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HISTORY OF PRESENT ILLNESS: ,The patient is a 50-year-old African American female with past medical history significant for hypertension and endstage renal disease, on hemodialysis secondary to endstage renal disease, last hemodialysis was on June 22, 2007. The patient presents with no complaints for cadaveric renal ...
Surgery
PREOPERATIVE DIAGNOSIS: , Acute lymphocytic leukemia in remission.,POSTOPERATIVE DIAGNOSIS: , Acute lymphocytic leukemia in remission.,OPERATION PERFORMED: ,Removal of venous port.,ANESTHESIA: , General.,INDICATIONS: , This 9-year-old young lady presented with ALL in Orange County and had a port placed at that time. ...
Surgery
PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of the scalp.,POSTOPERATIVE DIAGNOSIS:, Same.,OPERATION PERFORMED: , Radical resection of tumor of the scalp (CPT 11643). Excision of tumor from the skull with debridement of the superficial cortex with diamond bur. Advancement flap closure, with total undermined are...
Surgery
PREOPERATIVE DIAGNOSIS:, Complex Regional Pain Syndrome Type I.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1. Stellate ganglion RFTC (radiofrequency thermocoagulation) left side.,2. Interpretation of Radiograph.,ANESTHESIA: ,IV Sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None...
Surgery
PREOPERATIVE DIAGNOSES:,1. Nasal obstruction secondary to deviated nasal septum.,2. Bilateral turbinate hypertrophy.,PROCEDURE:, Cosmetic rhinoplasty. Request for cosmetic change in the external appearance of the nose.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: ,The patient is a 26-yea...
Surgery
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.,TOURNIQU...
Surgery
PREOPERATIVE DIAGNOSIS:, Congenital bilateral esotropia, 42 prism diopters.,PROCEDURE:, Bilateral rectus recession with the microscopic control, 8 mm, both eyes.,POSTOPERATIVE DIAGNOSIS: , Congenital bilateral esotropia, 42 prism diopters.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: , The patient was taken to the Sur...
Surgery
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 ...
Surgery
PREOPERATIVE DIAGNOSIS: , Radioactive plaque macular edema.,POSTOPERATIVE DIAGNOSIS:, Radioactive plaque macular edema.,TITLE OF OPERATION:, Removal of radioactive plaque, right eye with lateral canthotomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was prepped and draped in the usual manner for a local eye procedu...
Surgery
PREOPERATIVE DIAGNOSIS (ES):, Rectovaginal fistula.,POSTOPERATIVE DIAGNOSIS (ES):, Rectovaginal fistula.,PROCEDURE:, CPT code 57307 - Closure of rectovaginal fistula, transperineal approach.,MATERIAL FORWARDED TO THE LABORATORY FOR EXAMINATION:, Includes fistula tract.,ESTIMATED BLOOD LOSS:, 25 mL.,INDICATIONS:, The pa...
Surgery
PROCEDURE: , Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,ANESTHESIA: ,Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed. The patient was in the operating room in the prone position. The back prepped with B...
Surgery
PROCEDURE: , Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: ,INT was placed. The patient was in the operating room in the prone position with the back prepped and draped in a sterile f...
Surgery
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 associat...
Surgery
PROCEDURE PERFORMED: , Modified radical mastectomy.,ANESTHESIA: , General endotracheal tube.,PROCEDURE: ,After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating room table. General endotracheal anesthesia was induced without incident. The patient was pre...
Surgery
PREOPERATIVE DIAGNOSIS:, Invasive carcinoma of left breast.,POSTOPERATIVE DIAGNOSIS:, Invasive carcinoma of left breast.,OPERATION PERFORMED:, Left modified radical mastectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR THE PROCEDURE: ,The patient is a 52-year-old female who recently underwent a left breast...
Surgery
PREOPERATIVE DIAGNOSES: , Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post Pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,POSTOPERATIVE DIAGNOSES:, Left obstructed renal ureteropelvic junction o...
Surgery
PREOPERATIVE DIAGNOSIS: , Clinical stage III squamous cell carcinoma of the vulva.,POSTOPERATIVE DIAGNOSIS: , Clinical stage III squamous cell carcinoma of the vulva.,OPERATION PERFORMED:, Radical vulvectomy (complete), bilateral inguinal lymphadenectomy (superficial and deep).,ANESTHESIA: , General, endotracheal tube...
Surgery
PREOPERATIVE DIAGNOSIS:, Worrisome skin lesion, left hand.,POSTPROCEDURE DIAGNOSIS:, Worrisome skin lesion, left hand.,PROCEDURE:, The patient gave informed consent for his procedure. After informed consent was obtained, attention was turned toward the area of interest, which was prepped and draped in the usual ste...
