is seen with Groshong tip at the SVC/RA junction. No evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1. Interval development of moderate left-sided pneumothorax with corresponding left lung atelectasis.,2. Rest of visualized exam nonacute/stable.,3. Left central line appropriately situated and stable.,4. Preliminary report was issued at time of dictation. Dr. X was called for results. cardiovascular / pulmonary, effusion, interstitial thickening, chest pa & lateral, shortness of breath, chest, pneumothorax, Cardiovascular / Pulmonary Patient with a family history of premature coronary artery disease came in for evaluation of recurrent chest pain Chest Pain - Office Note DISCHARGE DIAGNOSES:,1. Chest pain. The patient ruled out for myocardial infarction on serial troponins. Result of nuclear stress test is pending.,2. Elevated liver enzymes, etiology uncertain for an outpatient followup.,3. Acid reflux disease.,TEST DONE: , Nuclear stress test, results of which are pending.,HOSPITAL COURSE: , This 32-year-old with family history of premature coronary artery disease came in for evaluation of recurrent chest pain, O2 saturation at 94% with both atypical and typical features of ischemia. The patient ruled out for myocardial infarction with serial troponins. Nuclear stress test has been done, results of which are pending. The patient is stable to be discharged pending the results of nuclear stress test and cardiologist's recommendations. He will follow up with cardiologist, Dr. X, in two weeks and with his primary physician in two to four weeks. Discharge medications will depend on results of nuclear stress test. cardiovascular / pulmonary, chest pain, serial troponins, premature coronary artery disease, coronary artery disease, nuclear stress test, stress test Cardiovascular / Pulmonary Patient with palpitations and rcent worsening of chronic chest discomfort. Chest discomfort & palpitations - Consult. CHIEF COMPLAINT:, Palpitations.,CHEST PAIN / UNSPECIFIED ANGINA PECTORIS HISTORY:, The patient relates the recent worsening of chronic chest discomfort. The quality of the pain is sharp and the problem started 2 years ago. Pain radiates to the back and condition is best described as severe. Patient denies syncope. Beyond baseline at present time. Past work up has included 24 hour Holter monitoring and echocardiography. Holter showed PVCs.,PALPITATIONS HISTORY:, Palpitations - frequent, 2 x per week. No caffeine, no ETOH. + stress. No change with Inderal.,VALVULAR DISEASE HISTORY:, Patient has documented mitral valve prolapse on echocardiography in 1992.,PAST MEDICAL HISTORY:, No significant past medical problems. Mitral Valve Prolapse.,FAMILY MEDICAL HISTORY:, CAD.,OB-GYN HISTORY:, The patients last child birth was 1997. Para 3. Gravida 3.,SOCIAL HISTORY:, Denies using caffeinated beverages, alcohol or the use of any tobacco products.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, Inderal 20 prn.,REVIEW OF SYSTEMS:, Generally healthy. The patient is a good historian.,ROS Head and Eyes: Denies vision changes, light sensitivity, blurred vision, or double vision.,ROS Ear, Nose and Throat: The patient denies any ear, nose or throat symptoms.,ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ROS Gastrointestinal: Patient denies any gastrointestinal symptoms, such as anorexia, weight loss, dysphagia, nausea, vomiting, abdominal pain, abdominal distention, altered bowel movements, diarrhea, constipation, rectal bleeding, hematochezia.,ROS Genitourinary: Patient denies any genito-urinary complaints, such as hematuria, dysuria, frequency, urgency, hesitancy, nocturia, incontinence.,ROS Gynecological: Denies any gynecological complaints, such as vaginal bleeding, discharge, pain, etc.,ROS Musculoskeletal: The patient denies any past or present problems related to the musculoskeletal system.,ROS Extremities: The patient denies any extremities complaints.,ROS Cardiovascular: As per HPI.,EXAMINATION:,Exam Abdomen/Flank: The abdomen is soft without tenderness or palpable masses. No guarding, rigidity or rebound tenderness. The liver and spleen are not palpable. Bowel sounds are active and normal.,Exam Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted.,Range of motion is normal. There is no cyanosis, clubbing or edema.,General: Healthy appearing, well developed,. The patient is in no acute distress.,Exam Skin Negative to inspection or palpation. There are no obvious lesions or new rashes noted. Non-diaphoretic.,Exam Ears Canals are clear. Throat is not injected. Tonsils are not swollen or injected.,Exam Neck: There is no thyromegaly, carotid bruits, lymphadenopathy, or JVD. Neck is supple.,Exam Respiratory: Normal breath sounds are heard bilaterally. There is no wheezing. There is no use of accessory muscles.,Exam Cardiovascular: Regular heart rate and rhythm, Normal S1 and S2 without murmur, gallops or rubs.,IMPRESSION / DIAGNOSIS:, Mitral Valve Prolapse. Palpitations.,TESTS ORDERED:, Cardiac tests: Echocardiogram.,MEDICATION PRESCRIBED:, ,Cardizem 30-60 qid prn. Cardiovascular / Pulmonary Delayed primary chest closure. Open chest status post modified stage 1 Norwood operation. 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. Chest Closure 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. cardiovascular / pulmonary, open chest, stage 1 norwood operation, hypoplastic left heart syndrome, delayed primary chest closure, chest closure, norwood operation Cardiovascular / Pulmonary Right hemothorax. Insertion of a #32 French chest tube on the right hemithorax. This is a 54-year-old female with a newly diagnosed carcinoma of the cervix. The patient is to have an Infuse-A-Port insertion. Chest Tube Insertion PREOPERATIVE DIAGNOSIS: , Right hemothorax.,POSTOPERATIVE DIAGNOSIS: , Right hemothorax.,PROCEDURE PERFORMED: , Insertion of a #32 French chest tube on the right hemithorax.,ANESTHESIA: , 1% Lidocaine and sedation.,INDICATIONS FOR PROCEDURE:, This is a 54-year-old female with a newly diagnosed carcinoma of the cervix. The patient is to have an Infuse-A-Port insertion today. Postoperatively from that, she started having a blood tinged pink frothy sputum. Chest x-ray was obtained and showed evidence of a hemothorax on the right hand side, opposite side of the Infuse-A-Port and a wider mediastinum. The decision was made to place a chest tube in the right hemithorax to allow for the patient to be stable for transfer out of the operating room.,DESCRIPTION OF PROCEDURE: , The area was prepped and draped in the sterile fashion. The area was anesthetized with 1% Lidocaine solution. The patient was given sedation. A #10 blade scalpel was used to make an incision approximately 1.5 cm long. Then a curved scissor was used to dissect down to the level of the rib. A blunt peon was then used to again enter into the right hemithorax. Immediately a blood tinged effusion was released. The chest tube was placed and directed in a posterior and superior direction. The chest tube was hooked up to the Pleur-evac device which was ________ tip suction. The chest tube was tied in with a #0 silk suture in a U-stitch fashion. It was sutured in place with sterile dressing and silk tape. The patient tolerated this procedure well. We will obtain a chest x-ray in postop to ensure proper placement and continue to follow the patient very closely. cardiovascular / pulmonary, hemothorax, hemithorax, pleur-evac device, infuse-a-port insertion, chest tube, carcinoma Cardiovascular / Pulmonary Chest pain, possible syncopal spells. She has been having multiple cardiovascular complaints including chest pains, which feel like cramps and sometimes like a dull ache, which will last all day long. Chest Pain - Cardiac Consult "REASON FOR REFERRAL:, Chest pain, possible syncopal spells.,She is a very pleasant 31-year-old mother of two children with ADD.,She was doing okay until January of 2009 when she had a partial hysterectomy. Since then she just says ""things have changed"". She just does not want to go out anymore and just does not feel the same. Also, at the same time, she is having a lot of household stressors with both of her children having ADD and ODD and she feels she does not get enough support from her husband. Her 11-year-old is having a lot of trouble at school and she often has to go there to take care of problems.,In this setting, she has been having multiple cardiovascular complaints including chest pains, which feel ""like cramps"" and sometimes like a dull ache, which will last all day long. She is also tender in the left breast area and gets numbness in her left hand. She has also had three spells of ""falling"", she is not really clear on whether these are syncopal, but they sound like they could be as she sees spots before her eyes. Twice it happened, when getting up quickly at night and another time in the grocery store. She suffered no trauma. She has no remote history of syncope. Her weight has not changed in the past year.,MEDICATIONS: , Naprosyn, which she takes up to six a day.,ALLERGIES:, Sulfa.,SOCIAL HISTORY: , She does not smoke or drink. She is married with two children.,REVIEW OF SYSTEMS:, Otherwise unremarkable.,PEX:, BP: 130/70 without orthostatic changes. PR: 72. WT: 206 pounds. She is a healthy young woman. No JVD. No carotid bruit. No thyromegaly. Cardiac: Regular rate and rhythm. There is no significant murmur, gallop, or rub. Chest: Mildly tender in the upper pectoral areas bilaterally (breast exam was not performed). Lungs: Clear. Abdomen: Soft. Moderately overweight. Extremities: No edema and good distal pulses.,EKG: , Normal sinus rhythm, normal EKG.,ECHOCARDIOGRAM (FOR SYNCOPE): , Essentially normal study.,IMPRESSION:,1. Syncopal spells - These do sound, in fact, to be syncopal. I suspect it is simple orthostasis/vasovagal, as her EKG and echocardiogram looks good. I have asked her to drink plenty of fluids and to not to get up suddenly at night. I think this should take care of the problem. I would not recommend further workup unless these spells continue, at which time I would recommend a tilt-table study.,2. Chest pains - Atypical for cardiac etiology, undoubtedly due to musculoskeletal factors from her emotional stressors. The Naprosyn is not helping that much, I gave her a prescription for Flexeril and instructed her in its use (not to drive after taking it).,RECOMMENDATIONS:,1. Reassurance that her cardiac checkup looks excellent, which it does.,2. Drink plenty of fluids and arise slowly from bed.,3. Flexeril 10 mg q 6 p.r.n.,4. I have asked her to return should the syncopal spells continue." cardiovascular / pulmonary, chest pain, syncopal, echocardiogram, ekg, cardiac etiology, syncopal spells, rhythm, flexeril, cardiac, chest, Cardiovascular / Pulmonary Carotid Ultrasonic & Color Flow Imaging Carotid Doppler Report 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. cardiovascular / pulmonary, atherosclerotic, atherosclerotic plaques, obstructive disease, carotid artery, carotid artery and bulb, common carotid artery, mild intimal thickening, external carotid artery, common carotid, internal carotid, external carotid, intimal thickening, carotid, intimal, plaques, artery, Cardiovascular / Pulmonary Left carotid endarterectomy with endovascular patch angioplasty. Critical left carotid stenosis. 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. Carotid Endarterectomy & Angioplasty. 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. cardiovascular / pulmonary, carotid stenosis, carotid endarterectomy, endovascular patch angioplasty, cervical block, carotid artery, common carotid artery, external carotid artery, endovascular patch, common carotid, external carotid, angioplasty, artery, endovascular, neurologically, carotid, stenosis, endarterectomy Cardiovascular / Pulmonary Right subclavian triple lumen central line placement Central Line Placement 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. cardiovascular / pulmonary, respiratory failure, central line placement, chronic obstructive coronary disease, normal saline, subclavian, subclavian triple lumen central line placement, subclavian vein, triple lumen, triple lumen central line, lumen central line placement, central line, line placement, respiratory, xylocaine, Cardiovascular / Pulmonary Carotid and cerebral arteriogram - abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery. Carotid & Cerebral Arteriograms EXAM: , Carotid and cerebral arteriograms.,INDICATION: , Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,IMPRESSION:,1. Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.,2. Mild stenosis of the right internal carotid artery measured at 20%.,3. Patent bilateral vertebral arteries.,4. No significant disease was identified of the anterior cerebral vessels.,DISCUSSION: ,Carotid and cerebral arteriograms were performed on Month DD, YYYY, previous studies are not available for comparison.,The right groin was sterilely cleansed and draped. Lidocaine 1% buffered with sodium bicarbonate was used as local anesthetic. A 19-French needle was then advanced into the common femoral artery and a wire was advanced. Over the wire, a sheath was placed. A wire was then advanced into the abdominal aorta and over the wire and the flushed catheter was then advanced to the arch of the aorta over a wire. Flushed arteriogram was performed. Arteriogram demonstrated no significant disease of the great vessels at their origins. There is demonstration of complete occlusion of the left common carotid artery approximately 3 cm distal to its origin. The vertebral arteries were widely patent. Following this, the flushed catheter was exchanged for ***** catheter and selective catheterization of the common carotid artery on the right was performed. Carotid and cerebral arteriograms were performed. The carotid arteriograms on the right demonstrated the carotid bulb to be unremarkable. The external carotid artery on the right is quite tortuous in its appearance. The internal carotid artery demonstrates a mild plaque creating stenosis, which is measured approximately 20%. Cerebral arteriogram on the right demonstrated the A1 and M1 segments bilaterally to be normal. No significant stenosis identified. There is complete cross-filling into the left brain via the right. No significant stenosis was appreciated.,Following this, the catheter was parked at the origin of the left common carotid artery and ejection demonstrated complete occlusion.,The patient tolerated the procedure well. No complications occurred during or immediately after the procedure. Stasis was achieved of the puncture site using a VasoSeal. The patient will be observed for at least 2-1/2 hours prior to being discharged to home. cardiovascular / pulmonary, carotid, arteriogram, bulb, carotid duplex, catheter, cerebral, distal, femoral artery, internal carotid artery, needle, occlusion, sheath, stenosis, vertebral arteries, vessels, cerebral arteriograms, carotid artery, artery, arteriograms, wire, Cardiovascular / Pulmonary Insertion of central venous line and arterial line and transesophageal echocardiography probe. Central Venous & Arterial Line INDICATIONS FOR PROCEDURES: , Impending open-heart surgery for atrial septectomy and bilateral bidirectional Glenn procedure.,The patient was already under general anesthesia in the operating room. Antibiotic prophylaxis with cephazolin and gentamicin were already given. A strict aseptic technique was used including use of gowns, mask, and gloves, etc. The skin was cleansed with alcohol and then prepped with ChloraPrep solution.,PROCEDURE #1:, Insertion of central venous line.,DESCRIPTION OF PROCEDURE #1: , Attention was directed to the right groin. A Cook 4-French double-lumen 12-cm long central venous heparin-coated catheter kit was opened. Using the 21-gauge needle that comes with this kit, the needle was inserted approximately 2 cm below the right inguinal ligament just medial to the pulsations of the femoral artery. There was good venous blood return on the first try. Using the Seldinger technique, the soft J-end of the wire was inserted through the needle without resistance approximately 15 cm. It was then exchanged for a 5-French dilator followed by the 4-French double-lumen catheter and the wire was removed intact. There was good blood return from both lumens, which were flushed with heparinized saline. The catheter was sutured to the skin at three points with #4-0 silk for stabilization.,PROCEDURE #2:, Insertion of arterial line.,DESCRIPTION OF PROCEDURE #2:, Attention was directed to the left wrist, which was placed on wrist rest. The Allen test was normal. A Cook 2.5-French 5 cm long arterial catheter kit was opened. A 22-gauge IV cannula was used to enter the artery, which was done on the first try with good pulsatile blood return. Using the Seldinger technique, the catheter was exchanged for a 2.5-French catheter and the wire was removed intact. There was pulsatile blood return and the catheter was flushed with heparinized saline solution. It was sutured to the skin with #4-0 silk at three points for stabilization.,Both catheters functioned well throughout the procedure. The distal circulation of the leg and the hand was intact immediately after insertion, approximately 20 minutes later, and at the end of the procedure. There were no complications.,PROCEDURE #3: , Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #3: , The probe was inserted under direct vision because initially there was some resistance to insertion. Under direct vision, using the #2 Miller blade, the upper esophageal opening was visualized and the probe was passed easily without resistance. There was good visualization of the heart. The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography. The probe was removed at the end. There was no trauma and there was no blood tingeing., cardiovascular / pulmonary, open-heart surgery, central venous line, arterial line, transesophageal echocardiography probe, glenn procedure, atrial septectomy, aseptic technique, pulsatile blood, central venous, blood return, arterial, central, probe, insertion, catheter Cardiovascular / Pulmonary Central line insertion. Empyema thoracis and need for intravenous antibiotics. Central Line Insertion 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. cardiovascular / pulmonary, thoracis, intravenous, central line insertion, empyema, catheter, Cardiovascular / Pulmonary Right common carotid endarterectomy, internal carotid endarterectomy, external carotid endarterectomy, and Hemashield patch angioplasty of the right common, internal and external carotid arteries. Carotid Endarterectomy - 1 PREOPERATIVE DIAGNOSIS:, Right common, internal and external carotid artery stenosis.,POSTOPERATIVE DIAGNOSIS:, Right common, internal and external carotid artery stenosis.,OPERATIONS,1. Right common carotid endarterectomy.,2. Right internal carotid endarterectomy.,3. Right external carotid endarterectomy.,4. Hemashield patch angioplasty of the right common, internal and external carotid arteries.,ANESTHESIA:, General endotracheal anesthesia.,URINE OUTPUT: , Not recorded,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 general endotracheal anesthesia was administered. Next the right neck was prepped and draped in the standard surgical fashion. A #10-blade scalpel was used to make an incision at the anterior tip of the sternocleidomastoid muscle. Dissection was carried down to the level of the carotid artery using Bovie electrocautery and sharp dissection with Metzenbaum scissors. The common, internal and external carotid arteries were identified. The facial vein was ligated with #3-0 silk. The hypoglossal nerve was identified and preserved as it coursed across the carotid artery. After dissecting out an adequate length of common, internal and external carotid artery, heparin was given. Next, an umbilical tape was passed around the common carotid artery. A #0 silk suture was passed around the internal and external carotid arteries. The hypoglossal nerve was identified and preserved. An appropriate sized Argyle shunt was chosen. A Hemashield patch was cut to the appropriate size. Next, vascular clamps were placed on the external carotid artery. DeBakey pickups were used to control the internal carotid artery and common carotid artery. A #11-blade scalpel was used to make an incision on the common carotid artery. The arteriotomy was lengthened onto the internal carotid artery. Next, the Argyle shunt was placed. It was secured in place. Next, an endarterectomy was performed; and this was done on the common, internal carotid and external carotid arteries. An inversion technique was used on the external carotid artery. The artery was irrigated and free debris was removed. Next, we sewed the Hemashield patch onto the artery using #6-0 Prolene in a running fashion. Prior to completion of our anastomosis, we removed our shunt. We completed the anastomosis. Next, we removed our clamp from the external carotid artery, followed by the common carotid artery, and lastly by the internal carotid artery. There was no evidence of bleeding. Full-dose protamine was given. The incision was closed with #0 Vicryl, followed by #2-0 Vicryl, followed by #4-0 PDS in a running subcuticular fashion. A sterile dressing was applied. cardiovascular / pulmonary, angioplasty, common carotid artery, external carotid artery, hemashield patch, common carotid, carotid endarterectomy, external, artery, carotid, hemashield, endarterectomy Cardiovascular / Pulmonary Right carotid stenosis and prior cerebrovascular accident. Right carotid endarterectomy with patch angioplasty. Carotid Endarterectomy 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. cardiovascular / pulmonary, carotid stenosis, cerebrovascular, platysmal, dacron patch, carotid endarterectomy, cerebrovascular accident, internal carotid, carotid, stenosis, carotids, endarterectomy Cardiovascular / Pulmonary Direct-current cardioversion. This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years. Successful DC cardioversion of atrial fibrillation. Cardioversion - Direct Current - 1 PROCEDURE: ,Direct-current cardioversion.,BRIEF HISTORY: ,This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years. He had a wide area of circumferential ablation done on November 9th for atrial fibrillation. He did develop recurrent atrial fibrillation the day before yesterday and this is persistent. Therefore, he came in for cardioversion today. He is still within the first 4 to 6 weeks post ablation where we would attempt early cardioversion.,The patient was in the SDI unit, attached to noninvasive monitoring devices. After Brevital was brought by the anesthesia service a single 150 joule synchronized biphasic shock using AP paddles did restore him to sinus rhythm in the 80s. He tolerated it well. He will be observed for couple hours and discharged home later today. He will continue on his current medications. He will follow back up in two to three weeks in the Atrial Fibrillation Clinic and then again in a couple months with myself.,CONCLUSIONS / FINAL DIAGNOSES: , Successful DC cardioversion of atrial fibrillation. cardiovascular / pulmonary, direct-current cardioversion, circumferential ablation, paroxysmal atrial, dc cardioversion, direct current, atrial fibrillation, ablation, cardioversion, Cardiovascular / Pulmonary Direct current cardioversion. Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication. Cardioversion - Direct Current PROCEDURE: , Direct current cardioversion.,REASON FOR PROCEDURE: , Atrial fibrillation.,PROCEDURE IN DETAIL: ,The procedure was explained to the patient with risks and benefits including risk of stroke. The patient understands as well as her husband. The patient had already a transesophageal echocardiogram showing no left atrial appendage thrombus or thrombus in the left atrium. There was spontaneous echocardiogram contrast noticed. The patient was on anticoagulation with Lovenox, received already 3 mg of Versed and 25 mcg of fentanyl for the TEE followed by next 2 mg of Versed for total of 5 mg of Versed. The pads applied in the anterior and posterior approach. With synchronized biphasic waveform at 150 J, one shock was successful in restoring sinus rhythm. The patient had some occasional PACs noticed with occasional sinus tachycardia. The patient had no immediate post-procedure complications. The rhythm was maintained and 12-lead EKG was requested.,IMPRESSION: ,Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication. cardiovascular / pulmonary, thrombus, atrium, echocardiogram, transesophageal, direct current cardioversion, atrial fibrillation, sinus rhythm, sinus, rhythm, cardioversion Cardiovascular / Pulmonary Cardiomyopathy and hypotension. A lady with dementia, coronary artery disease, prior bypass, reduced LV function, and recurrent admissions for diarrhea and hypotension several times. Cardiomyopathy & Hypotension - Consult 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: Cardiovascular / Pulmonary Problem of essential hypertension. Symptoms that suggested intracranial pathology. Cardiology Progress Note 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. cardiovascular / pulmonary, cardiology, ekg, k-dur, progerss note, soap, ankle swelling, blood pressure, chest x-ray, echocardiogram, essential hypertension, heart attack, hydrochlorothiazide, hypertension, pathology, chest, heart, intracranial, Cardiovascular / Pulmonary Cardioversion. Unsuccessful direct current cardioversion with permanent atrial fibrillation. Cardioversion - Unsuccessful REASON FOR EXAM: , Atrial flutter/cardioversion.,PROCEDURE IN DETAIL: , The procedure was explained to the patient with risks and benefits. The patient agreed and signed the consent form. The patient received sedation prior to the cardioversion with a transesophageal echo as dictated earlier with a total of 50 mcg of fentanyl and 6 mg of Versed. The pads were applied in the anterior-posterior approach. The synchronized cardioversion with biphasic energy delivered at 150 J. First attempt was unsuccessful. Second attempt at 200 J with anterior-posterior approach. With biphasic synchronized energy delivered was also unsuccessful with degeneration of the atrial flutter into atrial fibrillation.,The patient was decided to be on wave control and amiodarone and reattempted cardioversion after anticoagulation for four to six weeks and because of the reduced LV function, the success of the rate without antiarrhythmic may be low.,IMPRESSION: , Unsuccessful direct current cardioversion with permanent atrial fibrillation. cardiovascular / pulmonary, atrial flutter, cardioversion, anterior-posterior, transesophageal, atrial fibrillation, flutter/cardioversion, fibrillation, atrial, Cardiovascular / Pulmonary Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease. Cardiovascular - Letter Dear Sample Doctor:,Thank you for referring Mr. Sample Patient for cardiac evaluation. This is a 67-year-old, obese male who has a history of therapy-controlled hypertension, borderline diabetes, and obesity. He has a family history of coronary heart disease but denies any symptoms of angina pectoris or effort intolerance. Specifically, no chest discomfort of any kind, no dyspnea on exertion unless extreme exertion is performed, no orthopnea or PND. He is known to have a mother with coronary heart disease. He has never been a smoker. He has never had a syncopal episode, MI, or CVA. He had his gallbladder removed. No bleeding tendencies. No history of DVT or pulmonary embolism. The patient is retired, rarely consumes alcohol and consumes coffee moderately. He apparently has a sleep disorder, according to his wife (not in the office), the patient snores and stops breathing during sleep. He is allergic to codeine and aspirin (angioedema).,Physical exam revealed a middle-aged man weighing 283 pounds for a height of 5 feet 11 inches. His heart rate was 98 beats per minute and regular. His blood pressure was 140/80 mmHg in the right arm in a sitting position and 150/80 mmHg in a standing position. He is in no distress. Venous pressure is normal. Carotid pulsations are normal without bruits. The lungs are clear. Cardiac exam was normal. The abdomen was obese and organomegaly was not palpated. There were no pulsatile masses or bruits. The femoral pulses were 3+ in character with a symmetrical distribution and dorsalis pedis and posterior tibiales were 3+ in character. There was no peripheral edema. ,He had a chemistry profile, which suggests diabetes mellitus with a fasting blood sugar of 136 mg/dl. Renal function was normal. His lipid profile showed a slight increase in triglycerides with normal total cholesterol and HDL and an acceptable range of LDL. His sodium was a little bit increased. His A1c hemoglobin was increased. He had a spirometry, which was reported as normal. ,He had a resting electrocardiogram on December 20, 2002, which was also normal. He had a treadmill Cardiolite, which was performed only to stage 2 and was terminated by the supervising physician when the patient achieved 90% of the predicted maximum heart rate. There were no symptoms or ischemia by EKG. There was some suggestion of inferior wall ischemia with normal wall motion by Cardiolite imaging.,In summary, we have a 67-year-old gentleman with risk factors for coronary heart disease. I am concerned with possible diabetes and a likely metabolic syndrome of this gentleman with truncal obesity, hypertension, possible insulin resistance, and some degree of fasting hyperglycemia, as well as slight triglyceride elevation. He denies any symptoms of coronary heart disease, but he probably has some degree of coronary atherosclerosis, possibly affecting the inferior wall by functional testings. ,In view of the absence of symptoms, medical therapy is indicated at the present time, with very aggressive risk factor modification. I explained and discussed extensively with the patient, the benefits of regular exercise and a walking program was given to the patient. He also should start aggressively losing weight. I have requested additional testing today, which will include an apolipoprotein B, LPa lipoprotein, as well as homocystine, and cardio CRP to further assess his risk of atherosclerosis. ,In terms of medication, I have changed his verapamil for a long acting beta-blocker, he should continue on an ACE inhibitor and his Plavix. The patient is allergic to aspirin. I also will probably start him on a statin, if any of the studies that I have recommended come back abnormal and furthermore, if he is confirmed to have diabetes. Along this line, perhaps, we should consider obtaining the advice of an endocrinologist to decide whether this gentleman needs treatment for diabetes, which I believe he should. This, however, I will leave entirely up to you to decide. If indeed, he is considered to be a diabetic, a much more aggressive program should be entertained for reducing the risks of atherosclerosis in general, and coronary artery disease in particular.,I do not find an indication at this point in time to proceed with any further testing, such as coronary angiography, in the absence of symptoms.,If you have any further questions, please do not hesitate to let me know.,Thank you once again for this kind referral.,Sincerely,,Sample Doctor, M.D. cardiovascular / pulmonary, cardiovascular, letter, angioedema, beta-blocker, cardiac evaluation, chest discomfort, coronary heart disease, hypertension, metabolic syndrome, therapy-controlled hypertension, truncal obesity, controlled hypertension, borderline diabetes, risk factors, heart disease, intolerance, therapy, heart, atherosclerosis, diabetes, coronary, aspirin Cardiovascular / Pulmonary Cardiology office visit sample note. Cardiology Office Visit - 2 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. Cardiovascular / Pulmonary Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction. Cardiology Progress Note - 1 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. cardiovascular / pulmonary, atrial fibrillation, systolic dysfunction, ace inhibitors, coronary artery disease, rapid atrial fibrillation, congestive heart failure, beta blockers, heart failure, congestive, heart, asleep, Cardiovascular / Pulmonary Cardioversion. An 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation Cardioversion HISTORY: , The patient is an 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation who was admitted yesterday with the recurrence of such in a setting of hypokalemia, incomplete compliance with obstructive sleep apnea therapy with CPAP, chocolate/caffeine ingestion and significant mental stress. Despite repletion of her electrolytes and maintenance with Diltiazem IV she has maintained atrial fibrillation. I have discussed in detail with the patient regarding risks, benefits, and alternatives of the procedure. After an in depth discussion of the procedure (please see my initial consultation for further details) I asked the patient this morning if she would like me to repeat that as that discussion had happened yesterday. The patient declined. I invited questions for her which she stated she had none and wanted to go forward with the cardioversion which seemed appropriate.,PROCEDURE NOTE: , The appropriate time-out procedure was performed as per Medical Center protocol including proper identification of the patient, physician, procedure, documentation, and there were no safety issues identified by myself nor the staff. The patient participated actively in this. She received a total of 4 mg of Versed then and 50 micrograms of fentanyl with utilizing titrated conscious sedation with good effect. She was placed in the supine position and hands free patches had previously been placed in the AP position and she received one synchronized cardioversion attempt after Diltiazem drip had been turned off with successful resumption of normal sinus rhythm. This was confirmed on 12 lead EKG.,IMPRESSION/PLAN: , Successful resumption of normal sinus rhythm from recurrent atrial fibrillation. The patient's electrolytes are now normal and that will need close watching to avoid hypokalemia in the future, as well as she has been previously counseled for strict adherence to sleep apnea therapy with CPAP and perhaps repeat sleep evaluation would be appropriate to titrate her settings, as well as avoidance of caffeine ingestion including chocolate and minimization of mental stress. She will be discharged on her usual robust AV nodal antiarrhythmic therapy with sotalol 80 mg p.o. b.i.d., metoprolol 50 mg p.o. b.i.d., Diltiazem CD 240 mg p.o. daily and digoxin 0.125 mg p.o. daily and to be clear she does have a permanent pacemaker implanted. She will follow-up with her regular cardiologist, Dr. X, for whom I am covering this weekend.,This was all discussed in detail with the patient, as well as her granddaughter with the patient's verbal consent at the bedside. cardiovascular / pulmonary, atrial fibrillation, aortic valve, paroxysmal, normal sinus rhythm, sinus rhythm, cpap, cardioversion, fibrillation, atrial, Cardiovascular / Pulmonary Patient with chest pains, CAD, and cardiomyopathy. Cardiac Radionuclide Stress Test INDICATION FOR STUDY: , Chest pains, CAD, and cardiomyopathy.,MEDICATIONS:, Humulin, lisinopril, furosemide, spironolactone, omeprazole, carvedilol, pravastatin, aspirin, hydrocodone, and diazepam.,BASELINE EKG: , Sinus rhythm at 71 beats per minute, left anterior fascicular block, LVBB.,PERSANTINE RESULTS: , Heart rate increased from 70 to 72. Blood pressure decreased from 160/84 to 130/78. The patient felt slightly dizziness, but there was no chest pain or EKG changes.,NUCLEAR PROTOCOL: , Same day rest/stress protocol was utilized with 12 mCi for the rest dose and 33 mCi for the stress test. 53 mg of Persantine were used, reversed with 125 mg of aminophylline.,NUCLEAR RESULTS:,1. Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition. The resting images are normal. The post Persantine images show mildly decreased uptake in the septum. The sum score is 0.,2. The Gated SPECT shows enlarged heart with a preserved EF of 52%.,IMPRESSION:,1. Mild septal ischemia. Likely due to the left bundle-branch block.,2. Mild cardiomyopathy, EF of 52%.,3. Mild hypertension at 160/84.,4. Left bundle-branch block., cardiovascular / pulmonary, cardiac radionuclide, spect, sinus rhythm, cardiac radionuclide stress test, bundle branch block, stress test, bundle branch, chest pains, stress, test, cardiomyopathy, nuclear Cardiovascular / Pulmonary Follow up update on patient with left carotid angioplasty and stent placement. Cardiology - Letter Please accept this letter of follow up on patient xxx xxx. He is now three months out from a left carotid angioplasty and stent placement. He was a part of a CapSure trial. He has done quite well, with no neurologic or cardiac event in the three months of follow up. He had a follow-up ultrasound performed today that shows the stent to be patent, with no evidence of significant recurrence.,Sincerely,,XYZ, MD, cardiovascular / pulmonary, capsure, cardiac event, ultrasound, carotid angioplasty, stent placement, letter, angioplastyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., Cardiovascular / Pulmonary Need for cardiac catheterization. Coronary artery disease, chest pain, history of diabetes, history of hypertension, history of obesity, a 1.1 cm lesion in the medial aspect of the right parietal lobe, and deconditioning. Cardiac Transfer Summary REASON FOR TRANSFER:, Need for cardiac catheterization done at ABCD.,TRANSFER DIAGNOSES:,1. Coronary artery disease.,2. Chest pain.,3. History of diabetes.,4. History of hypertension.,5. History of obesity.,6. A 1.1 cm lesion in the medial aspect of the right parietal lobe.,7. Deconditioning.,CONSULTATIONS: , Cardiology.,PROCEDURES:,1. Echocardiogram.,2. MRI of the brain.,3. Lower extremity Duplex ultrasound.,HOSPITAL COURSE: , Please refer to my H&P for full details. In brief, the patient is a 64-year-old male with history of diabetes, who presented with 6 hours of chest pressure. He was brought in by a friend. The friend states that the patient deteriorated over the last few weeks to the point that he is very short of breath with exertion. He apparently underwent a cardiac workup 6 months ago that the patient states he barely passed. His vital signs were stable on admission. He was ruled out for myocardial infarction with troponin x2. An echocardiogram showed concentric LVH with an EF of 62%. I had Cardiology come to see the patient, who reviewed the records from Fountain Valley. Based on his stress test in the past, Dr. X felt the patient needed to undergo a cardiac cath during his inpatient stay.,The patient on initial presentation complained of, what sounded like, amaurosis fugax. I performed an MRI, which showed a 1 cm lesion in the right parietal lobe. I was going to call Neurology at XYZ for evaluation. However, secondary to his indication for transfer, this could be followed up at ABCD with Dr. Y.,The patient is now stable for transfer for cardiac cath.,Discharged to ABCD.,DISCHARGE CONDITION:, Stable.,DISCHARGE MEDICATIONS:,1. Aspirin 325 mg p.o. daily.,2. Lovenox 40 mg p.o. daily.,3. Regular Insulin sliding scale.,4. Novolin 70/30, 15 units b.i.d.,5. Metformin 500 mg p.o. daily.,6. Protonix 40 mg p.o. daily.,DISCHARGE FOLLOWUP: , Followup to be arranged at ABCD after cardiac cath. Cardiovascular / Pulmonary A 49-year-old man with respiratory distress, history of coronary artery disease with prior myocardial infarctions, and recently admitted with pneumonia and respiratory failure. Cardio/Pulmo Discharge Summary 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. cardiovascular / pulmonary, discharge summary, ada diet, congestive heart failure, coronary artery disease, respiratory arrest, chest pain, chronic obstructive pulmonary disease, emergency room, hypertension, sputum, wheezing, respiratory distress, myocardial infarctions, respiratory failure, pulmonary disease, basilar rales, heart failure, infarctions, heart, wheezes, coronary, pulmonary, discharge, respiratory, Cardiovascular / Pulmonary Cardiolite treadmill exercise stress test. 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. Cardiolite Treadmill Stress Test 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. cardiovascular / pulmonary, peak heart rate, bundle branch block, perfusion imaging, stress test, mci, ventricular, cardiolite, treadmill, Cardiovascular / Pulmonary Sample cardiology office visit note. Cardiology Office Visit - 1 HISTORY OF PRESENT ILLNESS:, This 66-year-old white male was seen in my office on Month DD, YYYY. Patient was recently discharged from Doctors Hospital at Parkway after he was treated for pneumonia. Patient continues to have severe orthopnea, paroxysmal nocturnal dyspnea, cough with greenish expectoration. His exercise tolerance is about two to three yards for shortness of breath. The patient stopped taking Coumadin for reasons not very clear to him. He was documented to have recent atrial fibrillation. Patient has longstanding history of ischemic heart disease, end-stage LV systolic dysfunction, and is status post ICD implantation. Fasting blood sugar this morning is 130.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: Blood pressure is 120/60. Respirations 18 per minute. Heart rate 75-85 beats per minute, irregular. Weight 207 pounds.,HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good. ,NECK: Supple. JVP is flat. Carotid upstroke is good. ,LUNGS: Severe inspiratory and expiratory wheezing heard throughout the lung fields. Fine crepitations heard at the base of the lungs on both sides. ,CARDIOVASCULAR: PMI felt in fifth left intercostal space 0.5-inch lateral to midclavicular line. First and second heart sounds are normal in character. There is a II/VI systolic murmur best heard at the apex.,ABDOMEN: Soft. There is no hepatosplenomegaly.,EXTREMITIES: Patient has 1+ pedal edema.,MEDICATIONS: , ,1. Ambien 10 mg at bedtime p.r.n.,2. Coumadin 7.5 mg daily.,3. Diovan 320 mg daily.,4. Lantus insulin 50 units in the morning.,5. Lasix 80 mg daily.,6. Novolin R p.r.n.,7. Toprol XL 100 mg daily.,8. Flovent 100 mcg twice a day.,DIAGNOSES:,1. Atherosclerotic coronary vascular disease with old myocardial infarction.,2. Moderate to severe LV systolic dysfunction.,3. Diabetes mellitus.,4. Diabetic nephropathy and renal failure.,5. Status post ICD implantation.,6. New onset of atrial fibrillation.,7. Chronic Coumadin therapy.,PLAN:,1. Continue present therapy.,2. Patient will be seen again in my office in four weeks. Cardiovascular / Pulmonary Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture. Cardiac Consultation - 6 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. Cardiovascular / Pulmonary Patient with atrial fibrillation with slow ventricular response, partially due to medications. Cardiac Consultation - 3 HISTORY OF PRESENT ILLNESS:, The patient is known to me secondary to atrial fibrillation with slow ventricular response, partially due to medications, at least when I first saw him in the office on 01/11/06. He is now 77 years old. He is being seen on the Seventh Floor. The patient is in Room 7607. The patient has a history of recent adenocarcinoma of the duodenum that was found to be inoperable, since it engulfed the porta hepatis. The workup began with GI bleeding. He was seen in my office on 01/11/06 for preop evaluation due to leg edema. A nonocclusive DVT was diagnosed in the proximal left superficial femoral vein. Both legs were edematous, and bilateral venous insufficiency was also present. An echocardiogram demonstrated an ejection fraction of 50%. The patient was admitted to the hospital and treated with a Greenfield filter since anticoagulant was contraindicated. Additional information on the echocardiogram, where a grossly dilated left atrium, moderately severely dilated right atrium. The rhythm was, as stated before, atrial fibrillation with slow atrioventricular conduction and an intraventricular conduction delay on the monitor strip. There was mild to moderate tricuspid regurgitation, mild pulmonic insufficiency. The ejection fraction was considered low normal, since it was estimated 50 to 54%. The patient received blood while in the hospital due to anemia. The leg edema improved while lying down, suggesting that the significant element of venous insufficiency was indeed present. The patient, who was diabetic, received consultation by Dr. R. He was also a chronic hypertensive and was treated for that with ACE inhibitors. The atrial fibrillation was slow, and no digitalis or beta blockers were recommended at the same time. As a matter of fact, they were discontinued. Now, the patient denied any shortness of breath or chest pain throughout this hospitalization, and cardiac nuclear studies performed earlier demonstrated no reversible ischemia.,ALLERGIES:, THE PATIENT HAS NO KNOWN DRUG ALLERGIES.,His diabetes was suspected to be complicated with neuropathy due to tingling in both feet. He received his immunizations with flu in 2005 but did not receive Pneumovax.,SOCIAL HISTORY:, The patient is married. He had 1 child who died at the age of 26 months of unknown etiology. He quit smoking 6 years ago but dips (smokeless) tobacco.,FAMILY HISTORY:, Mother had cancer, died at 70. Father died of unknown cause, and brother died of unknown cause.,FUNCTIONAL CAPACITY:, The patient is wheelchair bound at the time of his initial hospitalization. He is currently walking in the corridor with assistance. Nocturia twice to 3 times per night.,REVIEW OF SYSTEMS:,OPHTHALMOLOGIC: Uses glasses.,ENT: Complains of occasional sinusitis.,CARDIOVASCULAR: Hypertension and atrial fibrillation.,RESPIRATORY: Normal.,GI: Colon bleeding. The patient believes he had ulcers.,GENITOURINARY: Normal.,MUSCULOSKELETAL: Complains of arthritis and gout.,INTEGUMENTARY: Edema of ankles and joints.,NEUROLOGICAL: Tingling as per above. Denies any psychiatric problems.,ENDOCRINE: Diabetes, NIDDM.,HEMATOLOGIC AND LYMPHATIC: The patient does not use any aspirin or anticoagulants and is not of anemia.,LABORATORY:, Current EKG demonstrates atrial fibrillation with incomplete left bundle branch block pattern. Q waves are noticed in the inferior leads. Nonprogression of the R-wave from V1 to V4 with small R-waves in V5 and V6 are suggestive of an old anterior and inferior infarcts. Left ventilator hypertrophy and strain is suspected.,PHYSICAL EXAMINATION:,GENERAL: On exam, the patient is alert, oriented and cooperative. He is mildly pale. He is an elderly gentleman who is currently without diaphoresis, pallor, jaundice, plethora, or icterus.,VITAL SIGNS: Blood pressure is 159/69 with a respiratory rate of 20, pulse is 67 and irregularly irregular. Pulse oximetry is 100.,NECK: Without JVD, bruit, or thyromegaly. The neck is supple.,CHEST: Symmetric. There is no heave or retraction.,HEART: The heart sounds are irregular and no significant murmurs could be auscultated.,LUNGS: Clear to auscultation.,ABDOMEN: Exam was deferred.,LEGS: Without edema. Pulses: Dorsalis pedis pulse was palpated bilaterally.,MEDICATIONS:, Current medications include enalapril, low dose enoxaparin, Fentanyl patches. He is no longer on fluconazole. He is on a sliding scale as per Dr. Holden. He is on lansoprazole (Prevacid), Toradol, piperacillin/tazobactam, hydralazine p.r.n., Zofran, Dilaudid, Benadryl, and Lopressor p.r.n.,ASSESSMENT AND PLAN:, The patient is a very pleasant elderly gentleman with intractable/inoperable malignancy. His cardiac issues are chronic and most likely secondary to long term hypertension and diabetes. He has chronic atrial fibrillation. I do not envision a scenario whereby he will become a candidate for management of this arrhythmia beyond weight control. He is also not a candidate for anticoagulation, which is, in essence, a part and parcel of the weight control. Reason being is high likelihood for GI bleeding, especially given the diagnosis of invasive malignancy with involvement of multiple organs and lymph nodes. At this point, I agree with the notion of hospice care. If his atrioventricular conduction becomes excessive, occasional nondihydropyridine calcium channel blocker such as diltiazem or beta blockers would be appropriate; otherwise, I would keep him off those medications due to evidence of slow conduction in the presence of digitalis and beta blockers. Cardiovascular / Pulmonary The patient has a previous history of aortic valve disease, status post aortic valve replacement, a previous history of paroxysmal atrial fibrillation, congestive heart failure, a previous history of transient ischemic attack with no residual neurologic deficits. Cardiac Consultation - 7 HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old African-American male previously well known to me. He has a previous history of aortic valve disease, status post aortic valve replacement on 10/15/2007, for which he has been on chronic anticoagulation. There is a previous history of paroxysmal atrial fibrillation and congestive heart failure, both of which have been stable prior to this admission. He has a previous history of transient ischemic attack with no residual neurologic deficits.,The patient has undergone surgery by Dr. X for attempted nephrolithotomy. The patient has experienced significant postoperative bleeding, for which it has been necessary to discontinue all anticoagulation. The patient is presently seen at the request of Dr. X for management of anticoagulation and his above heart disease.,PAST MEDICAL AND SURGICAL HISTORY:,1. Type I diabetes mellitus.,2. Hyperlipidemia.,3. Hypertension.,4. Morbid obesity.,5. Sleep apnea syndrome.,6. Status post thyroidectomy for thyroid carcinoma.,REVIEW OF SYSTEMS:,General: Unremarkable.,Cardiopulmonary: No chest pain, shortness of breath, palpitations, or dizziness.,Gastrointestinal: Unremarkable.,Genitourinary: See above.,Musculoskeletal: Unremarkable.,Neurologic: Unremarkable.,FAMILY HISTORY: , There are no family members with coronary artery disease. His mother has congestive heart failure.,SOCIAL HISTORY: ,The patient is married. He lives with his wife. He is employed as a barber. He does not use alcohol, tobacco, or illicit drugs.,MEDICATIONS PRIOR TO ADMISSION:,1. Clonidine 0.3 mg b.i.d.,2. Atenolol 50 mg daily.,3. Simvastatin 80 mg daily.,4. Furosemide 40 mg daily.,5. Metformin 1000 mg b.i.d.,6. Hydralazine 25 mg t.i.d.,7. Diovan 320 mg daily.,8. Lisinopril 40 mg daily.,9. Amlodipine 10 mg daily.,10. Lantus insulin 50 units q.p.m.,11. KCl 20 mEq daily.,12. NovoLog sliding scale insulin coverage.,13. Warfarin 7.5 mg daily.,14. Levothyroxine 0.2 mg daily.,15. Folic acid 1 mg daily.,ALLERGIES: , None.,PHYSICAL EXAMINATION:,General: A well-appearing, obese black male.,Vital Signs: BP 140/80, HR 88, respirations 16, and afebrile.,HEENT: Grossly normal.,Neck: Normal. Thyroid, normal. Carotid, normal upstroke, no bruits.,Chest: Midline sternotomy scar.,Lungs: Clear.,Heart: PMI fifth intercostal space mid clavicular line. Normal S1 and prosthetic S2. No murmur, rub, gallop, or click.,Abdomen: Soft and nontender. No palpable mass or hepatosplenomegaly. Cardiovascular / Pulmonary To evaluate recurrent episodes of uncomfortable feeling in arm at rest, as well as during exertion. Cardiac Consultation - 1 CHIEF REASON FOR CONSULTATION:, Evaluate recurrent episodes of uncomfortable feeling in the left upper arm at rest, as well as during exertion for the last one month.,HISTORY OF PRESENT ILLNESS:, This 57-year-old black female complains of having pain and discomfort in the left upper arm, especially when she walks and after heavy meals. This lasts anywhere from a few hours and is not associated with shortness of breath, palpitations, dizziness, or syncope. Patient does not get any chest pain or choking in the neck or pain in the back. Patient denies history of hypertension, diabetes mellitus, enlarged heart, heart murmur, history suggestive of previous myocardial infarction, or acute rheumatic polyarthritis during childhood. Her exercise tolerance is one to two blocks for shortness of breath and easy fatigability.,MEDICATIONS:, Patient does not take any specific medications.,PAST HISTORY:, The patient underwent hysterectomy in 1986.,FAMILY HISTORY:, The patient is married, has four children who are doing fine. Family history is positive for hypertension, congestive heart failure, obesity, cancer, and cerebrovascular accident.,SOCIAL HISTORY:, The patient smokes one pack of cigarettes per day and takes drinks on social occasions. Cardiovascular / Pulmonary To evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG. Cardiac Consultation - 2 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:, Cardiovascular / Pulmonary Patient with right-sided chest pain, borderline elevated high blood pressure, history of hyperlipidemia, and obesity. Cardiac Consultation - 4 REASON FOR CONSULTATION:, Cardiac evaluation.,HISTORY: , This is a 42-year old Caucasian male with no previous history of hypertension, diabetes mellitus, rheumatic fever, rheumatic heart disease, or gout. Patient used to take medicine for hyperlipidemia and then that was stopped. He used to live in Canada and he moved to Houston four months ago. He started complaining of right-sided upper chest pain, starts at the right neck and goes down to the right side. It lasts around 10-15 minutes at times. It is 5/10 in quality. It is not associated with shortness of breath, nausea, vomiting, or sweating. It is not also associated with food. He denies exertional chest pain, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or pedal edema. No palpitations, syncope or presyncope. He said he has been having little cough at night and he went to see an allergy doctor who prescribed several medications for him and told him that he has asthma. No fever, chills, cough, hemoptysis, hematemesis or hematochezia. His EKG shows normal sinus rhythm, normal EKG.,PAST MEDICAL HISTORY:, Unremarkable, except for hyperlipidemia.,SOCIAL HISTORY: , He said he quit smoking 20 years ago and does not drink alcohol.,FAMILY HISTORY: , Positive for high blood pressure and heart disease. His father died in his 50s with an acute myocardial infarction.,MEDICATION:, Ranitidine 300 mg daily, Flonase 50 mcg nasal spray as needed, Allegra 100 mg daily, Advair 500/50 bid.,ALLERGIES:, No known allergies.,REVIEW OF SYSTEMS:, As mentioned above,EXAMINATION:, This is a 42-year old male awake, alert, and oriented x3 in no acute distress.,Wt: 238 Cardiovascular / Pulmonary Patient with a history of atrial fibrillation in the past, more recently who has had atrial flutter. The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred. Cardiac Consult & Cardioversion "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." Cardiovascular / Pulmonary Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain. Cardiac Consultation - 5 REASON FOR REFERRAL: , Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,HISTORY:, This is a 77-year-old white female patient whom I have known for the last about a year or so who has underlying multiple medical problems including hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease status post aortocoronary bypass surgery about eight years ago at Halifax Medical Center where she had triple vessel bypass surgery with left internal mammary artery to the left anterior descending artery, saphenous vein graft to the left circumflex and right coronary arteries. Since then, she has generally done well. She used to be seeing another cardiologist and apparently she had a stress test in September 2008 and she was otherwise cardiac catheterization and coronary angiography, but the patient declined to have one done and since then she has been on medical therapy.,The patient had been on medical therapy at home and generally doing well. Recently, she had no leg swelling, undue exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea. She denies any rest or exertional chest discomfort. Yesterday evening, she had her dinner and she was sitting around and she felt discomfort in the chest at about 7:00 p.m. The discomfort was a crampy pain in the left lower quadrant area, which seemed to radiating to the center of the abdomen and to the right side and it was off and on lasting for a few minutes at a time and then subsiding. Later on she was nauseous, but she did not have any vomiting. She denied any diarrhea. No history of fever or chills. Since the pain seemed to persist, the patient came to the hospital emergency room at 11:35 p.m. where she was seen and admitted for the same. She was given morphine, Zofran, Demerol, another Zofran, and Reglan as well as Demerol again and she was given intravenous fluids. Subsequently, her pain finally went away and she does not have any pain since about 7:00 a.m. this morning. The patient was admitted however for further workup and treatment. At the time of my examination this afternoon, the patient is sitting, lying in bed and comfortable and has no abdominal pain of any kind. She has not been fed any food, however. The patient also had had pelvis and abdominal CT scan performed, which has been described to be partial small bowel obstruction, internal hernia, volvulus or adhesion most likely in the left flank area. The patient has had left nephrectomy and splenectomy, which has been described. A 1.5-mm solid mass is described to be in the lower pole of the kidney. The patient also has been described to have diverticulosis without diverticulitis on this finding.,Currently however, the patient has no clinical symptoms according to her.,PAST MEDICAL HISTORY:, She has had hypertension and hyperlipidemia for the last 15 years, diabetes mellitus for the last eight years, and coronary artery disease for last about eight years or so. She had a chest and back pain about eight years ago for about two weeks and then subsequently she was reported to be evaluated. She has a small myocardial infarction and then she was under the care of Dr. A and she had aortocoronary bypass surgery at Halifax Medical Center by Dr. B, which was a three-vessel bypass surgery with left internal mammary artery to the left descending artery and saphenous vein graft to the left circumflex and distal right coronary artery respectively.,She had had nuclear stress test with Dr. C on September 3, 2008, which was described to be abnormal with ischemic defects, but I do not think the patient had any further cardiac catheterization and coronary angiography after that. She has been treated medically.,This patient also had an admission to this hospital in May 2008 also for partial small bowel obstruction and cholelithiasis and sigmoid diverticulosis. She was described to have had a hemorrhagic cyst of the right kidney. She has mild arthritis for the last 10 or 15 years. She has a history of GERD for the last 20 years, and she also has a history of peptic ulcer disease in the duodenum, but never had any bleeding. She has a history of diverticulosis as mentioned. No history of TIA or CVA. She has one kidney. She was in a car accident in 1978 and afterwards she had to have left nephrectomy as well as splenectomy because of rupture. The patient has a history of pulmonary embolism once about eight years ago after her aortocoronary bypass surgery. She describes this to be a clot on left lung. I am not sure if she had any long-term treatment, however.,In the past, the patient had aortocoronary bypass surgery in 2003 and incisional hernia surgery in 1979 as well as hysterectomy in 1979 and she had splenectomy and nephrectomy as described in 1978.,FAMILY HISTORY: , Her father died at age of 65 of massive heart attack and mother died at age of 62 of cancer. She had a one brother who died of massive heart attack in his 50s, a brother died at the age of 47 of cancer, and another brother died in his 60s of possible rupture of appendix.,SOCIAL HISTORY: , The patient is a widow. She lives alone. She does have three daughters, two of them live in Georgia and one lives in Tennessee. She did smoke in the past up to one to one and a half packs of cigarettes per day for about 10 years, but she quit long time ago. She never drank any alcohol. She likes to drink one or two cups of tea in a day.,ALLERGIES: , PAXIL.,MEDICATIONS:, Her home medications prior to coming in include some of the following medications, although the exact list is not available in the chart at this stage, but they have been on glyburide, Januvia, lisinopril, metformin, metoprolol, simvastatin, ranitidine, meloxicam, and furosemide.,REVIEW OF SYSTEMS:, Appetite is good. She sleeps good at night. She has no headaches and she has mild joint pains from arthritis.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse 90 per minute and regular, blood pressure 140/90 mmHg, respirations 18, and temperature of 98.5 degree Fahrenheit. Moderate obesity is present.,CARDIAC: Carotid upstroke is slightly diminished, but no clear bruit heard.,LUNGS: Slightly decreased air entry at both bases. No rales or rhonchi heard.,CARDIOVASCULAR: PMI in the left fifth intercostal space in the midclavicular line. Regular heart rhythm. S1 and S2 normal. S4 is present. No S3 heard. Short ejection systolic murmur grade I/VI is present at the left lower sternal border of the apex, peaking in LV systole, no diastolic murmur heard.,ABDOMEN: Soft, obese, no tenderness, no masses felt. Bowel sounds are present.,EXTREMITIES: Bilateral trace edema. The extremities are heavy. There is no pitting at this stage. No clubbing or cyanosis. Distal pulses are fair.,CENTRAL NERVOUS SYSTEM: Without any obvious focal deficits.,LABORATORY DATA: , Includes an electrocardiogram, which shows normal sinus rhythm, left atrial enlargement, and right bundle branch block. This is overall unchanged compared to previous electrocardiogram, which also has the same present. Nuclear stress test from 2008 was described to show ejection fraction of 49% and inferior and posterolateral ischemia. Otherwise, laboratory data includes on this patient at this stage WBC 18.3, hemoglobin 15.5, hematocrit is 47.1, and platelet count is 326,000. Electrolytes, sodium 137, potassium 5.2, chloride 101, CO2 27, BUN 34, creatinine 1.2, calcium 9.5, and magnesium 1.7. AST and ALT are normal. Albumin is 4.1. Lipase and amylase are normal. INR is 0.92. Urinalysis is relatively unremarkable except for trace protein. Chest x-ray has been described to show elevated left hemidiaphragm and median sternotomy sutures. No infiltrates seen. Abdomen and pelvis CAT scan findings are as described before with suggestion of partial small bowel obstruction and internal hernia. Volvulus or adhesions have been considered. Left nephrectomy and splenectomy demonstrated right kidney has a 1.5 cm solid mass at the lower pole suspicious for neoplasm according to the radiologist's description and there is diverticulosis.,IMPRESSION:,1. Coronary artery disease and prior aortocoronary bypass surgery, currently clinically the patient without any angina.,2. Possible small old myocardial infarction.,3. Hypertension with hypertensive cardiovascular disease.,4. Non-insulin-dependent diabetes mellitus.,5. Moderate obesity.,6. Hyperlipidemia.,7. Chronic non-pitting leg edema.,8. Arthritis.,9. GERD and positive history of peptic ulcer disease.,CONCLUSION:,1. Past left nephrectomy and splenectomy after an accident and injury and rupture of the spleen.,2. Abnormal nuclear stress test in September 2008, but no further cardiac studies performed, such as cardiac catheterization.,3. Lower left quadrant pain, which could be due to diverticulosis.,4. Diverticulosis and partial bowel obstruction.,RECOMMENDATION:,1. At this stage, the patient's cardiac medication should be continued if the patient is allowed p.o. intake. Cardiovascular / Pulmonary Cardiac catheterization and coronary intervention report. Cardiac Catheterization - 9 EXAM: , Cardiac catheterization and coronary intervention report.,PROCEDURES:,1. Left heart catheterization, coronary angiography, left ventriculography.,2. PTCA/Endeavor stent, proximal LAD.,INDICATIONS: , Acute anterior ST-elevation MI.,ACCESS: , Right femoral artery 6-French.,MEDICATIONS:,1. IV Valium.,2. IV Benadryl.,3. Subcutaneous lidocaine.,4. IV heparin.,5. IV ReoPro.,6. Intracoronary nitroglycerin.,ESTIMATED BLOOD LOSS: , 10 mL.,CONTRAST: ,185 mL.,COMPLICATIONS: , None.,PROCEDURE: , The patient was brought to the cardiac catheterization laboratory with acute ST-elevation MI and EKG. She was prepped and draped in the usual sterile fashion. The right femoral region was infiltrated with subcutaneous lidocaine, adequate anesthesia was obtained. The right femoral artery was entered with _______ modified Seldinger technique and a J wire was passed. The needle was exchanged for 6 French sheath. The wire was removed. The sheath was washed with sterile saline. Following this, the left coronary was attempted to be cannulated with an XP catheter, however, the catheter folded on itself and could not reach the left main, this was removed. A second 6-French JL4 guiding catheter was then used to cannulate the left main and initial guiding shots demonstrated occlusion of the proximal LAD. The patient had an ACT check, received additional IV heparin and IV ReoPro. The lesion was crossed with 0.014 BMW wire and redilated with a 2.5 x 20-mm balloon at nominal pressures. The balloon was deflated and angiography demonstrated establishment of flow. Following this, the lesion was stented with a 2.5 x 18-mm Endeavor stent at 10 atmospheres. The balloon was deflated, reinflated at 12 atmospheres, deflated and removed. Final angiography demonstrated excellent clinical result. Additional angiography was performed with a wire out. Following this, the wire and the catheter was removed. Following this, the right coronary was selectively cannulated with diagnostic catheter and angiographic views were obtained in multiple views. This catheter was removed. The pigtail catheter was placed in the left ventricle and left ventriculography was performed with pullback pressures across the aortic valve. At the end of procedure, wires and catheter were removed. Right femoral angiography was performed and a right femoral Angio-Seal kit was deployed at the right femoral arteriotomy site. There was no hematoma. Peripheral pulses _______ procedure. The patient tolerated the procedure well. Symptoms of chest pain resolved at the end of the procedure with no complications.,RESULTS:,1. Coronary angiography.,A. Left main free of obstruction.,B. LAD, subtotal proximal stenosis.,C. Circumflex large vessel with three large obtuse marginal branches. No high-grade obstruction, evidence of minimal plaquing.,D. Right coronary 70% mid vessel stenosis and 50% mid to distal stenosis before giving rise to a right dominant posterior lateral and posterior descending artery.,2. Left ventriculogram. Left ventricular ejection fraction estimated at 45% to 50%. There was an akinetic apical wall.,3. Hemodynamics. Aortic pressure 145/109, left ventricular pressure 147/13, left ventricular end-diastolic pressure 34 mmHg.,IMPRESSION:,1. Acute ST-elevation myocardial infarction, culprit lesion, left anterior descending occlusion.,2. Two-vessel coronary disease.,3. Mild-to-moderate impaired LV systolic function.,4. Successful stent left anterior descending, 100% occlusion, 0% residual stenosis.,PLAN: ,Overnight observation in ICU. Start aspirin, Plavix, beta-blocker and ACE inhibitor. Check serial cardiac enzymes. Further recommendations to follow. Check fasting lipid panel, in addition add a statin. Further recommendations to follow. Cardiovascular / Pulmonary A woman with history of coronary artery disease, 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. Cardiac Consultation 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. Cardiovascular / Pulmonary Left heart cardiac catheterization. Cardiac Catheterization - 8 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. cardiovascular / pulmonary, heart catheterization, ventriculogram, femoral artery access, coronary angiogram, lvef, distal left anterior descending, circumflex coronary artery, anterior descending artery, femoral artery, systolic function, cardiac catheterization, circumflex coronary, anterior descending, coronary artery, coronary, artery, catheterization, descending Cardiovascular / Pulmonary Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein. Cardiac Catheterization - 6 PRECATHETERIZATION DIAGNOSIS (ES):, Hypoplastic left heart, status post Norwood procedure and Glenn shunt.,POSTCATHETERIZATION DIAGNOSIS (ES):,1. Hypoplastic left heart.,A. Status post Norwood.,B. Status post Glenn.,2. Left pulmonary artery hypoplasia.,3. Diminished right ventricular systolic function.,4. Trivial neo-aortic stenosis.,5. Trivial coarctation.,6. Flow to right upper lobe more than left upper lobe from collaterals arising from branches of the aortic arch.,PROCEDURE (S):, Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.,I. PROCEDURES:, XXXXXX was brought to the catheterization lab and was anesthetized by anesthesia. He was intubated. His supplemental oxygen was weaned to 24%, on which all of his hemodynamics were obtained. The patient was prepped and draped in the routine sterile fashion, including both groins and the right neck. Xylocaine was administered in the right femoral area. A 6-French sheath was introduced into the right femoral vein percutaneously without complication. A 4-French sheath was introduced into the right femoral artery percutaneously without complication. A 4-French pigtail catheter was introduced and passed to the abdominal aorta.,Dr. Hayes, using the SiteRite device, introduced a 5-French sheath into the right internal jugular vein without complication.,A 5-French wedge catheter was introduced through the sheath in the right internal jugular vein and was passed to the left pulmonary artery and further to the left pulmonary capillary wedge position. This catheter would not pass to the right pulmonary artery. The wedge catheter was removed. A 5-French IMA catheter was then introduced and passed to the right pulmonary artery. After right pulmonary artery pressure was measured, this catheter was removed.,The 5 wedge catheter was advanced through the right femoral sheath and was passed to the following chambers or vessels: Inferior vena cava, right atrium, left atrium, and right ventricle.,The previously introduced 4 pigtail catheter was advanced to the ascending aorta. Simultaneous right ventricular and ascending aortic pressures were measured. A pullback from ascending aorta to descending aorta was then performed. Simultaneous measurements of right ventricular and descending aortic pressures were measured.,The wedge catheter was removed. A 5-French Berman catheter was advanced down the Glenn shunt to the right pulmonary artery, where a pullback from right pulmonary artery to Glenn shunt was performed. An injection was then performed using Omnipaque 16 mL at 8 mL per second with the Berman catheter positioned in the Glenn shunt. The 5-French Berman was removed.,A 6-French Berman was introduced through the right femoral vein sheath and was advanced to the right ventricle. A right ventriculogram was performed using Omnipaque 18 mL at 12 mL per second. The Berman catheter was pulled back to the inferior vena cava, where an inferior vena cavagram was performed using Omnipaque 10 mL at 8 mL per second.,The 4-French pigtail catheter was advanced to the ascending aorta and an ascending aortogram was performed using Omnipaque 16 mL at 12 mL per second.,Following the ascending angiograms, two kidneys and a bladder were noted. The catheters and sheaths were removed, and hemostasis was obtained by direct pressure. The estimated blood loss was less than 30 mL, and none was replaced. Heparin was administered following placement of all of the sheaths. Pulse oximetry saturation, pulse in the right foot, and EKG were monitored continuously.,II. PRESSURES:,A. Left pulmonary artery, mean of 11; left capillary wedge, mean of 9; main pulmonary artery, mean of 12; right pulmonary artery, mean of 10; descending aorta, 75/45, mean of 57; right atrium, A6 to 9, V6 to 8, mean 7; left atrium, mean 8; inferior vena cava, mean 7.,B. Ascending aorta, 65/35, with a simultaneous right ventricular pressure of 70/10; descending aorta, 60/35, with a right ventricular pressure of 72/10.,C. Pullbacks, left pulmonary artery to main pulmonary artery, mean of 11 to mean of 12; main pulmonary artery to Glenn, mean of 12 to mean of 13; right pulmonary artery to Glenn, mean of 12 to mean of 13; ascending aorta 68/35 to descending aorta 62/35.,INTERPRETATION:, Right and left pulmonary artery pressures are appropriate for this situation. There is a gradient of, at most, 2 mmHg on pullback from both the right and left pulmonary arteries to the Glenn shunt. The left atrial mean pressure is normal. Right ventricular end-diastolic pressure is, at most, slightly elevated. There is a trivial gradient between the right ventricle and ascending aorta consistent with trivial neo-aortic valve stenosis. There is a roughly 10-mm gradient between the right ventricle and descending aorta, consistent with additional coarctation of the aorta. On pullback from ascending to descending aorta, there is a 6-mmHg gradient between the two. Systemic blood pressure is normal.,III. OXIMETRY:, Superior vena cava 65, right pulmonary artery 67, left pulmonary artery 65, left atrium 96, right atrium 87, inferior vena cava 69, aorta 86, right ventricle 83.,INTERPRETATION:, Systemic arteriovenous oxygenation difference is normal, consistent with a normal cardiac output. Left atrial saturation is fairly normal, consistent with normal oxygenation in the lungs. The saturation falls passing from the left atrium to the right atrium and further to the right ventricle, consistent with mixing of pulmonary venous return and inferior vena cava return, as would be expected in this patient.,IV. SPECIAL PROCEDURE (S):, None done.,V. CALCULATIONS:,Please see the calculation sheet. Calculations were based upon an assumed oxygen consumption. The _____ saturation used was 67%, with a pulmonary artery saturation of 65%, a left atrial saturation of 96%, and an aortic saturation of 86%. Using the above information, the pulmonary to systemic flow ratio was 0.6. Systemic blood flow was 5.1 liters per minute per meter squared. Pulmonary blood flow was 3.2 liters per minute per meter squared. Systemic resistance was 9.8 Wood's units times meter squared, which is mildly diminished. Pulmonary resistance was 2.5 Wood's units times meter squared, which is in the normal range.,VI. ANGIOGRAPHY:, The injection to the Glenn shunt demonstrates a wide-open Glenn connection. The right pulmonary artery is widely patent, without stenosis. The proximal portion of the left pulmonary artery is significantly narrowed, but does open up near its branch point. The right pulmonary artery measures 6.5, the left pulmonary artery measures 3.0 mm. The aorta at the diaphragm on a later injection was 5.5 mm. There is a small collateral off the innominate vein passing to the left upper lobe. Flow to both upper lobes is diminished versus lower lung fields. There is normal return of the pulmonary veins from the right, with simultaneous filling of the left atrium and right atrium. There is normal return of the left lower pulmonary vein and left upper pulmonary vein. There is some reflux of dye into the inferior vena cava from the right atrium.,The right ventriculogram demonstrates a heavily pedunculated right ventricle with somewhat depressed right ventricular systolic function. The calculated ejection fraction from the LAO projection is only mildly diminished at 59%. There is no significant tricuspid regurgitation. The neo-aortic valve appears to open well with no stenosis. The ascending aorta is dilated. There is mild narrowing of the aorta at the isthmal area. On some projections, there appears to be a partial duplication of the aortic arch, probably secondary to this patient's style of Norwood reconstruction. There is some filling of the right upper and left upper lobes from collateral blood flow, with the left being more opacified than the right.,The inferior vena cavagram demonstrates normal return of the inferior vena cava to the right atrium.,The ascending aortogram demonstrates trivial aortic insufficiency, which is probably catheter-induced. The coronary arteries are poorly seen. Again, a portion of the aorta appears to be partially duplicated. There is faint opacification of the left upper lung from collateral blood flow. The above-mentioned narrowing of the aortic arch is again noted. Cardiovascular / Pulmonary Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement. Cardiac Catheterization - 7 INDICATIONS FOR PROCEDURE:, The patient has presented with crushing-type substernal chest pain, even in the face of a normal nuclear medicine study. She is here for catheterization.,APPROACH:, Right common femoral artery.,ANESTHESIA:, IV sedation per cardiac catheterization protocol. Local sedation with 1% Xylocaine.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Less than 10 mL.,ESTIMATED CONTRAST:, Less than 150 mL.,PROCEDURES PERFORMED:, Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.,OPERATIVE TECHNIQUE:, The patient was brought to the cardiac catheterization lab in the usual fasting state. She was placed supine on the cardiac catheterization table and the right groin was prepped and draped in the usual sterile fashion. One percent Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was then placed in the right common femoral artery by the modified Seldinger technique.,SELECTIVE CORONARY ARTERIOGRAPHY:, Next, right and left Judkins diagnostic catheters were advanced through their respective ostia and injected in multiple views.,LEFT VENTRICULOGRAM:, Next, a pigtail catheter was advanced across the aortic valve and left ventricular pressure recorded. Next, an LV-gram was then performed with a hand injection of 50 mL of contrast. Next, pull-back pressure was measured across the aortic valve.,AORTA ARCH ANGIOGRAM:, Next, aortic arch angiogram was then performed with injection of 50 mL of contrast at a rate of 20 mL/second to maximum pressure of 750 PSI performed in the 40-degree LAO view.,Next, right iliofemoral angiogram was performed in the 20-degree RAO view. Next Angio-Seal was applied successfully.,The patient left the cath lab without problems or issues.,DIAGNOSES:, Left ventricular end-diastolic pressure was 18 mmHg. There was no gradient across the aortic valve. The central aortic pressure was 160 mmHg.,LEFT VENTRICULOGRAM:, The left ventriculogram demonstrated normal LV systolic function with estimated ejection fraction greater than 50%.,AORTIC ARCH ANGIOGRAM: ,The aortic arch angiogram demonstrated normal aortic arch. No aortic regurgitation was seen.,SELECTIVE CORONARY ARTERIOGRAPHY:, The right coronary artery is large and dominant.,The left main is patent.,The left anterior descending is patent.,The left circumflex is patent.,IMPRESSION:, This study demonstrates normal coronary arteries in the presence of normal left ventricular systolic function. In addition, the aortic root is normal. Cardiovascular / Pulmonary Percutaneous intervention with drug-eluting stent placement to the ostium of the PDA. Cardiac Catheterization - 4 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. cardiovascular / pulmonary, coronary angiography, ventricular pressure, coronary angioplasty, french, pda, drug-eluting stent, coronary artery disease, cardiac catheterization lab, plv branch, cardiac catheterization, femoral artery, coronary artery, artery, coronary, angioplasty, angiogram, angiographically, arteriotomy, angiography, cardiac, circumflex, ostium, ventricular, femoral, percutaneous, catheterization, Cardiovascular / Pulmonary Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography. Cardiac Catheterization - 5 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. cardiovascular / pulmonary, catheterization, vein graft, angiography, angiogram, angio-seal, closure device, coronary atherosclerotic heart disease, saphenous vein graft, ventricular pressure, coronary artery, saphenous vein, atherosclerotic, coronary, artery, bifurcation, pda, ventricular, saphenous Cardiovascular / Pulmonary Cardiac catheterization. Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis. Cardiac Catheterization - 12 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. cardiovascular / pulmonary, intimal calcification, stenosis, coronary artery disease, mid abdominal aorta, coronary artery, cardiac catheterization, coronary arteries, descending artery, calcification, mid, proximal, aorta, catheterization, abdominal, cardiac, intimal, coronary, artery, Cardiovascular / Pulmonary Left Heart Catheterization. Chest pain, coronary artery disease, prior bypass surgery. Left coronary artery disease native. Patent vein graft with obtuse marginal vessel and also LIMA to LAD. Native right coronary artery is patent, mild disease. Cardiac Catheterization - 10 EXAM: , Left Heart Catheterization,REASON FOR EXAM:, Chest pain, coronary artery disease, prior bypass surgery.,INTERPRETATION: , The procedure and complications were explained to the patient in detail and formal consent was obtained. The patient was brought to the cath lab. The right groin was draped in the usual sterile manner. Using modified Seldinger technique, a 6-French arterial sheath was introduced in the right common femoral artery. A JL4 catheter was used to cannulate the left coronary arteries. A JR4 catheter was used to cannulate the right coronary artery and also bypass grafts. The same catheter was used to cannulate the vein graft and also LIMA. I tried to attempt to cannulate other graft with Williams posterior catheter and also bypass catheter was unsuccessful. A 6-French pigtail catheter was used to perform left ventriculography and pullback was done. No gradient was noted. Arterial sheath was removed. Hemostasis was obtained with manual compression. The patient tolerated the procedure very well without any complications.,FINDINGS:,1. Native coronary arteries. The left main is patent. The left anterior descending artery is not clearly visualized. The circumflex artery appears to be patent. The proximal segment gives rise to small caliber obtuse marginal vessel.,2. Right coronary artery is patent with mild distal and mid segment. No evidence of focal stenosis or dominant system.,3. Bypass graft LIMA to the left anterior descending artery patent throughout the body as well the anastomotic site. There appears to be possible _______ graft to the diagonal 1 vessel. The distal LAD wraps around the apex. No stenosis following the anastomotic site noted.,4. Vein graft to what appears to be obtuse marginal vessel was patent with a small caliber obtuse marginal 1 vessel.,5. No other bypass grafts are noted by left ventriculography and also aortic root shot.,6. Left ventriculography with an ejection fraction of 60%.,IMPRESSION:,1. Left coronary artery disease native.,2. Patent vein graft with obtuse marginal vessel and also LIMA to LAD. _______ graft to the diagonal 1 vessel.,3. Native right coronary artery is patent, mild disease.,RECOMMENDATIONS: , Medical treatment. cardiovascular / pulmonary, chest pain, coronary artery disease, bypass surgery, heart catheterization, lima, lad, obtuse marginal vessel, vein graft, obtuse marginal, marginal vessel, coronary artery, catheterization, coronary, artery, obtuse, marginal, bypass, vessel, graft Cardiovascular / Pulmonary Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer. Cardiac Catheterization EXAMINATION: , Cardiac catheterization.,PROCEDURE PERFORMED: , Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.,INDICATION: , Syncope with severe aortic stenosis.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained from the patient, the patient was brought to the cardiac catheterization laboratory in a post observed state. The right groin was prepped and draped in the usual sterile fashion. After adequate conscious sedation and local anesthesia was obtained, a 6-French sheath was placed in the right common femoral artery and a 8-French sheath was placed in the right common femoral vein. Following this, a 7.5-French Swan-Ganz catheter was advanced into the right atrium where the right atrial pressure was 10/7 mmHg. The catheter was then manipulated into the right ventricle where the right ventricular pressure was 37/10/4 mmHg. The catheter was then manipulated into the wedge position where the wedge pressure was noted to be 22 mmHg. The pulmonary arterial pressures were noted to be 31/14/21 mmHg. Following this, the catheter was removed, the sheath was flushed and a 6-French JL4 diagnostic catheter was the advanced over the guidewire and the left main coronary artery was cannulated and selective angiogram was obtained in orthogonal views. Following this, the catheter was exchanged over the guidewire for 6-French JR4 diagnostic catheter. We were unable to cannulate the right coronary artery. Therefore, we exchanged for a Williams posterior catheter and we were able to cannulate the right coronary artery and angiographs were performed in orthogonal views. Following this, this catheter was exchanged over a guidewire for a 6-French Langston pigtail catheter and the left ventricle was entered and left ventriculography was performed. Following this, the catheters were removed. Sheath angiograms revealed the sheath to be in the right common femoral artery and the right common femoral arteriotomy was sealed using a 6-French Angio-Seal device. The patient tolerated the procedure well. There were no complications.,DESCRIPTION OF FINDINGS: , The left main coronary artery is a large vessel, which bifurcates into the left anterior descending artery and left circumflex artery and has moderate diffuse luminal irregularities with no critical lesions. The left circumflex artery is a short vessel, which gives off one major obtuse marginal artery and has moderate diffuse luminal irregularities with no critical lesions. The left anterior descending artery has moderate diffuse luminal irregularities and gives off two major diagonal branches. There is a 70% ostial lesion in the first diagonal branch and the second diagonal branch has mild-to-moderate luminal irregularities. The right coronary artery is a very large dominant vessel with a 60% to 70% lesion in its descending mid-portion. The remainder of the vessel has moderate diffuse luminal irregularities with no critical lesions. The left ventricle appears to be normal sized. The aortic valve is heavily calcified. The estimated ejection fraction is approximately 60%. There was 4+ mitral regurgitation noted. The mean gradient across the aortic valve was noted to be 33 mmHg yielding an aortic valve area of 0.89 cm2.,CONCLUSION:,1. Moderate-to-severe coronary artery disease with a high-grade lesion seen at the ostium of the first diagonal artery as well as a 60% to 70% lesion seen at the mid portion of the right coronary artery.,2. Moderate-to-severe aortic stenosis with an aortic valve area of 0.89 cm2.,3. 4+ mitral regurgitation.,PLAN: , The patient will most likely need a transesophageal echocardiogram to better evaluate the valvular architecture and the patient will be referred to Dr Kenneth Fang for possible aortic valve replacement as well as mitral valve repair/replacement and possible surgical revascularization. cardiovascular / pulmonary, heart catheterization, cineangiography, selective coronary angiography, thermodilution technique, transducer, diffuse luminal irregularities, cardiac catheterization, luminal irregularities, aortic valve, coronary artery, artery, catheterization, regurgitation, angiography, thermodilution, coronary, Cardiovascular / Pulmonary Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement. Cardiac Cath & Coronary Angiography "PROCEDURE:, Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.,INDICATIONS: , Atherosclerotic coronary artery disease.,PATIENT HISTORY: , This is a 55-year-old male. He presented with 3 hours of unstable angina.,PAST CARDIAC HISTORY: , History of previous arteriosclerotic cardiovascular disease. Previous ST elevation MI.,REVIEW OF SYSTEMS., The creatinine value is 1.3 mg/dL mg/dL.,PROCEDURE MEDICATIONS:,1. Visipaque 361 mL total dose.,2. Clopidogrel bisulphate (Plavix) 225 mg PO,3. Promethazine (Phenergan) 12.5 mg total dose.,4. Abciximab (Reopro) 10 mg IV bolus,5. Abciximab (Reopro) 0.125 mcg/kg/minute, 4.5 mL/250 mL D5W x 17 mL,6. Nitroglycerin 300 mcg IC total dose.,DESCRIPTION OF PROCEDURE:,APPROACH: , Left heart catheterization via right femoral artery approach.,ACCESS METHOD: , Percutaneous needle puncture.,DEVICES USED:,1. Balloon catheter utilized: Manufacturer: Boston Sci Quantum Maverick RX 2.75mm x 20mm.,2. Cordis Vista Brite Tip 6Fr JR 4.0,3. ACS/Guidant Sport .014"" (190cm) Wire,4. Stent utilized: Boston Sci Taxus RX Stent 3.0mm x 32mm.,FINDINGS/INTERVENTIONS:,LEFT VENTRICULOGRAPHY:, The overall left ventricular systolic function is mildly reduced. Left ventricular ejection fraction is 40% by left ventriculogram. Mild hypokinesis of the anterior wall of the left ventricle. There was no transaortic gradient. Mitral valve regurgitation is not seen.,LEFT MAIN CORONARY ARTERY: , There were no obstructing lesions in the left main coronary artery. Blood flow appeared normal.,LEFT ANTERIOR DESCENDING ARTERY: , There was a 95%, discrete stenosis in the mid left anterior descending artery. A drug eluting, Boston Sci Taxus RX Stent 3.0mm x 32mm stent was placed in the mid left anterior descending artery and post-dilated to 3.5 mm. Post-procedure stenosis was 0%. There was no dissection and no perforation.,LEFT CIRCUMFLEX ARTERY: , There was a 50%, diffuse stenosis in the left circumflex artery.,RIGHT CORONARY ARTERY:, The right coronary artery is dominant to the posterior circulation. There were no obstructing lesions in the right coronary artery. Blood flow appeared normal.,COMPLICATIONS:,There were no complications during the procedure., ,IMPRESSION:,1. Severe two-vessel coronary artery disease.,2. Severe left anterior descending coronary artery disease. There was a 95% mid left anterior descending artery stenosis. The lesion was successfully stented.,3. Moderate left circumflex artery disease. There was a 50% left circumflex artery stenosis. Intervention not warranted.,4. The overall left ventricular systolic function is mildly reduced with ejection fraction of 40%. Mild hypokinesis of the anterior wall of the left ventricle.,RECOMMENDATION:,1. Clopidogrel (Plavix) 75 mg PO daily for 1 year." Cardiovascular / Pulmonary Left cardiac catheterization with selective right and left coronary angiography. Post infarct angina. Cardiac Cath & Selective Coronary Angiography PREOPERATIVE DIAGNOSIS: , Post infarct angina.,TYPE OF PROCEDURE: , Left cardiac catheterization with selective right and left coronary angiography.,PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory, and the groin was prepped in the usual fashion. Using 1% lidocaine, the right groin was infiltrated, and using the Seldinger technique, the right femoral artery was cannulated. Through this, a moveable guidewire was then advance to the level of the diaphragm, and through it, a 6 French pigtail catheter was advanced under hemodynamic monitoring to the ascending aorta and inserted into the left ventricle. Pressure measurements were obtained and cineangiograms in the RAO and LAO positions were then obtained. Catheter was then withdrawn and a #6 French non-bleed-back sidearm sheath was then introduced, and through this, a 6 French Judkins left coronary catheter was then advanced under hemodynamic monitoring to the left coronary ostium, engaged. Cineangiograms were obtained of the left coronary system. This catheter was then exchanged for a Judkins right 4 coronary catheter of similar dimension and under hemodynamic monitoring again was advanced to the right coronary ostium, engaged. Cineangiograms were obtained, and the catheter and sheath were then withdrawn. The patient tolerated the procedure well and left the Cardiac Catheterization Laboratory in stable condition. No evidence of hematoma formation or active bleeding. ,COMPLICATIONS: , None. ,TOTAL CONTRAST: , 110 cc of Hexabrix. ,TOTAL FLUOROSCOPY TIME: ,1.8 minutes. ,MEDICATIONS: , Reglan 10 mg p.o., 5 mg p.o. Valium, Benadryl 50 mg p.o. and heparin 3,000 units IV push. cardiovascular / pulmonary, selective, angiography, post infarct angina, engaged cineangiograms, coronary angiography, hemodynamic monitoring, cardiac catheterization, catheterization, cineangiograms, cardiac, coronary, Cardiovascular / Pulmonary Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass, open sternotomy covered with Ioban, insertion of Mahurkar catheter for hemofiltration via the left common femoral vein. Cardiac Allograft Transplant 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. cardiovascular / pulmonary, cardiomyopathy, ioban, ischemic, ischemic cardiomyopathy, mahurkar catheter, orthostatic, seldinger, swan-ganz, allograft, aorta, balloon, cardiac, cardiopulmonary bypass, catheter, coagulopathy, coronary artery bypass, femoral vein, hemofiltration, intraaortic, intraaortic balloon, sternotomy, transplantation, ventricle, inferior vena cava, cardiac allograft, common femoral, vena cava, pulmonary artery, atrium, insertion, cardiopulmonary, artery Cardiovascular / Pulmonary Cardiac Catheterization - An obese female with a family history of coronary disease and history of chest radiation for Hodgkin disease, presents with an acute myocardial infarction with elevated enzymes. Cardiac Catheterization - 1 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. cardiovascular / pulmonary, cardiac catheterization, hodgkin disease, beta blocker, coronary angiography, coronary artery, coronary disease, elevated enzymes, inferoapical, myocardial infarction, ventriculogram, ventriculography, acute myocardial infarction, proximal right coronary, diastolic pressure, ejection fraction, coronary, echocardiogram, cardiac, catheterization, myocardial, enzymes, infarction, artery Cardiovascular / Pulmonary The patient with atypical type right arm discomfort and neck discomfort. Cardiac Catheterization - 2 INDICATIONS FOR PROCEDURE:, The patient has presented with atypical type right arm discomfort and neck discomfort. She had noninvasive vascular imaging demonstrating suspected right subclavian stenosis. Of note, there was bidirectional flow in the right vertebral artery, as well as 250 cm per second velocities in the right subclavian. Duplex ultrasound showed at least a 50% stenosis.,APPROACH:, Right common femoral artery.,ANESTHESIA:, IV sedation with cardiac catheterization protocol. Local infiltration with 1% Xylocaine.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Less than 10 ml.,ESTIMATED CONTRAST:, Less than 250 ml.,PROCEDURE PERFORMED:, Right brachiocephalic angiography, right subclavian angiography, selective catheterization of the right subclavian, selective aortic arch angiogram, right iliofemoral angiogram, 6 French Angio-Seal placement.,DESCRIPTION OF PROCEDURE:, The patient was brought to the cardiac catheterization lab in the usual fasting state. She was laid supine on the cardiac catheterization table, and the right groin was prepped and draped in the usual sterile fashion. 1% Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was introduced into the right femoral artery via the modified Seldinger technique.,AORTIC ARCH ANGIOGRAM:, Next, a pigtail catheter was advanced to the aortic arch. Aortic arch angiogram was then performed with injection of 45 ml of contrast, rate of 20 ml per second, maximum pressure 750 PSI in the 4 degree LAO view.,SELECTIVE SUBCLAVIAN ANGIOGRAPHY:, Next, the right subclavian was selectively cannulated. It was injected in the standard AP, as well as the RAO view. Next pull back pressures were measured across the right subclavian stenosis. No significant gradient was measured.,ANGIOGRAPHIC DETAILS:, The right brachiocephalic artery was patent. The proximal portion of the right carotid was patent. The proximal portion of the right subclavian prior to the origin of the vertebral and the internal mammary showed 50% stenosis.,IMPRESSION:,1. Moderate grade stenosis in the right subclavian artery.,2. Patent proximal edge of the right carotid. cardiovascular / pulmonary, discomfort, subclavian stenosis, artery, french angio-seal, lao view, rao view, aortic arch angiogram, arch angiogram, cardiac catheterization, aortic arch, brachiocephalic, cardiac, angiography, aortic, angiogram, stenosis, catheterization, atypical, subclavian, Cardiovascular / Pulmonary White male with onset of chest pain, with history of on and off chest discomfort over the past several days. Cardiac Catheterization - 3 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. cardiovascular / pulmonary, cpk, q wave, st elevation, french angio-seal, pigtail catheter, st segment, ejection fraction, wall motion, diagonal branch, posterior descending, coronary artery, catheterization, circumflex, rca, cardiac, st, elevation, ventricular, stenosis, artery, coronary, branch, Cardiovascular / Pulmonary Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection. Placement of a right femoral intraaortic balloon pump. CABG - Redo OPERATIVE PROCEDURE:,1. Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.,2. Placement of a right femoral intraaortic balloon pump.,DESCRIPTION: , The patient was brought to the operating room and placed in the supine position. After adequate endotracheal anesthesia was induced, appropriate monitoring lines were placed. Chest, abdomen an legs were prepped and draped in sterile fashion. The femoral artery on the right was punctured and a guidewire was placed. The track was dilated and intraaortic balloon pump was placed in the appropriate position, sewn in place and ballooning started.,The left greater saphenous vein was harvested from the groin to the knee and prepared by ligating all branches with 4-0 silk and flushed with vein solution. The leg was closed with running 3-0 Dexon subcu and running 4-0 Dexon on the skin.,The old mediastinal incision was opened. The wires were cut and removed. The sternum was divided in the midline. Retrosternal attachments were taken down. The left internal mammary was dissected free from its takeoff at the left subclavian bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The heart was dissected free of its adhesions. The patient was fully heparinized and cannulated with a single aorta and single venous cannula. Retrograde cardioplegia cannula was attempted to be placed, but could not be fitted into the coronary sinus safely, therefore, it was banded and oversewn with 5-0 Prolene. An antegrade cardioplegia needle sump was placed and secured to the ascending aorta. Cardiopulmonary bypass ensued. The ascending aorta was cross clamped. Cold-blood potassium cardioplegia was given antegrade, a total of 10 cc/kg. It was followed by sumping the ascending aorta. The obtuse marginal was identified and opened and an end-to-side anastomosis was performed with a running 7-0 Prolene suture. The vein was cut to length. Antegrade cardioplegia was given, a total of 200 cc. The posterior descending branch of the right coronary artery was identified, opened and end-to-side anastomosis then performed with a running 7-0 Prolene suture. The vein was cut to length. Antegrade cardioplegia was given. The mammary was clipped distally, divided and spatulated for anastomosis. The anterior descending was identified, opened and end-to-side anastomosis then performed with running 8-0 Prolene suture and warm blood potassium cardioplegia was given. The cross clamp was removed. A partial-occlusion clamp was placed. Aortotomies were made. The vein was 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. The patient was fully warmed and ventilation was commenced. The patient was weaned from cardiopulmonary bypass, ventricular balloon pumping and inotropic support and weaned from cardiopulmonary bypass. The patient was decannulated in routine fashion. Protamine was given. Good hemostasis was noted. A single mediastinal chest tube and bilateral pleural Blake drains were placed. The sternum was closed with figure-of-eight stainless steel wire. The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch. The patient tolerated the procedure well. cardiovascular / pulmonary, coronary bypass grafting, internal mammary, cardiopulmonary, intraaortic, femoral artery, cabg, running prolene suture, intraaortic balloon, balloon pump, ascending aorta, prolene suture, cardiopulmonary bypass, potassium, aorta, anastomosis, prolene, coronary, cardioplegia, bypass, Cardiovascular / Pulmonary He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD. He has been having some chest pains, but overall he does not sound too concerning. He does note some more shortness of breath than usual. He has had no palpitations or lightheadedness. No problems with edema. CAD - 6-Month Followup REASON FOR VISIT:, Six-month follow-up visit for CAD.,He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD.,He has been having a lot of pain in his back and pain in his left knee. He is also having trouble getting his nerves under control. He is having stomach pains and occasional nausea. His teeth are bad and need to be pulled.,He has been having some chest pains, but overall he does not sound too concerning. He does note some more shortness of breath than usual. He has had no palpitations or lightheadedness. No problems with edema.,MEDICATIONS:, Lipitor 40 mg q.d., metoprolol 25 mg b.i.d., Plavix 75 mg q.d-discontinued, enalapril 10 mg b.i.d., aspirin 325 mg-reduced to 81 mg, Lorcet 10/650-given a 60 pill prescription, and Xanax 0.5 mg b.i.d-given a 60 pill prescription.,REVIEW OF SYSTEMS: , Otherwise unremarkable.,PEX:, BP: 140/78. HR: 65. WT: 260 pounds (which is up one pound). There is no JVD. No carotid bruit. Cardiac: Regular rate and rhythm and distant heart sounds with a 1/6 murmur at the upper sternal border. Lungs: Clear. Abdomen: Mildly tender throughout the epigastrium.,Extremities: No edema.,EKG:, Sinus rhythm, left axis deviation, otherwise unremarkable.,Echocardiogram (for dyspnea and CAD): Normal systolic and diastolic function. Moderate LVH. Possible gallstones seen.,IMPRESSION:,1. CAD-Status post anterior wall MI 07/07 and was found to a have multivessel CAD. He has a stent in his LAD and his obtuse marginal. Fairly stable.,2. Dyspnea-Seems to be due to his weight and the disability from his knee. His echocardiogram shows no systolic or diastolic function.,3. Knee pain-We well refer to Scotland Orthopedics and we will refill his prescription for Lorcet 60 pills with no refills.,4. Dyslipidemia-Excellent numbers today with cholesterol of 115, HDL 45, triglycerides 187, and LDL 33, samples of Lipitor given.,5. Panic attacks and anxiety-Xanax 0.5 mg b.i.d., 60 pills with no refills given.,6. Abdominal pain-Asked to restart his omeprazole and I am also going to reduce his aspirin to 81 mg q.d.,7. Prevention-I do not think he needs to be on the Plavix any more as he has been relatively stable for two years.,PLAN:,1. Discontinue Plavix.,2. Aspirin reduced to 81 mg a day.,3. Lorcet and Xanax prescriptions given.,4. Refer over to Scotland Orthopedics.,5. Peridex mouthwash given for his poor dentition and told he was cardiovascularly stable and have his teeth extracted. Cardiovascular / Pulmonary Coronary artery bypass grafting (CABG) x4. Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function. CABG x4 PREOPERATIVE DIAGNOSES: , Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.,POSTOPERATIVE DIAGNOSES:, Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.,OPERATIVE PROCEDURE: , Coronary artery bypass grafting (CABG) x4.,GRAFTS PERFORMED: , LIMA to LAD, left radial artery from the aorta to the PDA, left saphenous vein graft from the aorta sequential to the diagonal to the obtuse marginal.,INDICATIONS FOR PROCEDURE: , The patient is a 74-year-old gentleman, who presented with six-month history of progressively worsening exertional angina. He had a positive stress test and cardiac cath showed severe triple-vessel coronary artery disease including left main disease with preserved LV function. He was advised surgical revascularization of his coronaries.,FINDINGS DURING THE PROCEDURE: ,The aorta was free of any significant plaque in the ascending portion at the sites of cannulation and cross clamp. Left internal mammary artery and saphenous vein grafts were good quality conduits. Radial artery graft was a smaller sized conduit, otherwise good quality. All distal targets showed heavy plaque involvement with calcification present. The smallest target was the PDA, which was about 1.5 mm in size. All the other targets were about 2 mm in size or greater. The patient came off cardiopulmonary bypass without any problems. He was transferred on Neo-Synephrine, nitroglycerin, Precedex drips. Cross clamp time was 102 minutes, bypass time was 120 minutes.,DETAILS OF THE PROCEDURE: ,The patient was brought into the operating room and laid supine on the table. After he had been interfaced with the appropriate monitors, general endotracheal anesthesia was induced and invasive monitoring lines including right IJ triple-lumen catheter and Cordis catheter, right radial A-line, Foley catheter, TEE probes were placed and interfaced appropriately. The patient was then prepped and draped from chin to bilateral ankles including the left forearm in the usual sterile fashion. Preoperative checkup of the left forearm has revealed good collateral filling from the ulnar with the radial occluded thus indicating good common arch and thus left radial artery was suitable for harvest.,After prepping and draping the patient from the chin to bilateral ankles including left forearm in the usual sterile fashion, proper time-out was conducted and site identification was performed, and subsequently incision was made overlying the sternum and median sternotomy was performed. Left internal mammary artery was taken down. Simultaneously, left forearm radial artery was harvested using endoscopic harvesting techniques. Simultaneously, endoscopic left leg saphenous vein was harvested using endoscopic minimally invasive techniques. Subsequent to harvest, the incisions were closed in layers during the course of the procedure.,Heparin was given. Pericardium was opened and suspended. During the takedown of the left internal mammary artery, it was noted that the left pleural space was globally softened and left lung was adherent to the chest wall and mediastinum globally. Only a limited dissection was performed to free up the lung from the mediastinal structures to accommodate the left internal mammary artery.,Pericardium was opened and suspended. Pursestring sutures were placed. Aortic and venous as well as antegrade and retrograde cardioplegia cannulation was performed and the patient was placed on cardiopulmonary bypass. With satisfactory flow, the aorta was cross clamped and the heart was arrested using a combination of antegrade and retrograde cold blood cardioplegia. An initial dose of about 1500 mL was given and this was followed by intermittent doses given both antegrade and retrograde throughout the procedure to maintain a good arrest and to protect the heart.,PDA was exposed first. The right coronary artery was calcified along its course all the way to its terminal bifurcation. Even in the PDA, calcification was noted in a spotty fashion. Arteriotomy on the PDA was performed in a soft area and 1.5 probe was noted to be accommodated in both directions. End radial to side PDA anastomosis was constructed using running 7-0 Prolene. Next, the posterolateral obtuse marginal was exposed. Arteriotomy was performed. An end saphenous vein to side obtuse marginal anastomosis was constructed using running 7-0 Prolene. This graft was then apposed to the diagonal and corresponding arteriotomy and venotomies were performed and a diamond shaped side-to-side anastomosis was constructed using running 7-0 Prolene. Next, a slit was made in the left side of the pericardium and LIMA was accommodated in the slit on its way to the LAD. LAD was exposed. Arteriotomy was performed. An end LIMA to side LAD anastomosis was constructed using running 7-0 Prolene. LIMA was tacked down to the epicardium securely utilizing its fascial pedicle.,Two stab incisions were made in the ascending aorta and enlarged using 4-mm punch. Two proximal anastomosis were constructed between the proximal end of the saphenous vein graft and the side of the aorta, and the proximal end of the radial artery graft and the side of the aorta separately using running 6-0 Prolene. The patient was given terminal dose of warm retrograde followed by antegrade cardioplegia during which de-airing maneuvers were performed. Following this, the aortic cross clamp was removed and the heart was noted to resume spontaneous coordinated contractile activity. Temporary V-pacing wires were placed. Blake drains were placed in the left chest, the right chest, as well as in the mediastinum. Left chest Blake drain was placed just in the medial section where dissection had been performed. After an adequate period of rewarming during which time, temporary V-pacing wires were also placed, the patient was successfully weaned off cardiopulmonary bypass without any problems. With satisfactory hemodynamics, good LV function on TEE and baseline EKG, heparin was reversed using protamine. Decannulation was performed after volume resuscitation. Hemostasis was assured. Mediastinal and pericardial fat and pericardium were loosely reapproximated in the midline and chest was closed in layers using interrupted stainless steel wires to reappose the two sternal halves, heavy Vicryl for musculofascial closure, and Monocryl for subcuticular skin closure. Dressings were applied. The patient was transferred to the ICU in stable condition. He tolerated the procedure well. All counts were correct at the termination of the procedure. Cross clamp time was 102 minutes. Bypass time was 120 minutes. The patient was transferred on Neo-Synephrine, nitroglycerin, and Precedex drips. cardiovascular / pulmonary, radial artery, lima, pda, obtuse marginal, exertional angina, coronary artery disease, triple-vessel, graft, conduit, ij triple-lumen catheter, cordis catheter, a-line, foley catheter, tee probes, coronary artery bypass grafting, cross clamp, mammary artery, saphenous vein, coronary artery, artery, cabg, coronary, grafting, aorta, angina, bypass Cardiovascular / Pulmonary Patient with significant angina with moderate anteroapical ischemia on nuclear perfusion stress imaging only. He has been referred for cardiac catheterization. Cardiac Catheterization - 11 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. cardiovascular / pulmonary, wall motion abnormalities, cardiac catheterization, mid lad, timi flow, femoral arteriotomy, catheterization, ischemia, angina, distal, stenosis, stress, artery, coronary, lad, cardiac, Cardiovascular / Pulmonary 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. CABG - 2 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. cardiovascular / pulmonary, coronary artery disease, angina, coronary artery bypass grafting, internal mammary artery, coronary artery, vein graft, artery, bivad, cabg, medtronic, anastomosis, mammary, vein, circumflex, Cardiovascular / Pulmonary Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection. CABG TITLE OF PROCEDURE: ,Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room and placed in the supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring devices were placed. The chest, abdomen and legs were prepped and draped in the sterile fashion. The right greater saphenous vein was harvested and prepared by ligating all branches with 4-0 Surgilon and flushed with heparinized blood. Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin. Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The pericardium was opened. The pericardial cradle was created. The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted. A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet. An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene. The ascending aorta was crossclamped. Cold blood potassium cardioplegia was given to the ascending aorta followed by sumping through the ascending aorta followed by cold retrograde potassium cardioplegia. The obtuse marginal coronary artery was identified and opened and end-to-side anastomosis was performed to the reversed autogenous saphenous vein with running 7-0 Prolene suture and the vein was cut to length. Cold antegrade and retrograde cardioplegia were given and the posterior descending branch of the right coronary artery was identified and opened. End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length. Cold antegrade and retrograde potassium cardioplegia were given. The mammary artery was clipped distally, divided and spatulated for anastomosis. The anterior descending was identified and opened. End-to-side anastomosis was performed through the left internal mammary artery with running 8-0 Prolene suture. The mammary pedicle was sutured to the heart with interrupted 5-0 Prolene suture. A warm antegrade and retrograde cardioplegia were given. The aortic crossclamp was removed. The partial occlusion clamp was placed. Aortotomies were made. The veins were cut to fit these and sutured in place with running 5-0 Prolene suture. A partial occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Ventricular and atrial pacing wires were placed. The patient was fully warmed and weaned from cardiopulmonary bypass. The patient was decannulated in the routine fashion and Protamine was given. Good hemostasis was noted. A single mediastinal and left pleural chest tube were placed. The sternum was closed with interrupted wire, linea alba with running 0 Prolene, the sternal fascia was closed with running 0 Prolene, the subcutaneous tissue with running 2-0 Dexon and the skin with running 3-0 Dexon subcuticular stitch. The patient tolerated the procedure well. cardiovascular / pulmonary, cabg, cardioplegia, potassium, cardiopulmonary, coronary artery, marginal, obtuse, myocardial, autogenous, coronary artery bypass grafting, running prolene suture, saphenous vein, ascending aorta, prolene suture, artery, coronary, bypassNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., Cardiovascular / Pulmonary Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection. CABG - 1 PREOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,POSTOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,OPERATION PROCEDURE: , Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.,INDICATION FOR THE PROCEDURE: ,The patient was a 71-year-old female transferred from an outside facility with the left main, proximal left anterior descending, and proximal circumflex severe coronary occlusive disease, ejection fraction about 40%.,FINDINGS: , The LAD was 2-mm vessel and good, mammary was good, and obtuse marginal was 2-mm vessel and good, and the main was good.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room and placed in the supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring devices were placed. The chest, abdomen and legs were prepped and draped in the sterile fashion. The right greater saphenous vein was harvested and prepared by 2 interrupted skin incisions and by ligating all branches with 4-0 Surgilon and flushed with heparinized blood. Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin.,Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The pericardium was opened. The pericardial cradle was created. The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted. A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet. An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene. Cardiopulmonary bypass was instituted and the ascending aorta was crossclamped. Antegrade cardioplegia was given at a total of 5 mL per kg through the aortic route. This was followed by something in the aortic route and retrograde cardioplegia through the coronary sinus at a total of 5 mL per kg. The obtuse marginal coronary was identified and opened.,End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length. Cold antegrade and retrograde potassium cardioplegia were given. The mammary artery was clipped distally, divided and spatulated for anastomosis. The anterior descending was identified and opened. End-to-side anastomosis was performed with running 8-0 Prolene suture and the warm blood potassium cardioplegia was given antegrade and retrograde and the aortic cross-clamp was removed. The partial occlusion clamp was placed. Aortotomies were made. The veins were cut to fit these and sutured in place with running 5-0 Prolene suture. A partial occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Ventilation was commenced. The patient was fully warm and the patient was then wean from cardiopulmonary bypass. The patient was decannulated in routine fashion. Protamine was given. Good hemostasis was noted. A single mediastinal chest tube and bilateral pleural Blake drains were placed. The sternum was closed with figure-of-eight stainless steel wire plus two 5-mm Mersiline tapes.,The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch. The patient tolerated the procedure well. cardiovascular / pulmonary, coronary occlusive disease, coronary bypass graft, cabg, myocardial, mammary artery, obtuse marginal, cardiopulmonary bypass, potassium cardioplegia, prolene suture, bypass, artery, anastomosis, autogenous, obtuse, marginal, cardiopulmonary, potassium, retrograde, cardioplegia, antegrade, coronary Cardiovascular / Pulmonary Lumbar osteomyelitis and need for durable central intravenous access. Placement of left subclavian 4-French Broviac catheter. Broviac Catheter Placement 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. cardiovascular / pulmonary, lumbar osteomyelitis, central intravenous access, subclavian, osteomyelitis, broviac catheter, catheter, toddler, intravenous, Cardiovascular / Pulmonary Flexible Bronchoscopy (pediatric) Bronchoscopy - Pediatric 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. cardiovascular / pulmonary, flexible bronchoscopy, pediatric intensive care unit, bleeding, bronchi, bronchoalveolar lavage, bronchoscopy, conscious sedation, nasal mucosa, nasopharynx, pneumothorax, respiratory, pediatric flexible bronchoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. Cardiovascular / Pulmonary Bronchoscopy brushings, washings and biopsies. Patient with a bilateral infiltrates, immunocompromised host, and pneumonia. Bronchoscopy Brushings 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. cardiovascular / pulmonary, mac, fluoroscopy, fiberoptic bronchoscope, bronchoscopy brushings, fiberoptic, bronchoscope, bronchoscopy, biopsies, pneumonia, immunocompromised Cardiovascular / Pulmonary Bronchoscopy with bronchoalveolar lavage. Refractory pneumonitis. A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis. Bronchoscopy & Bronchoalveolar Lavage 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. cardiovascular / pulmonary, respiratory failure, bronchoalveolar lavage, refractory pneumonitis, tracheostomy, bronchoalveolar, bronchoscopy, pneumonitis Cardiovascular / Pulmonary Diagnostic bronchoscopy and limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2. Bilateral bronchopneumonia and empyema of the chest, left. Bronchoscopy & Thoracotomy PREOPERATIVE DIAGNOSES,1. Bilateral bronchopneumonia.,2. Empyema of the chest, left.,POSTOPERATIVE DIAGNOSES,1. Bilateral bronchopneumonia.,2. Empyema of the chest, left.,PROCEDURES,1. Diagnostic bronchoscopy.,2. Limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2.,DESCRIPTION OF PROCEDURE:, After obtaining an informed consent, the patient was taken to the operating room where a time-out process was followed. Initially, the patient was intubated with a #6 French tube because of the presence of previous laryngectomy. Because of this, I proceeded to use a pediatric bronchoscope, which provided limited visualization, but I was able to see the trachea and the carina and both left and right bronchial systems without significant pathology, although there was some mucus secretion that was aspirated.,Then, with the patient properly anesthetized and looking very stable, we decided to insert a larger endotracheal tube that allowed for the insertion of the regular adult bronchoscope. Therefore, we were able to obtain a better visualization and see the trachea and the carina that were normal and also the left and right bronchial systems. Some brownish secretions were obtained, particularly from the right side and were sent for culture and sensitivity, both aerobic and anaerobic fungi and acid fast.,Then, the patient was turned with left side up and prepped for a left thoracotomy. He was properly draped. I had recently re-inspected the CT of the chest and decided to make a limited thoracotomy of about 6 cm or so in the midaxillary line about the sixth intercostal space. Immediately, it was evident that there was a large amount of pus in the left chest. We proceeded to insert the suction catheters and we rapidly obtained about 1400 mL of frank pus. Then, we proceeded to open the intercostal space a bit more with a Richardson retractor and it was immediately obvious that there was an abundant amount of solid exudate throughout the lung. We spent several minutes trying to clean up this area. Initially, I had planned only to drain the empyema because the patient was in a very poor condition, but at this particular moment, he was more stable and well oxygenated, and the situation was such that we were able to perform a partial pulmonary decortication where we broke up a number of loculations that were present and we were able to separate the lung from the diaphragm and also the pulmonary fissure. On the upper part of the chest, we had limited access, but overall we obtained a large amount of solid exudate and we were able to break out loculations. We followed by irrigation with 2000 cc of warm normal saline and then insertion of two #32 chest tubes, which are the largest one available in this institution; one we put over the diaphragm and the other one going up and down towards the apex.,The limited thoracotomy was closed with heavy intercostal sutures of Vicryl, then interrupted sutures of #0 Vicryl to the muscle layers, and I loosely approximately the skin with a few sutures of nylon because I am suspicious that the incision may become infected because he has been exposed to intrapleural pus.,The chest tubes were secured with sutures and then connected to Pleur-evac. Then, the patient was transported.,Estimated blood loss was minimal and the patient tolerated the procedure well. He was extubated in the operating room and he was transferred to the ICU to be admitted. A chest x-ray was ordered stat. cardiovascular / pulmonary, chest tubes, insertion, partial pulmonary decortication, thoracotomy, bronchoscopy, empyema, bronchopneumonia, diagnostic bronchoscopy, pulmonary decortication, bilateral bronchopneumonia, decortication, intercostal, pulmonary, tubes, Cardiovascular / Pulmonary Plastic piece foreign body in the right main stem bronchus. Rigid bronchoscopy with foreign body removal. Bronchoscopy & Foreign Body Removal PREOPERATIVE DIAGNOSIS: , Foreign body in airway.,POSTOPERATIVE DIAGNOSIS:, Plastic piece foreign body in the right main stem bronchus.,PROCEDURE: , Rigid bronchoscopy with foreign body removal.,INDICATIONS FOR PROCEDURE: , This patient is 7-month-old baby boy who presented to emergency room today with increasing stridor and shortness of breath according to mom. The patient had a chest x-ray and based on that there is concern by the Radiology it could be a foreign body in the right main stem. The patient has been taken to the operating room for rigid bronchoscopy and foreign body removal.,DESCRIPTION OF PROCEDURE: ,The patient was taken to the operating room, placed supine, put under general mask anesthesia. Using a 3.5 rigid bronchoscope we visualized between the cords into the trachea. There were some secretions but that looked okay. Got down at the level of the carina to see a foreign body flapping in the right main stem. I then used graspers to grasp to try to pull into the scope itself. I could not do that, I thus had to pull the scope out along with the foreign body that was held on to with a grasper. It appeared to be consisting of some type of plastic piece that had broke off some different object. I took the scope and put it back down into the airway again. Again, there was secretion in the trachea that we suctioned out. We looked down into the right bronchus intermedius. There was no other pathology noted, just some irritation in the right main stem area. I looked down the left main stem as well and that looked okay as well. I then withdrew the scope. Trachea looked fine as well as the cords. I put the patient back on mask oxygen to wake the patient up. The patient tolerated the procedure well. cardiovascular / pulmonary, main stem bronchus, bronchoscopy, airway, foreign body removal, rigid bronchoscopy, Cardiovascular / Pulmonary Bronchoscopy for hypoxia and increasing pulmonary secretions Bronchoscopy - 6 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. cardiovascular / pulmonary, pulmonary secretions, bronchoscopy, hypoxia, peep, smv occlusion, atelectasis, bedside sedation, bronchoscope, chest x-ray, mainstem, right lower lobe, mainstem bronchus, Cardiovascular / Pulmonary Diagnostic fiberoptic bronchoscopy. Bronchoscopy - 7 PROCEDURE:, Diagnostic fiberoptic bronchoscopy.,ANESTHESIA: , Plain lidocaine 2% was given intrabronchially for local anesthesia.,PREOPERATIVE MEDICATIONS:, ,1. Lortab (10 mg) plus Phenergan (25 mg), p.o. 1 hour before the procedure.,2. Versed a total of 5 mg given IV push during the procedure.,INDICATIONS: , cardiovascular / pulmonary, fiberoptic, intrabronchially, larynx, distal trachea, diagnostic fiberoptic bronchoscopy, bronchoscopy, bronchoscope, Cardiovascular / Pulmonary Rigid bronchoscopy, removal of foreign body, excision of granulation tissue tumor, bronchial dilation , Argon plasma coagulation, placement of a tracheal and bilateral bronchial stents. Bronchoscopy - 5 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. cardiovascular / pulmonary, airway, argon plasma coagulation, bronchial dilation, balloon bronchoplasty, bronchoscopy, bronchus, foreign body, granulation, metallic stent, stenosis, vocal cords, granulation tissue tumor, plasma coagulation, granulation tissue, tracheal, argon, stents, bronchial, metallic, Cardiovascular / Pulmonary Bronchoscopy with aspiration and left upper lobectomy. Carcinoma of the left upper lobe. Bronchoscopy & Lobectomy PREOPERATIVE DIAGNOSIS: ,Carcinoma of the left upper lobe.,PROCEDURES PERFORMED:,1. Bronchoscopy with aspiration.,2. Left upper lobectomy.,PROCEDURE DETAILS: ,With patient in supine position under general anesthesia with endotracheal tube in place, the flexible bronchoscope was then placed down through the endotracheal tube to examine the carina. The carina was in the midline and sharp. Moving directly to the right side, the right upper and middle lower lobes were examined and found to be free of obstructions. Aspiration was carried out for backlog ________ examination. We then moved to left side, left upper lobe. There was a tumor mass located in the lingula of the left lobe and left lower lobe found free of obstruction. No anatomic lesions were demonstrated. The patient was prepared for left thoracotomy rotated to his right side with a double lumen endotracheal tube in place with an NG tube and a Foley catheter. After proper position, utilizing Betadine solution, they were draped. A posterolateral left thoracotomy incision was performed. Hemostasis was secured with electrocoagulation. The chest wall muscle was then divided over the sixth rib. The periosteum of the sixth rib was then removed superiorly and the pleural cavity was entered carefully. At this time, the mass was felt in the left upper lobe, which measures greater than 3 cm by palpation. We examined the superior mediastinum. No lymph nodes were demonstrated as well as in the anterior mediastinum. Direction was then moved to the fascia where by utilizing sharp and blunt dissection, lingual artery was separated into the left upper lobe. Casual dissection was carried out with superior segmental arteries and left lower lobe was examined.,Dissection was carried out around the pulmonary artery thus exposing the posterior artery to the left upper lobe. Direction was carried out to the superior pulmonary vein and utilizing sharp and blunt dissection the entire superior pulmonary vein was separated from the surrounding tissue. From the top side, the bronchus was then separated away from the pulmonary artery anteriorly, thus exposing the apical posterior artery, which was short. Tumor mass was close to the artery at this time. We then directed ourselves once again to the lingual artery which was doubly ligated and cut free. The posterior artery of the superior branch was doubly ligated and cut free also. At this time, the bronchus of the left upper lobe was encountered in the fissure on palpation to separate the upper lobe bronchus from lower lobe bronchus and the area was accomplished. We then moved anteriorly to doubly ligate the pulmonary vein using #00 silk sutures for ligation and a transection #00 silk suture was used to fixate the vein. Using sharp and blunt dissection, the bronchus through the left upper lobe was freed proximal. Using the TA 50, the bronchus was then cut free allowing the lung to fall superiorly at which time direction was carried out to the pulmonary artery where the tumor was in close proximity at this time. A Potts clamp arterial was then placed over the artery and shaving off the tumor and the apical posterior artery was then accomplished. The anterior artery was seen in the clamp also and was separated and ligated and separated. At this time, the entire tumor in the left upper lobe was then removed. ,Direction was carried to the suture where #000 silk was used as a running suture over the pulmonary artery and was here doubly run and tied in place. The clamp was then removed. No bleeding was seen at this time. Lymph nodes were then removed from the sump of the separation between the upper lobe and the lower lobe and sent for separate pathology. We then carried out incision in the inferior pulmonary ligament up to the pulmonary vein allowing the lung to reexpand to its normal position. At this time, two chest tubes #28 and #32 were placed anteriorly and posteriorly to fixate the skin using raw silk suture. The chest cavity was then closed. After reexamination, no bleeding was seen with three pericostal sutures of #1 chromic double strength. A #2-0 Polydek was then used to close the chest wall muscle the anterior as well as latissimus dorsi #000 chromic subcutaneous tissue skin clips to the skin. The chest tubes were attached to the Pleur-Evac drainage and placed on suction at this time. The patient was extubated in the room without difficulty and sent to Recovery in satisfactory. cardiovascular / pulmonary, ng tube, chest tubes, endotracheal tube, pulmonary vein, artery, aspiration, lobectomy, bronchoscopy, tumor, vein, bronchus, pulmonary, Cardiovascular / Pulmonary Bronchoscopy with brush biopsies. Persistent pneumonia, right upper lobe of the lung, possible mass. Bronchoscopy - 8 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., cardiovascular / pulmonary, persistent pneumonia, bronchoscopy, brush biopsies, endotracheal tube, biopsies, bronchial, abnormalities, pneumonia, secretions, endotracheal, Cardiovascular / Pulmonary Bronchoscopy for persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis. Bronchoscopy - 2 INDICATIONS FOR PROCEDURE:, Persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis.,PREMEDICATION:,1. Demerol 50 mg.,2. Phenergan 25 mg.,3. Atropine 0.6 mg IM.,4. Nebulized 4% lidocaine followed by nasal insufflation of lidocaine through the right naris and topical 4% lidocaine gel through the right naris, 4 mg of Versed was given at the start of the procedure and another 1 mg shortly after traversing the cords.,PROCEDURE DETAILS:, With the patient breathing oxygen by nasal cannula, being monitored by noninvasive blood pressure cuff and continuous pulse oximetry, the Olympus bronchoscope was introduced through the right naris to the level of the cords. The cords move normally with phonation and ventilation. Two times 2 mL of 1% lidocaine were instilled on the cords and the cords were traversed. Further 2 mL of 1% lidocaine was instilled in the trachea just distal to the cords, at mid trachea above the carina, and on the right, and on the left mainstem bronchus. Scope was then introduced on to the left where immediately some hyperemia of the mucosa was noted. Upper lobe and lingula were unremarkable. There appeared to be some narrowing or tenting of the left lower lobe bronchus such that after inspection of the superior segment, one almost had to pop the bronchoscope around to go down the left mainstem. This had been a change from the prior bronchoscopy of unclear significance. Distal to this, there was no hyperemia or inspissated mucus or mucoid secretions or signs of infection. The scope was wedged in the left lower lobe posterior basal segment and a BAL was done with good returns, which were faintly hemorrhagic. The scope was then removed, re-introduced up to the right upper lobe, middle lobe, superior segment, right lower, anterior lateral, and posterior basal subsegments were all evaluated and unremarkable. The scope was withdrawn. The patient's saturation remained 93%-95% throughout the procedure. Blood pressure was 103/62. Heart rate at the end of the procedure was about 100. The patient tolerated the procedure well. Samples were sent as follows. Washings for AFB, Gram-stain Nocardia, Aspergillus, and routine culture. Lavage for AFB, Gram-stain Nocardia, Aspergillus, cell count with differential, cytology, viral mycoplasma, and Chlamydia culture, GMS staining, RSV by antigen, and Legionella and Chlamydia culture. cardiovascular / pulmonary, cough, bronchoscopy, olympus, bronchoscope, nasal insufflation, oral antibiotics, pulse oximetry, sputum, ventilation, antibiotics, nocardia, aspergillus, chlamydia, atropine, lidocaine, cords, topical, Cardiovascular / Pulmonary Fiberoptic bronchoscopy with endobronchial biopsies. A CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma. Bronchoscopy - Fiberoptic HISTORY OF PRESENT ILLNESS:, A 67-year-old gentleman who presented to the emergency room with chest pain, cough, hemoptysis, shortness of breath, and recent 30-pound weight loss. He had a CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma. There was also a question of liver metastases at that time.,OPERATION PERFORMED:, Fiberoptic bronchoscopy with endobronchial biopsies.,The bronchoscope was passed into the airway and it was noted that there was a large, friable tumor blocking the bronchus intermedius on the right. The tumor extended into the carina, involving the lingula and the left upper lobe, appearing malignant. Approximately 15 biopsies were taken of the tumor.,Attention was then directed at the left upper lobe and lingula. Epinephrine had already been instilled and multiple biopsies were taken of the lingula and the left upper lobe and placed in a separate container for histologic review. Approximately eight biopsies were taken of the left upper lobe. cardiovascular / pulmonary, endobronchial, intermedius, fiberoptic bronchoscopy, lung carcinoma, bronchoscopy, fiberoptic, chest, tumor, lobeNOTE Cardiovascular / Pulmonary Implantation of biventricular automatic implantable cardioverter defibrillator, fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator, coronary sinus venogram for left ventricular lead placement, and defibrillation threshold testing x2. Biventricular Cardioverter Defibrillator Implantation REFERRAL INDICATION AND PREPROCEDURE DIAGNOSES,1. Dilated cardiomyopathy.,2. Ejection fraction less than 10%.,3. Ventricular tachycardia.,4. Bradycardia with likely high degree of pacing.,PROCEDURES PLANNED AND PERFORMED,1. Implantation of biventricular automatic implantable cardioverter defibrillator.,2. Fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator.,3. Coronary sinus venogram for left ventricular lead placement.,4. Defibrillation threshold testing x2.,FLUOROSCOPY TIME: ,18.5 minutes.,MEDICATIONS AT THE TIME OF STUDY,1. Vancomycin 1 g (the patient was allergic to penicillin).,2. Versed 10 mg.,3. Fentanyl 100 mcg.,4. Benadryl 50 mg.,CLINICAL HISTORY: , The patient is a pleasant 57-year-old gentleman with a dilated cardiomyopathy, an ejection fraction of 10%, been referred for AICD implantation because of his low ejection fraction and a non-sustained ventricular tachycardia. He has underlying sinus bradycardia. Therefore, will likely be pacing much of the time and would benefit from a biventricular pacing device.,RISKS AND BENEFITS:, Risks, benefits, and alternatives to implantation of biventricular AICD and defibrillation threshold testing were discussed with the patient. Risks including but not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, the need for urgent cardiovascular surgery, and death were discussed with the patient. The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state. The region of the left deltopectoral groove was prepped and draped in the usual sterile manner. Lidocaine 1% (20 mL) was administered to the area. After achieving appropriate anesthesia, a percutaneous access of the left axillary vein was performed under fluoroscopy with two separate sticks. Guidewires were advanced down into the left axillary vein. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Hemostasis was achieved with electrocautery. Lidocaine 1% (10 mL) was administered to the medial aspect of the incision and a pocket was fashioned in the medial direction. Using the more lateral of the guidewires, a 7-French side-arm sheath was advanced into the left axillary vein. The dilator was removed and another wire was advanced down into the sheath. The sheath was then backed up over the top of the two wires. One wire was pinned to the drape and using the alternate wire, a 9-French side-arm sheath was advanced down into the left axillary vein. The dilator and wire were removed. A defibrillation lead was then advanced down into the atrium. The peel-away sheath was removed. The lead was then passed across the tricuspid valve and positioned in the apical septal location. The active fix screw was deployed. Adequate pacing and sensing functions were established. A 10-volt pacing was used temporarily and there was no diaphragmatic stimulation. The suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. Using the wire that had been pinned to the drape, a 7-French side-arm sheath was advanced over this wire into the axillary vein. The wire and dilator were removed. An active pacing lead was then advanced down to the right atrium and the peel-away sheath was removed. The lead was parked until a later time. Using the separate access point, a 9-French side-arm sheath was advanced into the left axillary vein. The dilator and wire were removed. A curved outer sheath catheter as well as an inner catheter were advanced down into the area of the coronary sinus. The coronary sinus was cannulated. Inner catheter was removed and a balloon-tipped catheter was advanced into the coronary sinus. A coronary sinus venogram was then performed. It was noted that the most suitable location for lead placement was the middle cardiac vein. This was cannulated and a passive lead was advanced over a Whisper EDS wire into a distal position. Adequate pacing and sensing functions were established. A 10-volt pacing was used temporarily. There was no diaphragmatic stimulation. The outer sheath was peeled away. The 9 French sheath was then peeled away. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. At this point, the atrial lead was then positioned in the right atrial appendage using a preformed J-curved stylet. The lead body was turned several times and the lead was affixed to the tissue. Adequate pacing and sensing function were established. A suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. The pocket was then washed with antibiotic-impregnated saline. Pulse generator was obtained and connected securely to the leads. The leads were carefully wrapped behind the pulse generator and the entire system was placed in the pocket. The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. Sponge and needle counts were correct at the end of the procedure and no acute complications were noted.,The patient was sedated further and shock on T was performed on two separate occasions. The device was allowed to detect the charge and defibrillate, establishing the entire workings of the ICD system.,DEVICE DATA,1. Pulse generator, manufacturer Boston Scientific, model # N119, serial #12345.,2. Right atrial lead, manufacturer Guidant, model #4470, serial #12345.,3. Right ventricular lead, manufacturer Guidant, model #0185, serial #12345.,4. Left ventricular lead, manufacturer Guidant, model #4549, serial #12345.,MEASURED INTRAOPERATIVE DATA,1. Right atrial lead impedance 705 ohms. P-waves measured at 1.7 millivolts. Pacing threshold 0.5 volt at 0.4 milliseconds.,2. Right ventricular lead impedance 685 ohms. R-waves measured 10.5 millivolts. Pacing threshold 0.6 volt at 0.4 milliseconds.,3. Left ventricular lead impedance 1098 ohms. R-waves measured 5.2 millivolts. Pacing threshold 1.4 volts at 0.4 milliseconds.,DEFIBRILLATION THRESHOLD TESTING,1. Shock on T. Charge time 2.9 seconds. Energy delivered 17 joules, successful with lead impedance of 39 ohms.,2. Shock on T. Charge time 2.8 seconds. Energy delivered 17 joules, successful with a type 2 break lead impedance of 38 ohms.,DEVICE SETTINGS,1. A pacing DDD 60 to 120.,2. VT-1 zone 165 beats per minute. VT-2 zone 185 beats per minute. VF zone 205 beats per minute.,CONCLUSIONS,1. Successful implantation of a biventricular automatic implantable cardiovascular defibrillator,2. Defibrillation threshold of less than or equal to 17.5 joules.,2. No acute complications.,PLAN,1. The patient will be taken back to his room for continued observation and dismissed to the discretion of the primary service.,2. Chest x-ray to rule out pneumothorax and verified lead position.,3. Device interrogation in the morning.,4. Completion of the course of antibiotics. Cardiovascular / Pulmonary Bronchoscopy. Atelectasis and mucous plugging. Bronchoscopy PREOPERATIVE DIAGNOSIS: , Atelectasis.,POSTOPERATIVE DIAGNOSIS: , Mucous plugging.,PROCEDURE PERFORMED: , Bronchoscopy.,ANESTHESIA: , Lidocaine topical 2%, Versed 3 mg IV. Conscious sedation.,PROCEDURE: , At bedside, a bronchoscope was passed down the tracheostomy tube under monitoring. The main carina was visualized. The trachea was free of any secretions. The right upper lobe, middle and lower lobes appeared to have some mucoid secretions but minimal and with some erythema. Left mainstem appeared patent. Left lower lobe had slight plugging in the left base, but much better that previous bronchoscopy findings. The area was lavaged with some saline and cleared. The patient tolerated the procedure well. cardiovascular / pulmonary, Cardiovascular / Pulmonary Evaluation of airway for possible bacterial infection performed using bronchoalveolar lavage. Bronchoalveolar lavage. 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. cardiovascular / pulmonary, abdominal trauma, bal lavage, lukens trap suction, splenectomy, splenic laceration, bronchoalveolar lavage, fever, catheter, bronchoalveolar, lavage, airwayNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., Cardiovascular / Pulmonary Bronchiolitis, respiratory syncytial virus positive; improved and stable. Innocent heart murmur, stable. Bronchiolitis - Discharge Summary DIAGNOSES:,1. Bronchiolitis, respiratory syncytial virus positive; improved and stable.,2. Innocent heart murmur, stable.,HOSPITAL COURSE: , The patient was admitted for an acute onset of congestion. She was checked for RSV, which was positive and admitted to the hospital for acute bronchiolitis. She has always been stable on room air; however, because of her age and her early diagnosis, she was admitted for observation as RSV bronchiolitis typically worsens the third and fourth day of illness. She was treated per pathway orders. However, on the second day of admission, the patient was not quite eating well and parents live far away and she did have a little bit of trouble on first night of admission. There was a heart murmur that was heard that sounded innocent, but yet there was no chest x-ray that was obtained. We did obtain a chest x-ray, which did show a slight perihilar infiltrate in the right upper lobe. However, the rest of the lungs were normal and the heart was also normal. There were no complications during her hospitalization and she continued to be stable and eating better. On day 2 of the admission, it was decided she was okay to go home. Mother was advised regarding signs and symptoms of increased respiratory distress, which includes tachypnea, increased retractions, grunting, nasal flaring etc. and she was very comfortable looking for this. During her hospitalization, albuterol MDI was given to the patient and more for mom to learn outpatient care. The patient did receive a couple of doses, but she did not have any significant respiratory distress and she was discharged in improved condition.,DISCHARGE PHYSICAL EXAMINATION:,VITAL SIGNS: She is afebrile. Vital signs were stable within normal limits on room air.,GENERAL: She is sleeping and in no acute distress.,HEENT: Her anterior fontanelle was soft and flat. She does have some upper airway congestion.,CARDIOVASCULAR: Regular rate and rhythm with a 2-3/6 systolic murmur that radiates to bilateral axilla and the back.,EXTREMITIES: Her femoral pulses were 2+ and her extremities were warm and well perfused with good capillary refill.,LUNGS: Her lungs did show some slight coarseness, but good air movement with equal breath sounds. She does not have any wheezes at this time, but she does have a few scattered crackles at bilateral bases. She did not have any respiratory distress while she was asleep.,ABDOMEN: Normal bowel sounds. Soft and nondistended.,GENITOURINARY: She is Tanner I female.,DISCHARGE WEIGHT:, Her weight at discharge 3.346 kg, which is up 6 grams from admission.,DISCHARGE INSTRUCTIONS: , ,ACTIVITY: No one should smoke near The patient. She should also avoid all other exposures to smoke such as from fireplaces and barbecues. She is to avoid contact with other infants since she is sick and they are to limit travel. There should be frequent hand washings.,DIET: Regular diet. Continue breast-feeding as much as possible and encourage oral intake.,MEDICATIONS: She will be sent home on albuterol MDI to be used as needed for cough, wheezes or dyspnea.,ADDITIONAL INSTRUCTIONS:, Mom is quite comfortable with bulb suctioning the nose with saline and they know that they are to return immediately if she starts having difficulty breathing, if she stops breathing or she decides that she does not want to eat., cardiovascular / pulmonary, bronchiolitis, respiratory syncytial virus, bulb suctioning, innocent heart murmur, chest x ray, syncytial virus, heart murmur, respiratory distress, lungs, Cardiovascular / Pulmonary Fiberoptic bronchoscopy for diagnosis of right lung atelectasis and extensive mucus plugging in right main stem bronchus. Bronchoscopy - 3 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. cardiovascular / pulmonary, bronchoscopy, fiberoptic, mucomyst, atelectasis, bronchoscope, bronchus, carinae, larynx, main stem, mucus, nasal, plugging, trachea, fiberoptic bronchoscopy, mucus plugging, secretionsNOTE Cardiovascular / Pulmonary Rigid bronchoscopy with dilation, excision of granulation tissue tumor, application of mitomycin-C, endobronchial ultrasound. Bronchoscopy - 4 PREOPERATIVE DIAGNOSIS: ,Tracheal stenosis and metal stent complications.,POSTOPERATIVE DIAGNOSIS: ,Tracheal stenosis and metal stent complications.,ANESTHESIA: ,General endotracheal.,ENDOSCOPIC FINDINGS:,1. Normal true vocal cords.,2. Subglottic stenosis down to 5 mm with mature cicatrix.,3. Tracheal granulation tissue growing through the stents at the midway point of the stents.,5. Three metallic stents in place in the proximal trachea.,6. Distance from the true vocal cords to the proximal stent, 2 cm.,7. Distance from the proximal stent to the distal stent, 3.5 cm.,8. Distance from the distal stent to the carina, 8 cm.,9. Distal airway is clear.,PROCEDURES:,1. Rigid bronchoscopy with dilation.,2. Excision of granulation tissue tumor.,3. Application of mitomycin-C.,4. Endobronchial ultrasound.,TECHNIQUE IN DETAIL: ,After informed consent was obtained from the patient and her husband, she was brought to the operating theater after sequence induction was done. She had a Dedo laryngoscope placed. Her airways were inspected thoroughly with findings as described above. She was intermittently ventilated with an endotracheal tube placed through the Dedo scope. Her granulation tissue was biopsied and then removed with a microdebrider. Her proximal trachea was dilated with a combination of balloon, Bougie, and rigid scopes. She tolerated the procedure well, was extubated, and brought to the PACU. cardiovascular / pulmonary, tracheal stenosis, dedo scope, bronchoscopy, cicatrix, dilation, endotracheal, granulation, metal stent, mitomycin-c, proximal trachea, vocal cords, endobronchial ultrasound, granulation tissue, proximal, tracheal, stent, Cardiovascular / Pulmonary Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram. Bilateral Carotid Cerebral Angiogram 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. cardiovascular / pulmonary, femoral-popliteal angiogram, carotid cerebral angiogram, internal carotid artery, carotid artery, angiogram, carotid, cerebral, artery, Cardiovascular / Pulmonary Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration. Bronchoscopy - 1 PROCEDURE:, Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration.,DETAILS OF THE PROCEDURE: , The risks, alternatives, and benefits of the procedure were explained to the patient as well as conscious sedation and she agrees to proceed. The patient received topical lidocaine by nebulization. The flexible fiberoptic bronchoscope was introduced orally. The patient had normal teeth, normal tongue, normal jaw, and her vocal cords moved symmetrically and were without lesions. I proceeded to the right upper lobe where a mucous plug was noted in the subsegmental bronchus of the posterior segment of the right upper lobe. I proceeded under fluoroscopic guidance to guide the biopsy wire in this area and took four biopsies. Followup fluoroscopy was negative for pneumothorax. I wedged the bronchoscope in the subsegmental bronchus and achieved good hemostasis after three minutes.,I then proceeded to inspect the rest of the tracheobronchial tree, which was without lesions. I performed a bronchial washing after the biopsies in the right upper lobe. I then performed two transbronchial needle aspirations with a Wang needle biopsy in the precarinal area. All of these samples were sent for histology and cytology respectively. Estimated blood loss was approximately 5 cc. Good hemostasis was achieved. The patient received a total of 12.5 mg of Demerol and 3 mg of Versed and tolerated the procedure well. Her ASA score was 2. cardiovascular / pulmonary, bronchoscopy, wang needle, biopsy, bronchial washing, bronchoscope, bronchus, fiberoptic, hemostasis, lidocaine, nebulization, right upper lobe, transbronchial, transbronchial needle aspiration, needle aspiration, transbronchial needle, upper lobe, bronchial, precarinal, biopsies, needle, lobeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. Cardiovascular / Pulmonary 2-month-old female - increased work of breathing. Bronchiolitis - 2-month-old 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. Cardiovascular / Pulmonary The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch. Atrioventricular Septal Defect HISTORY: ,The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch. As an infant, he was initially palliated with the right and modified Blalock-Taussig shunt in October of 2002 and underwent atrioventricular septal defect and repair of pulmonary artery unifocalization and homograft placement between the right ventricle and unifocalized pulmonary arteries. He developed a significant branch of pulmonary artery stenosis for which on 07/20/2004, he underwent a bilateral balloon pulmonary arterioplasty and stent implantation at the San Diego at Children's Hospital. This was followed on 09/13/2007 with replacement of pulmonary valve utilizing a 16-mm Contegra valve. A recent echocardiogram demonstrated a significant branch of pulmonary artery stenosis with the predicted gradient of 41 to 55 mmHg and a well-functioning Contegra valve. The lung perfusion scan from 11/14/2007 demonstrated 47% flow to the left lung and 53% flow to the right lung. The patient underwent a repeat catheterization in consideration for further balloon angioplasty of the branch pulmonary arteries.,PROCEDURE: , After sedation, the patient was placed under general endotracheal anesthesia breathing 50% oxygen throughout the case. The patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures,Using a 7-French sheath, 6-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch pulmonary arteries. This catheter was exchanged over wire. A 5-French marker pigtail catheter was directed into the main pulmonary artery. A second site of venous access was achieved in and the left femoral vein with the placement of 5-French sheath.,Using a 4-French sheath, a 4-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta and left ventricle. Angiogram with injection in the main pulmonary artery demonstrated stable stent configuration of the proximal branch pulmonary arteries with intimal ingrowth in the region of the proximal stents. The distal right pulmonary measured approximately 10 mm in diameter with a mid stent section measuring 9.4 mm and the proximal stent near the origin of the right pulmonary artery of 5.80 mm. The distal left pulmonary measured approximately 10 mm in diameter with a mid stent measuring 10.3 mm and the proximal stent near the origin of the left pulmonary artery is 6.8 mm diameter. The left femoral venous sheath was exchanged over wire for a 7-French sheath. Guidewires were then advanced through the respective venous sheath into the branch pulmonary arteries and simultaneous balloon pulmonary arterioplasty was performed using the two Z-Med 12 x 4 cm balloon catheter was advanced into the branch of pulmonary arteries and inflated maximally to 9 hemispheres of pressure on 5 occasions near complete disappearance of proximal waist. The balloon catheter was then exchanged for a 5-French Mistique catheter for pressure pull-back and measurement in the angiogram. The catheter's wires were then removed and final hemodynamic assessment was made with the wedge catheter.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with angiograph injection in the main pulmonary artery.,After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.,DISCUSSION: ,Oxygen consumption was assumed to be in normal. Mixed venous saturation that was not normal with no evidence of intracardiac shunt. Left side of the heart was mildly desaturated following a part to parenchymal lung disease with the partial pressure of oxygen of only 82 mmHg. Aphasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure. Left ventricular systolic pressure was moderately elevated at 70% of systemic level and there was no obstruction into the proximal main pulmonary artery. There was a 20 mmHg of peak systolic gradient across the branch pulmonary artery stents to the distal artery. Right and left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the mildly elevated left ventricular end-diastolic pressure of 13 mmHg. Left ventricular systolic pressure was systemic. No outflow constriction to the ascending aorta. Phasic ascending and descending pressures were similar and normal. The calculated systemic and pulmonary flows were equal and normal. Vascular resistances were normal. Angiogram with injection in the main pulmonary artery showed catheter induced pulmonary insufficiency, well functioning Contegra valve with no appreciable calcification. The proximal narrowing of the distal main pulmonary artery was appreciated. Neointimal ingrowth within the proximal stents were appreciated. There is good distal growth of the pulmonary arteries. Arborization appeared normal. Levophase contrast returned to the heart appeared normal with a well-functioning left ventricle and the right aortic arch. Following the branch pulmonary artery angioplasty that was increased in the mixed venous saturation, as well as an increase in the systemic arterial saturation. Right ventricular systolic pressure felt slightly to 40 mmHg with an increase in systemic arterial pressure with a systolic pressure ratio of 54%. The main pulmonary pressures remained similar. There was 10 mmHg systolic gradient into the branch of pulmonary arteries. There is an increase in distal branch of pulmonary arteries with the mean pressure increased from 16 mmHg to 21 mmHg. Final angiogram with injection in the main pulmonary artery showed a competent Contegra valve. A brisk flow through the proximal branch stents with the improved caliber of the branch pulmonary artery lumens. There was no evidence of intimal disruption.,DIAGNOSES: ,1. Atrioventricular septal defect.,2. Tetralogy of Fallot with the pulmonary atresia.,3. Bilateral superior vena cava. The left cava draining to the coronary sinus.,4. The right aortic arch.,5. Discontinuous pulmonary arteries.,6. Down syndrome.,PRIOR SURGERIES AND INTERVENTIONS: ,1. Right modified Blalock-Taussig shunt.,2. Repair of tetralogy of Fallot with external conduit.,3. The atrioventricular septal defect repair.,4. Unifocalization of branch pulmonary arteries.,5. Bilateral balloon pulmonary angioplasty and stent implantation.,6. Pulmonary valve replacement with 16-mm Contegra valve.,CURRENT DIAGNOSES: ,1. Mild-to-moderate proximal branch pulmonary stenosis.,2. Well-functioning Contegra valve and current intervention. A balloon dilation of the right pulmonary artery.,3. Balloon dilation of left pulmonary artery.,MANAGEMENT: , The case will be discussed at Combined Cardiology and Cardiothoracic Surgery Case Conference and conservative outpatient management will be pursued. Further cardiologic care be directed by Dr. X. Cardiovascular / Pulmonary A 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. Atrial Flutter - Progress Note 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. cardiovascular / pulmonary, rapid ventricular response, volume depletion, atrial flutter, atrial, hypotension, flutter, Cardiovascular / Pulmonary The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred for evaluation and management of atrial fibrillation. Atrial Fibrillation Management REASON FOR CONSULTATION: , Atrial fibrillation management.,HISTORY OF PRESENT ILLNESS: ,The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred by Dr. X for evaluation and management of atrial fibrillation. The patient states that on Monday during routine Holt exam, it was detected by Dr. X that her heart was irregular on exam. EKG obtained after that revealed atrial fibrillation, and subsequently the patient was started on Coumadin as well as having Toprol and referred for evaluation. The patient states that for the last 3 years, she has had episodes of her heart racing. It may last for minutes up to most 1 hour, and it will occasionally be related to eating a heavy meal or her caffeine or chocolate intake. Denies dyspnea, diaphoresis, presyncope or syncope with the events, and she has had no episodes of chest pain. They subsequently resolve on their own and do not limit her in anyway. However, she states that for the last several years may be up to 7 years that she can recollect that she has been fatigued, and over the past couple of years, her symptoms have become more severe. She said she can walk no more than 25 feet without becoming tired. She states that she has to rest then her symptoms will go away, but she has been limited from that standpoint. Denies peripheral edema, PND, orthopnea, abdominal pain, swelling, recent fever or chills. She actually today has no complaints, and states that she has been compliant with her medications and has started taking her Coumadin as directed.,PAST MEDICAL HISTORY:,1. Hypertension.,2. Myocardial infarction in 2003.,3. Left heart catheterization at University Hospital.,4. Hypercholesterolemia.,5. Arthritis.,6. CVA in 2002 and in 2003 with right eye blindness.,PAST SURGICAL HISTORY:,1. Left total knee replacement in 2002.,2. Left lower quadrant abscess drainage in 12/07,FAMILY MEDICAL HISTORY: , Significant for lung and brain cancer. There is no history that she is aware of cardiovascular disease in her family nor has any family member had sudden cardiac death.,SOCIAL HISTORY: , She is retired as a cook in a school cafeteria, where she worked for 34 years. She retired 7 years ago because of low back pain. She used to smoke 2-1/2 packs per day for 32 years, but quit in 1995. Denies alcohol, and denies IV or illicit drug use.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,1. Coumadin 5 mg a day.,2. Toprol-XL 50 mg a day.,3. Aspirin 81 mg a day.,4. Hydrochlorothiazide 25 mg a day.,5. Plendil 10 mg daily.,6. Lipitor 40 mg daily.,REVIEW OF SYSTEMS: ,As above stating that following her stroke, she has right eye blindness, but she does have some minimal vision in her periphery.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 138/66, pulse 96, and weight 229 pounds or 104 kg. GENERAL: A well-developed, well-nourished, middle-aged African American female in no acute distress. NECK: Supple. No JVD. No carotid bruits. CARDIOVASCULAR: Irregularly irregular rate and rhythm. Normal S1 and S2. No murmurs, gallops or rubs. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Bowel sounds positive, soft, nontender, and nondistended. No masses. EXTREMITIES: No clubbing, cyanosis or edema. Pulses 2+ bilaterally.,LABORATORY DATA: , EKG today revealed atrial fibrillation with nonspecific lateral T-wave abnormalities and a rate of 94.,IMPRESSION: ,The patient is a very pleasant 62-year-old African American female with atrial fibrillation of unknown duration with symptoms of paroxysmal episodes of palpitations, doing well today.,RECOMMENDATIONS:,1. Her rate is suboptimally controlled, we will increase her Toprol-XL to 75 mg per day.,2. We will obtain a transthoracic echocardiogram to evaluate her LV function as well as her valvular function.,3. We will check a thyroid function panel.,4. We will continue Coumadin as directed and to follow up with Dr. X for INR management.,5. Given the patient's history of a stroke in her age and recurrent atrial fibrillation, the patient should be continued on Coumadin indefinitely.,6. Depending upon the results of her transthoracic echocardiogram, the patient may benefit from repeat heart catheterization. We will await results of transthoracic echocardiogram.,7. We will arrange for the patient to wear a Holter monitor to monitor the rate controlled on a 24-hour period. She will then return to the electrophysiology clinic in 1 month for followup visit with Dr. Y.,The patient was seen, discussed, and examined with Dr. Y in electrophysiology. Cardiovascular / Pulmonary Ash split venous port insertion. The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion. Ash Split Venous Port "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." cardiovascular / pulmonary, ash split venous port, venous port, anterior chest, incision, dilators, sheath, port, supraclavicular, needle, fluoroscopic, venous, insertion, catheter Cardiovascular / Pulmonary Carotid artery angiograms. Bilateral Carotid Angiography PROCEDURE PERFORMED:,1. Selective ascending aortic arch angiogram.,2. Selective left common carotid artery angiogram.,3. Selective right common carotid artery angiogram.,4. Selective left subclavian artery angiogram.,5. Right iliac angio with runoff.,6. Bilateral cerebral angiograms were performed as well via right and left common carotid artery injections.,INDICATIONS FOR PROCEDURE: , TIA, aortic stenosis, postoperative procedure. Moderate carotid artery stenosis.,ESTIMATED BLOOD LOSS:, 400 ml.,SPECIMENS REMOVED:, Not applicable.,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 fashion. Lidocaine 2% was used for infiltration anesthesia. Using modified Seldinger technique, a 6-French sheath was placed into the right common femoral artery and vein without complication. Using injection through the side port of the sheath, a right iliac angiogram with runoff was performed. Following this, straight pigtail catheter was used to advance the aortic arch and aortic arch angiogram under digital subtraction was performed. Following this, selective engagement in left common carotid artery, right common carotid artery, and left subclavian artery angiograms were performed with a V-Tech catheter over an 0.035-inch wire.,ANGIOGRAPHIC FINDINGS:,1. Type 2 aortic arch.,2. Left subclavian artery was patent.,3 Left vertebral artery was patent.,4. Left internal carotid artery had a 40% to 50% lesion with ulceration, not treated and there was no cerebral cross over.,5. Right common carotid artery had a 60% to 70% lesion which was heavily calcified and was not treated with the summed left-to-right cross over flow.,6. Closure was with a 6-French Angio-Seal of the artery, and the venous sheath was sutured in.,PLAN:, Continue aspirin, Plavix, and Coumadin to an INR of 2 with a carotid duplex followup. cardiovascular / pulmonary, aortic arch angiogram, carotid artery angiogram, artery was patent, common carotid artery, arch angiogram, subclavian artery, aortic arch, carotid artery, carotid, angiography, artery, angiograms, subclavian, catheterization, aortic, angiogram, Cardiovascular / Pulmonary Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia. Atrial Fibrillation - SOAP SUBJECTIVE: , The patient states that she feels better. She is on IV amiodarone, the dosage pattern is appropriate for ventricular tachycardia. Researching the available records, I find only an EMS verbal statement that tachycardia of wide complex was seen. There is no strip for me to review all available EKG tracings show a narrow complex atrial fibrillation pattern that is now converted to sinus rhythm.,The patient states that for a week, she has been home postoperative from aortic valve replacement on 12/01/08 at ABC Medical Center. The aortic stenosis was secondary to a congenital bicuspid valve, by her description. She states that her shortness of breath with exertion has been stable, but has yet to improve from its preoperative condition. She has not had any decline in her postoperative period of her tolerance to exertion.,The patient had noted intermittent bursts of fast heart rate at home that had been increasing over the last several days. Last night, she had a prolonged episode for which she contacted EMS. Her medications at home had been uninterrupted and without change from those listed, being Toprol-XL 100 mg q.a.m., Dyazide 25/37.5 mg, Nexium 40 mg, all taken once a day. She has been maintaining her Crestor and Zetia at 20 and 10 mg respectively. She states that she has been taking her aspirin at 325 mg q.a.m. She remains on Zyrtec 10 mg q.a.m. Her only allergy is listed to latex.,OBJECTIVE:,VITAL SIGNS: Temperature 36.1, heart rate 60, respirations 14, room air saturation 98%, and blood pressure 108/60. The patient shows a normal sinus rhythm on the telemetry monitor with an occasional PAC.,GENERAL: She is alert and in no apparent distress.,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 clear bilaterally to auscultation. The incision is well healed and without evidence of significant cellulitis.,HEART: Shows a regular rate and rhythm without murmur, gallop, heave, click, thrill or rub. There is an occasional extra beat noted, which corresponds to a premature atrial contraction on the monitor.,ABDOMEN: Soft and benign without hepatosplenomegaly, rebound, rigidity or guarding.,EXTREMITIES: Show no evidence of DVT, acute arthritis, cellulitis or pedal edema.,NEUROLOGIC: Nonfocal without lateralizing findings for cranial or peripheral nervous systems, strength, sensation, and cerebellar function. Gait and station were not tested.,MENTAL STATUS: Shows the patient to be alert, coherent with full capacity for decision making.,BACK: Negative to inspection or percussion.,LABORATORY DATA: , Shows from 12/15/08 2100, hemoglobin 11.6, white count 12.9, and platelets 126,000. INR 1.0. Electrolytes are normal with exception potassium 3.3. GFR is decreased at 50 with creatinine of 1.1. Glucose was 119. Magnesium was 2.3. Phosphorus 3.8. Calcium was slightly low at 7.8. The patient has had ionized calcium checked at Munson that was normal at 4.5 prior to her discharge. Troponin is negative x2 from 2100 and repeat at 07:32. This morning, her BNP was 163 at admission. Her admission chest x-ray was unremarkable and did not show evidence of cardiomegaly to suggest pericardial effusion. Her current EKG tracing from 05:42 shows a sinus bradycardia with Wolff-Parkinson White Pattern, a rate of 58 beats per minute, and a corrected QT interval of 557 milliseconds. Her PR interval was 0.12.,We received a call from Munson Medical Center that a bed had been arranged for the patient. I contacted Dr. Varner and we reviewed the patient's managed to this point. All combined impression is that the patient was likely to not have had actual ventricular tachycardia. This is based on her EP study from October showing her to be non-inducible. In addition, she had a cardiac catheterization that showed no evidence of coronary artery disease. What is most likely that the patient has postoperative atrial fibrillation. Her WPW may have degenerated into a ventricular tachycardia, but this is unlikely. At this point, we will convert the patient from IV amiodarone to oral amiodarone and obtain an echocardiogram to verify that she does not have evidence of pericardial effusion in the postoperative period. I will recheck her potassium, magnesium, calcium, and phosphorus at this point and make adjustments if indicated. Dr. Varner will be making arrangements for an outpatient Holter monitor and further followup post-discharge.,IMPRESSION:,1. Atrial fibrillation with rapid ventricular response.,2. Wolff-Parkinson White Syndrome.,3. Recent aortic valve replacement with bioprosthetic Medtronic valve.,4. Hyperlipidemia. cardiovascular / pulmonary, ventricular tachycardia, wolff-parkinson white syndrome., ventricular response, medtronic valve, wolff parkinson white syndrome, aortic valve replacement, atrial fibrillation, atrial, aortic, tachycardia, fibrillation, ventricular, valve, medtronic, Cardiovascular / Pulmonary Aortogram with bilateral, segmental lower extremity run off. Left leg claudication. The patient presents with lower extremity claudication. Aortogram - Leg claudication. 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. cardiovascular / pulmonary, claudication, extremity run off, angio suite, superficial femoral artery, popliteal, superficial, femoral, aortogram, artery, balloon, glidewire, angioplasty, stenosis, renal, Cardiovascular / Pulmonary 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. Aortic Valve Replacement 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. cardiovascular / pulmonary, coronary artery bypass grafting, saphenous vein graft, radial artery graft, coronary artery disease, congestive heart failure, descending artery territory, aortic cross clamp, aortic valve replacement, coronary artery bypass, obtuse marginal artery, anterior descending artery, mechanical valve, artery bypass, bypass grafting, marginal artery, radial artery, aortic valve, coronary artery, anterior descending, descending artery, valve, artery, aortic, grafting, Cardiovascular / Pulmonary Aortoiliac occlusive disease. Aortobifemoral bypass. 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. Aortobifemoral Bypass 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. cardiovascular / pulmonary, aorta, bypass, arteriosclerosis, abdominal contents, aortoiliac occlusive disease, gore tex graft, aortobifemoral bypass, longitudinal incision, aortobifemoral, hemostasis, artery, graft, Cardiovascular / Pulmonary Dementia and aortoiliac occlusive disease bilaterally. Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft. Aortobifemoral Bypass - 1 PREOPERATIVE DIAGNOSIS,1. Aortoiliac occlusive disease bilaterally.,2. Dementia.,POSTOPERATIVE DIAGNOSIS,1. Aortoiliac occlusive disease bilaterally.,2. Dementia.,OPERATION: , Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.,ANESTHESIA:, General endotracheal,ESTIMATED BLOOD LOSS: , 300 cc,INTRAVENOUS FLUIDS: , 1200 cc of crystalloid,URINE OUTPUT: , 250 cc,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 general endotracheal anesthesia was administered. Note that previously the patient was found to have some baseline dementia, although slight. The patient was seen and evaluated by the neurology team, who cleared the patient for surgery. The patient was taken to the operating room and general endotracheal anesthesia was administered. The abdomen was prepped and draped in the standard surgical fashion. We first began our dissection by using a #10-blade scalpel to incise the skin over the femoral artery in the groin bilaterally. Dissection was carried down to the level of the femoral vessels using Bovie electrocautery. The common femoral, superficial femoral, and profunda femoris arteries were encircled and dissected out peripherally. Vessel loops were placed around the aforementioned arteries. After doing so, we turned our attention to beginning our abdominal dissection. We used a #10-blade scalpel to make a midline laparotomy incision. Dissection was carried down to the level of the fascia using Bovie electrocautery. The abdomen was opened and an Omni retractor was positioned. The aorta was dissected out in the abdomen. The left femoral vein was identified. There was a nicely clampable portion of aorta visible. We, as mentioned, placed our Omni retractor and then turned our attention to performing our anastomosis. Full-dose heparin was given. Next, vascular clamps were applied to the iliac vessels as well as to the proximal aorta just below the renal vessels. A #11-blade scalpel was used to make an arteriotomy in the aorta, which was lengthened both proximally and distally using Potts scissors. We then beveled our proximal graft and constructed an end graft-to-side artery anastomosis using 3-0 Prolene in a running fashion. Upon completion of our anastomosis, we flushed our graft and noted there was no evidence of a leak from the newly constructed anastomosis. We then created our tunnels over the iliac vessels. We pulled the distal limbs over our ABF graft into the groin. We then proceeded to perform our right anastomosis first. We applied vascular clamps on the proximal common femoral, profunda, and superficial femoral arteries. We incised the common femoral artery and lengthened our arteriotomy in the vessel both proximally and distally. We then footed the graft down onto the common femoral artery to the level of the SFA and constructed our anastomosis using 6-0 Prolene in a running fashion. Upon completion of our anastomosis, we flushed the common femoral, SFA, and profunda femoris arteries. We then removed our clamp. We opened the limb more proximally in the abdomen on the right side. We then turned our attention to the left side and similarly placed our vascular clamps. We used a #11-blade scalpel to make an arteriotomy in the vessel. We then lengthened our arteriotomy both proximally and distally again onto the SFA. We constructed a footed end graft-to-side artery anastomosis using 6-0 Prolene in a running fashion. Upon completion of our anastomosis, we opened our clamps. There was no noticeable leak from the newly constructed anastomosis. We checked our proximal graft to aortic anastomosis, which was noted to be in good condition. We then gave full-dose protamine. We closed the peritoneum over the graft with 4-0 Vicryl in a running fashion. The abdomen was closed with #1 nylon in a running fashion. The skin was closed with subcuticular 4-0 Monocryl in a running subcuticular fashion. The instrument and sponge count was correct at end of case. Patient tolerated the procedure well and was transferred to the intensive care unit in good condition. cardiovascular / pulmonary, bifurcated, hemashield graft, aortoiliac occlusive disease, aortobifemoral bypass, vascular clamps, common femoral, graft, femoral, anastomosis, aortobifemoral, aortoiliac, proximal, arteriotomy, bypass, artery, endotracheal, vessels, Cardiovascular / Pulmonary A 74-year-old woman for Cardiology consultation regarding atrial fibrillation and anticoagulation after a fall. The patient denies any chest pain nor clear shortness of breath. Atrial Fibrillation - Consult HISTORY OF PRESENT ILLNESS:, I was kindly asked to see Ms. ABC who is a 74-year-old woman for cardiology consultation regarding atrial fibrillation and anticoagulation after a fall.,The patient is somnolent at this time, but does arouse, but is unable to provide much history. By review of the chart, it appears that she fell, which is what she states when she got up out of a rocking chair and could not get herself off the floor. She states that 1-1/2 hours later she was able to get herself off the floor.,The patient denies any chest pain nor clear shortness of breath.,PAST MEDICAL HISTORY: , Includes, end-stage renal disease from hypertension. She follows up with Dr. X in her office and has been known to have a small-to-moderate sized pericardial effusion since 11/07 that has apparently been followed and it appears that the patient was not interested in having diagnostic pericardiocentesis done. She had an echocardiogram today (please see also that report), which shows stable and small-to-moderate sized pericardial effusion without tamponade, normal left ventricular ejection fraction at 55% with mild concentric left ventricular hypertrophy, mildly dilated right ventricular size, normal right ventricular ejection fraction, moderate mitral regurgitation and severe tricuspid regurgitation with severe pulmonary hypertension, estimated PA systolic pressure of 71 mmHg when compared to the prior echocardiogram done 08/29/07, previously the mitral regurgitation was mild and previously the PA systolic pressure was estimated at 90 mmHg. Other findings were not significantly changed including pericardial effusion description. She has a history of longstanding hypertension. She has been on hemodialysis since 1997 for renal failure, history of mini-strokes documented several years ago, history of seizure disorder, she has a history of right upper extremity edema and right breast enlargement from right subclavian vein occlusion. She has a history of hypertension, depression, hyperlipidemia, on Sensipar for tertiary hyperparathyroidism.,PAST SURGICAL HISTORY: , Includes, cholecystectomy, post fistula in the left arm, which has failed, and right arm, which is being used including number of operative procedures to the fistula. She follows up with Dr. Y regarding neurovascular surgery.,MEDICATIONS: , On admission:,1. Norvasc 10 mg once a day.,2. Aspirin 81 mg once a day.,3. Colace 200 mg two at bedtime.,4. Labetalol 100 mg p.o. b.i.d.,5. Nephro-Vite one tablet p.o. q.a.m.,6. Dilantin 100 mg p.o. t.i.d.,7. Renagel 1600 mg p.o. t.i.d.,8. Sensipar 120 mg p.o. every day.,9. Sertraline 100 mg p.o. nightly.,10. Zocor 20 mg p.o. nightly.,ALLERGIES: , TO MEDICATIONS PER CHART ARE NONE.,FAMILY HISTORY: ,Unable to obtain as the patient becomes quite sleepy when I am talking.,SOCIAL HISTORY: ,Unable to obtain as the patient becomes quite sleepy when I am talking.,REVIEW OF SYSTEMS: , Unable to obtain as the patient becomes quite sleepy when I am talking.,PHYSICAL EXAM: ,Temperature 99.2, blood pressure ranges from 88/41 to 108/60, pulse 70, respiratory rate, 20, O2 saturation 98%. Height is 5 feet 1 inch, weight 147 pounds. On general exam, she is a pleasant elderly woman who does arouse to voice, but then becomes quite sleepy and apparently that is an improvement from when she was admitted. HEENT shows the cranium is normocephalic and atraumatic. She has moist mucosal membranes. Neck veins are difficult to assess, but do not appear clinically distended. No carotid bruits. Lungs are clear to auscultation anteriorly. No wheezes. Cardiac exam: S1, S2 regular rate, 3/6 holosystolic murmur heard with radiation from the left apex towards the left axilla. No rub, no gallop. PMI is nondisplaced. Abdomen: Soft, nondistended. CVA is benign. Extremities with no significant edema. Pulses appear grossly intact. She has evidence of right upper extremity edema, which is apparently chronic.,DIAGNOSTIC DATA/LAB DATA: , EKGs are reviewed including from 07/07/09 at 08:31 a.m., which shows atrial fibrillation with left anterior fascicular block, poor R-wave progression when compared to one done on 07/06/09 at 18:25, there is really no significant change. The atrial fibrillation appears present since at least on EKG done on 11/02/07 and this EKG is not significantly changed from the most recent one. Echocardiogram results as above. Chest x-ray shows mild pulmonary vascular congestion. BNP shows 3788. Sodium 136, potassium 4.5, chloride 94, bicarbonate 23, BUN 49, creatinine 5.90. Troponin was 0.40 followed by 0.34. INR 1.03 on 05/18/07. White blood cell count 9.4, hematocrit 42, platelet count 139.,IMPRESSION: , Ms. ABC is a 74-year-old woman admitted to the hospital with a fall and she has a history of vascular dementia, so her history is somewhat unreliable it seems and she is somnolent at that time. She does have chronic atrial fibrillation again documented at least present since 2007 and I found an EKG report by Dr. X, which shows atrial fibrillation on 08/29/07 per her report. One of the questions we were asked was whether the patient would be a candidate for Coumadin. Clearly given her history of small mini-strokes, I think Coumadin would be appropriate given this chronic atrial fibrillation, but the main issue is the fall risk. If not felt to be significant fall risk then I would strongly recommend Coumadin as the patient herself states that she has only fallen twice in the past year. I would defer that decision to Dr. Z and Dr. XY who know the patient well and it may be that physical therapy consult is appropriate to help adjudicate.,RECOMMENDATIONS:,1. Fall assessment as per Dr. Z and Dr. XY with possible PT consult if felt appropriate and if the patient is not felt to be at significant fall risk, would put her on Coumadin. Given her history of small strokes as documented in the chart and her chronic atrial fibrillation, she does have reasonable heart rate control on current labetalol.,2. The patient has elevated BNP and I suspect that is due to her severe pulmonary hypertension and renal failure and in the light of normal LV function, I would not make any further evaluation of that other than aggressive diuresis.,3. Regarding this minimal troponin elevation, I do not feel this is a diagnosis especially in the setting of pulmonary hypertension and her small-to-moderate sized stable pericardial effusion again that has been longstanding since 2007 from what I can tell and there is no evidence of tamponade. I would defer to her usual cardiologist Dr. X whether an outpatient stress evaluation is appropriate for risk stratification. I did find that the patient had a prior cardiac stress test in 08/07 where they felt that there was some subtle reversibility of the anterior wall, but it was felt that it may be artifact rather than true ischemia with normal LV function seen on that study as well.,4. Continue Norvasc for history of hypertension as well as labetalol.,5. The patient is felt to be a significant fall risk and will at least continue her aspirin 81 mg once a day for secondary CVA, thromboprophylaxis (albeit understanding that it is inferior to Coumadin).,6. Continue Dilantin for history of seizures. Cardiovascular / Pulmonary Arterial imaging of bilateral lower extremities. Arterial Imaging 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. cardiovascular / pulmonary, peripheral vascular disease, ankle brachial index, arterial waveform, peak systolic velocity, arterial imaging, biphasic, claudication, lower extremities, lower extremity, posterior tibial artery, triphasic, systolic velocity is normal, arterial waveform is triphasic, waveform is triphasic, normal arterial imaging, systolic velocity, brachial index, velocity, brachial, imaging, arterial, Cardiovascular / Pulmonary Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery. Angiogram & StarClose Closure 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. cardiovascular / pulmonary, heart cath, selective coronary angiogram, common femoral angiogram, abnormal stress test, common femoral artery, starclose closure, femoral artery, angiogram, angiographically, artery, femoral, Cardiovascular / Pulmonary Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis. Angiography & Catheterization - 1 INDICATION:, Acute coronary syndrome.,CONSENT FORM: , The procedure of cardiac catheterization/PCI risks included but not restricted to death, myocardial infarction, cerebrovascular accident, emergent open heart surgery, bleeding, hematoma, limb loss, renal failure requiring dialysis, blood loss, infection had been explained to him. He understands. All questions answered and is willing to sign consent.,PROCEDURE PERFORMED:, Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.,NARRATIVE: , The patient was brought to the cardiac catheterization laboratory in a fasting state. Both groins were draped and sterilized in the usual fashion. Local anesthesia was achieved with 2% lidocaine to the right groin area and a #6-French femoral sheath was inserted via modified Seldinger technique in the right common femoral artery. Selective coronary angiography was performed with #6 French JL4 catheter for the left coronary system and a #6 French JR4 catheter of the right coronary artery. Left ventricular catheterization and angiography was performed at the end of the procedure with a #6-French angle pigtail catheter.,FINDINGS,1. Hemodynamics systemic blood pressure 140/70 mmHg. LVEDP at the end of the procedure was 13 mmHg.,2. The left main coronary artery is a large with mild diffuse disease in the distal third resulting in less than 20% angiographic stenosis at the take off of the left circumflex artery. The left circumflex artery is a large caliber vessel with diffuse disease in the ostium of the proximal segment resulting in less than 30% angiographic stenosis. The left circumflex artery gives rise to a high small obtuse marginal branch that has high moderate-to-severe ostium. The rest of the left circumflex artery has mild diffuse disease and it gives rise to a second large obtuse marginal branch that bifurcates into an upper and lower trunk.,The LAD is calcified and diffusely disease in the proximal and mid portion. There is mild nonobstructive disease in the proximal LAD resulting in less than 20% angiographic stenosis.,3. The right coronary artery is dominant. It is septal to be occluded in the mid portion.,The findings were discussed with the patient and she opted for PCI. Angiomax bolus was started. The ACT was checked. It was higher in 300. I have given the patient 600 mg of oral Plavix.,The right coronary artery was engaged using a #6-French JR4 guide catheter. I was unable to cross through this lesion using a BMW wire and a 3.0x8 mm balloon support. I was unable to cross with this lesion using a whisper wire. I was unable to cross with this lesion using Cross-IT 100 wire. I have also used second #6-French Amplatz right I guide catheter. At one time, I have lost flow in the distal vessel. The patient experienced severe chest pain, ST-segment elevation, bradycardia, and hypotension, which responded to intravenous fluids and atropine along with intravenous dopamine.,Dr. X was notified.,Eventually, an Asahi grand slam wire using the same 3.0 x 8 mm Voyager balloon support, I was able to cross into the distal vessel. I have performed careful balloon angioplasty of the mid RCA. I have given nitroglycerin under the nursing several times during the procedure.,I then performed arthrectomy using #5-French export catheter.,I performed more balloon predilation using a 3.0 x16 mm Voyager balloon. I then deployed 4.0 x15 mm, excised, and across the mid RCA at 18 atmospheres with good angiographic result. Proximal to the proximal edge of the stent, there was still some persistent haziness most likely just diseased artery/diffuse plaquing. I decided to cover this segment using a second 4.0 x 15 mm, excised, and two stents were overlapped, the overlap was postdilated using the same stent delivery balloon at high pressure with excellent angiographic result.,Left ventricular catheterization was performed with #6-French angle pigtail catheter. The left ventricle is rather smaller in size. The mid inferior wall is minimally hypokinetic, ejection fraction is 70%. There is no evidence of aortic wall stenosis or mitral regurgitation.,Femoral angiography revealed that the entry point was above the bifurcation of the right common femoral artery and I have performed this as Perclose hemostasis.,CONCLUSIONS,1. Normal left ventricular size and function. Ejection fraction is 65% to 70%. No MR.,2. Successful angioplasty and stenting of the subtotally closed mid RCA. This was hard, organized thrombus, very difficult to penetrate. I have deployed two overlapping 4.0 x15 mm excised and with excellent angiographic result. The RCA is dominant.,3. No moderate disease in the distal left main. Moderate disease in the ostium of the left circumflex artery. Mild disease in the proximal LAD.,PLAN: , Recommend smoking cessation. Continue aspirin lifelong and continue Plavix for at least 12 months. cardiovascular / pulmonary, acute coronary syndrome, circumflex artery, ventricular catheterization, ventricular angiography, angioplasty, coronary artery, coronary angiography, arthrectomy, femoral angiography, perclose hemostasis, selective coronary angiography, angiographic stenosis, rca, coronary, catheterization, artery, angiography, hemostasis, wire, lad, femoral, angiographic, stenting, proximal, Cardiovascular / Pulmonary Left heart catheterization, bilateral selective coronary angiography, left ventriculography, and right heart catheterization. Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion. Angiography & Catheterization PROCEDURES PERFORMED:,1. Left heart catheterization.,2. Bilateral selective coronary angiography.,3. Left ventriculography.,4. Right heart catheterization.,INDICATION: , Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery and vein. Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery. A steel guidewire was inserted through the needle into the vascular lumen without resistance. A small nick was then made in the skin. The pressure was held. The needle was removed over the guidewire. Next, a #6 French arterial sheath was then advanced over the guidewire into the vascular lumen without resistance. The guidewire and dilator were then removed. The sheath was flushed. Next, an angulated pigtail catheter was advanced to the level of the ascending aorta under the direct fluoroscopy visualization with the use of a guidewire. The catheter was then guided into the left ventricle. The guidewire and dilator were then removed. The catheter was then flushed. LVEDP was measured and found to be favorable for a left ventriculogram. The left ventriculogram was performed in the RAO position with a single power injection of nonionic contrast material. LVEDP was then remeasured. Pullback was performed, which failed to reveal an LVAO gradient. The catheter was then removed. Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the left main coronary was unable to be engaged with this catheter. Thus it was removed over a guidewire. Next, a Judkins left #5 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. Left main coronary artery was then engaged. Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views. The catheter was then removed from the ostium of the left main coronary artery and was removed over a guidewire. Next, a Judkins right #4 catheter was then 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. Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views. The catheter was then removed from the ostium of the right coronary artery and then removed. The sheath was then flushed. Because the patient did have high left ventricular end-diastolic pressures, it was determined that the patient wound need a right heart catheterization. Thus an #18 gauge Argon needle was used to cannulate the right femoral vein. A steel guidewire was inserted through the needle into the vascular lumen. The needle was removed over the guidewire. Next, an #8 French venous sheath was advanced over the guidewire into lumen without resistance. The guidewire and dilator were then removed. The sheath was then flushed. Next, a Swan-Ganz catheter was advanced to the level of 20 cm. The balloon was inflated. Under fluoroscopic visualization, the catheter was guided into the right atrium, right ventricle, and into the pulmonary artery wedge position. Hemodynamics were measured along the way. PA saturation, right atrial saturation, femoral artery saturation were all obtained. Once adequate study has been performed, the catheter was then removed. Both sheaths were flushed and found fine. The patient was returned to the cardiac catheterization holding area in stable satisfactory condition.,FINDINGS:,LEFT VENTRICULOGRAM: ,There is no evidence of any wall motion abnormalities with estimated ejection fraction of 60%. Left ventricular end-diastolic pressure was 38 mmHg preinjection and 40 mmHg postinjection. There is no LVAO. There is no mitral regurgitation. There is a trileaflet aortic valve noted.,LEFT MAIN CORONARY ARTERY: ,The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries. There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING: , The LAD is a moderate caliber vessel, which traverses through the intraventricular groove and reaches the apex of the heart. There is a proximal 60% to 70% stenotic lesion. There was also a mid 70% to 80% stenotic lesion at the takeoff of the first and second diagonal branches.,CIRCUMFLEX ARTERY: ,The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove. There is a mid 60% to 70% stenotic lesion followed by a second mid 90% stenotic lesion. The first obtuse marginal branch is small and the second obtuse marginal branch is large without any evidence of critical disease. The third obtuse marginal branch is also small.,RIGHT CORONARY ARTERY: ,The RCA is a moderate caliber vessel with minor luminal irregularities throughout. There is no evidence of any critical disease. The right coronary artery is the dominant right coronary vessel.,RIGHT HEART FINDINGS: ,Pulmonary artery pressure equals 61/23 with a mean of 44. Pulmonary artery wedge pressure equals 32. Right ventricle pressure equals 65/24. The right atrial pressure equals to 22. Cardiac output by Fick is 4.9. Cardiac index by Fick is 2.3. Hand calculated cardiac output equals 7.8. Hand calculated cardiac index equals 3.7. On 2 liters nasal cannula, pulmonary artery saturation equals 77.8%. Femoral artery saturation equals 99.1%. Pulse oximetry is 99%. Right atrial saturation is 76.3%. Systemic blood pressure is 166/58. Body surface area equals 2.12. Hemoglobin equals 12.6.,IMPRESSION:,1. Two-vessel coronary artery disease with a complex left anterior descending arterial lesion as well as circumflex disease.,2. Normal left ventricular function with an estimated ejection fraction of 60%.,3. Biventricular overload.,4. Moderate pulmonary hypertension.,5. There is no evidence of shunt.,PLAN:,1. The patient will be admitted for IV diuresis in light of the biventricular overload.,2. The findings of the heart catheterization were discussed in detail with the patient and the patient's family. There is some concern with the patient's two-vessel coronary artery disease in light of the patient's diabetic history. We will obtain a surgical evaluation for the possibility of a coronary artery bypass grafting.,3. The patient will remain on aggressive medical regimen including ACE inhibitor, aspirin, Plavix, and nitrate.,4. The patient will need to undergo aggressive risk factor modification including weight loss and diet control.,5. The patient will have an Internal Medicine evaluation regarding the patient's diabetic history. Cardiovascular / Pulmonary Lower extremity angiogram, superficial femoral artery laser atherectomy and percutaneous transluminal balloon angioplasty, external iliac artery angioplasty and stent placement, and completion angiogram. Angiogram & Angioplasty PREOPERATIVE DIAGNOSES:,1. Left superficial femoral artery subtotal stenosis.,2. Arterial insufficiency, left lower extremity.,POSTOPERATIVE DIAGNOSES:,1. Left superficial femoral artery subtotal stenosis.,2. Arterial insufficiency, left lower extremity.,OPERATIONS PERFORMED:,1. Left lower extremity angiogram.,2. Left superficial femoral artery laser atherectomy.,3. Left superficial femoral artery percutaneous transluminal balloon angioplasty. ,4. Left external iliac artery angioplasty.,5. Left external iliac artery stent placement.,6. Completion angiogram.,FINDINGS: ,This patient was brought to the OR with a non-severe stenosis of the proximal left superficial femoral artery in the upper one-third of his thigh. He is also known to have severe calcific disease involving the entire left external iliac system as well as the common femoral and deep femoral arteries.,Our initial plan today was to perform an atherectomy with angioplasty and stenting of the left superficial femoral artery as necessary. However, whenever we started the procedure, it became clear that there was a severe stenosis of the left superficial femoral artery at its takeoff from the left common femoral artery. The area was severely calcified including the external iliac artery extending up underneath the left inguinal ligament. Indeed, this ultimately was dissected due to manipulation of sheath catheters and sheath through the area. Ultimately, this wound up being a much more complex case than initially anticipated.,Because of the above, we ultimately performed a laser atherectomy of the left superficial femoral artery, which then had to be angioplastied to obtain a satisfactory result. The completion angiogram showed that there was a dissection of the left external iliac artery, which precluded flow down into the left lower extremity. We then had to come up and perform angioplasty and stenting of the left external iliac artery as well as aggressively dilating the takeoff of the less superficial femoral artery from the common femoral artery.,The left superficial femoral artery was dilated with a 6-mm balloon.,The left external iliac artery and common femoral arteries were dilated with an 8-mm balloon.,A 2.5-mm ClearPath laser probe was used to initially arthrectomize and debulk the superficial femoral artery starting at its takeoff from the common femoral artery and extending down to the tight stenotic area in the upper one-third of the thigh. After the laser atherectomy was performed, the area still did not look good and so an angioplasty was then done, which looked good; however, as noted above, after we had dealt with the superficial femoral artery, we then had proximal inflow problems, which had to be dealt by angioplasty and stenting.,The patient had good dorsalis pedis pulses bilaterally upon completion.,The right common femoral artery was used for access in an up-and-over technique.,PROCEDURE: , With the patient in the supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in the sterile fashion.,The right common femoral artery was punctured percutaneously, and a #5-French sheath was initially placed. We used a pigtail catheter to go up and over the aortic bifurcation and placed a stiff Amplatz guidewire down into the left common femoral artery. We then heparinized the patient and placed a #7-French Raby sheath over the Amplatz wire. A selective left lower extremity angiogram was then done with the above-noted findings.,We then used a ClearPath 2.5-mm laser probe to laser the proximal superficial femoral artery. Because of the findings as noted above, this became more involved than initially hoped for. Once the laser atherectomy had been completed, the vessel still did not look good, so we used a 6-mm balloon to thoroughly dilate the area. Once that had been done, it looked good and we performed what we felt would be a completion angiogram only to find out that we had a more proximal problem precluding flow down into the left femoral artery.,Once that was discovered, we then had to proceed with angioplasty and stenting of the left external iliac artery right down to the acetabular level.,Once we had dealt with our run-on problems, we then did another completion angiogram, which showed a good flow through the entire area and down into the left lower extremity.,Following completion of the above, all wires, sheaths, and catheters were removed from the right common femoral artery. Firm pressure was held over the puncture site for 20 minutes followed by application of a sterile Coverlet dressing and a firm pressure dressing.,The patient tolerated the procedure well throughout. He had good palpable dorsalis pedis pulses bilaterally on completion. He was taken to the recovery room in satisfactory condition. Protamine was given to partially reverse the heparin. Cardiovascular / Pulmonary A sample note on Angina. Angina ANGINA, is chest pain due to a lack of oxygen to the heart most often occurring in men age 35 or older and postmenopausal women. It is usually located right under the breast bone. Physical and emotional stress, as well as eating heavy meals, can bring it on. In a healthy person, these stresses are easily handled. In a person with an underlying heart condition like coronary artery disease, heart valve problem, arrhythmias or high blood pressure, the heart doesn't get enough blood (i.e. not enough oxygen to the heart muscles). Other causes could be due to a hyperactive thyroid disorder or anemia. People more likely to have angina may also have diabetes mellitus, be overweight, smoke, have a poor diet with lots of salt and fat, fail to exercise, have a stressful workload or have a family history of coronary artery disease.,SIGNS AND SYMPTOMS:,* Pain in chest described as tightness, heavy pressure, aching or squeezing.,* The pain sometimes radiates to the jaw, left arm, teeth and/or outer ear.,* Possibly a left-sided numbness, tingling, or pain in the arm, shoulder, elbow or chest.,* Occasionally a sudden difficulty in breathing occurs.,* Pain may be located between the shoulder blades.,TREATMENT:,* Nitroglycerin relieves the immediate symptoms of angina in seconds. Carry it with you at all times.,* Other medications may be prescribed for the underlying heart problems. It is important to take them as prescribed by your doctor.,* Surgery may be necessary to open the blocked coronary arteries (balloon angioplasty) or to bypass them.,* Correct the contributing factors you have control over. Lose weight, don't smoke, eat a low-salt, low-fat diet and avoid physical and emotional stresses that cause angina. Such stressors include anger, overworking, going between extremes in hot and cold, sudden physical exertion and high altitudes (pressurized airplanes aren't a risk). Practice relaxation techniques.,* Exercise! Discuss first what you are able to do with your doctor and then go do it.,* Even with treatment, angina may result in a heart attack, congestive heart failure or a fatal abnormal heartbeat. Treatment decreases the odds that these will occur.,* Let your doctor know if your angina doesn't go away after 10 minutes, even when you have taken a nitroglycerin tablet. Call if you have repeated chest pains that awaken you from sleep regardless if the nitroglycerin helps. If your pain changes or feels different, call your doctor or call 911 if the pain is severe. cardiovascular / pulmonary, lack of oxygen, heart valve, arrhythmias, blood pressure, heart, tightness, nitroglycerin, coronary artery disease, oxygen, angina, coronary, chest, Cardiovascular / Pulmonary Adenosine with nuclear scan as the patient unable to walk on a treadmill. Nondiagnostic adenosine stress test. Normal nuclear myocardial perfusion scan. Adenosine Nuclear Scan INDICATION: , Chest pain.,TYPE OF TEST: , Adenosine with nuclear scan as the patient unable to walk on a treadmill.,INTERPRETATION:, Resting heart rate of 67, blood pressure of 129/86. EKG, normal sinus rhythm. Post-Lexiscan 0.4 mg, heart rate was 83, blood pressure 142/74. EKG remained the same. No symptoms were noted.,SUMMARY:,1. Nondiagnostic adenosine stress test.,2. Nuclear interpretation as below.,NUCLEAR INTERPRETATION:, Resting and stress images were obtained with 10.4, 33.1 mCi of tetrofosmin injected intravenously by standard protocol. Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect. Gated SPECT revealed normal wall motion, ejection fraction of 58%. End-diastolic volume of 74, end-systolic volume of 31.,IMPRESSION:,1. Normal nuclear myocardial perfusion scan.,2. Ejection fraction 58% by gated SPECT. cardiovascular / pulmonary, adenosine nuclear myocardial perfusion scan, chest pain, adenosine stress test, nuclear myocardial perfusion scan, gated spect, spect, mci, myocardial perfusion scan, myocardial, perfusion, adenosine, nuclear, Cardiovascular / Pulmonary Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction. Acute Inferior Myocardial Infarction "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" Cardiovascular / Pulmonary Patient had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin. Angina - Consult 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. Cardiovascular / Pulmonary Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only. Abnormal Stress Test HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only. He required 3 sublingual nitroglycerin in total (please see also admission history and physical for full details).,The patient underwent cardiac catheterization with myself today which showed mild-to-moderate left main distal disease of 30%, moderate proximal LAD with a severe mid-LAD lesion of 99%, and a mid-left circumflex lesion of 80% with normal LV function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right PDA.,I discussed these results with the patient, and he had been relating to me that he was having rest anginal symptoms, as well as nocturnal anginal symptoms, and especially given the severity of the mid left anterior descending lesion, with a markedly abnormal stress test, I felt he was best suited for transfer for PCI. I discussed the case with Dr. X at Medical Center who has kindly accepted the patient in transfer.,CONDITION ON TRANSFER: , Stable but guarded. The patient is pain-free at this time.,MEDICATIONS ON TRANSFER:,1. Aspirin 325 mg once a day.,2. Metoprolol 50 mg once a day, but we have had to hold it because of relative bradycardia which he apparently has a history of.,3. Nexium 40 mg once a day.,4. Zocor 40 mg once a day, and there is a fasting lipid profile pending at the time of this dictation. I see that his LDL was 136 on May 3, 2002.,5. Plavix 600 mg p.o. x1 which I am giving him tonight.,Other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation, GERD, arthritis,DISPOSITION: ,The patient and his wife have requested and are agreeable with transfer to Medical Center, and we are enclosing the CD ROM of his images. cardiovascular / pulmonary, standard bruce, nitroglycerin, abnormal stress test, st depressions, anginal symptoms, stress test, lad, anginal, stress Cardiovascular / Pulmonary Abnormal echocardiogram findings and followup. Shortness of breath, congestive heart failure, and valvular insufficiency. 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. Abnormal Echocardiogram 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. Cardiovascular / Pulmonary