Surgery
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-m...
Surgery
PREOPERATIVE DIAGNOSIS:, Cervical adenocarcinoma, stage I.,POSTOPERATIVE DIAGNOSIS: , Cervical adenocarcinoma, stage I.,OPERATION PERFORMED:, Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Uter...
Surgery
PROCEDURES:,1. Robotic-assisted pyeloplasty.,2. Anterograde right ureteral stent placement.,3. Transposition of anterior crossing vessels on the right.,4. Nephrolithotomy.,DIAGNOSIS:, Right ureteropelvic junction obstruction.,DRAINS:,1. Jackson-Pratt drain times one from the right flank.,2. Foley catheter times ...
Surgery
PROCEDURE:, Punch biopsy of right upper chest skin lesion.,ESTIMATED BLOOD LOSS:, Minimal.,FLUIDS: , Minimal.,COMPLICATIONS:, None.,PROCEDURE:, The area around the lesion was anesthetized after she gave consent for her procedure. Punch biopsy including some portion of lesion and normal tissue was performed. Hemos...
Surgery
PREOPERATIVE DIAGNOSIS:, Macular edema, right eye.,POSTOPERATIVE DIAGNOSIS: ,Macular edema, right eye.,TITLE OF OPERATION: , Insertion of radioactive plaque, right eye with lateral canthotomy.,OPERATIVE PROCEDURE IN DETAIL: ,The patient was prepped and draped in the usual manner for a local eye procedure. Initially...
Surgery
PREOPERATIVE DIAGNOSIS: , Adenocarcinoma of the prostate.,POSTOPERATIVE DIAGNOSIS: , Adenocarcinoma of the prostate.,PROCEDURE,1. Radical retropubic prostatectomy, robotic assisted.,2. Bladder suspension.,ANESTHESIA:, General by intubation.,The patient understands his diagnosis, grade, stage and prognosis. He under...
Surgery
PREOPERATIVE DIAGNOSIS:, Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,POSTOPERATIVE DIAGNOSIS:, Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,PROCEDURE DONE: , Open radical retropubic prostatectomy with bilateral lymph node dissection.,INDICATIONS:, This i...
Surgery
PREOPERATIVE DIAGNOSIS: ,Prostate cancer.,POSTOPERATIVE DIAGNOSIS:, Prostate cancer.,OPERATION PERFORMED:, Radical retropubic nerve-sparing prostatectomy without lymph node dissection.,ESTIMATED BLOOD LOSS: , 450 mL.,REPLACEMENT:, 250 mL of Cell Saver and crystalloid.,COMPLICATIONS: , None.,INDICATIONS OF SURGERY: ...
Surgery
PREOPERATIVE DIAGNOSIS:, Prostate cancer.,POSTOPERATIVE DIAGNOSIS: , Prostate cancer.,OPERATIVE PROCEDURE: , Radical retropubic prostatectomy with pelvic lymph node dissection.,ANESTHESIA: ,General epidural,ESTIMATED BLOOD LOSS: , 800 cc.,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY: , This is a 64-year-old man wit...
Surgery
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, pulm...
Surgery
PREOPERATIVE DIAGNOSIS: , Ovarian cancer.,POSTOPERATIVE DIAGNOSIS:, Ovarian cancer.,OPERATION PERFORMED:, Insertion of a Port-A-Catheter via the left subclavian vein approach under fluoroscopic guidance.,DETAILED OPERATIVE NOTE:, The patient was placed on the operating table and placed under LMA general anesthesia i...
Surgery
PREOPERATIVE DIAGNOSIS: ,Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,POSTOPERATIVE DIAGNOSIS: , Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneur...
Surgery
TITLE OF PROCEDURE: , Insertion of Port-A-Cath via left subclavian vein using fluoroscopy.,PREOPERATIVE DIAGNOSIS: ,Metastatic renal cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Metastatic renal cell carcinoma.,PROCEDURE IN DETAIL:, This is a 49-year-old gentleman was referred by Dr. A. The patient underwent a left ne...
Surgery
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 ...
Surgery
PREOPERATIVE DIAGNOSES: ,1. Bilateral breast carcinoma.,2. Chemotherapy required.,POSTOPERATIVE DIAGNOSES:,1. Bilateral breast carcinoma.,2. Chemotherapy required.,OPERATION: , Right subclavian Port-a-Cath insertion.,FINDINGS AND PROCEDURE: ,With the patient under satisfactory general orotracheal anesthesia and in...
Surgery
PREOPERATIVE DIAGNOSIS: , Bleeding after transanal excision five days ago.,POSTOPERATIVE DIAGNOSIS: , Bleeding after transanal excision five days ago.,PROCEDURE:, Exam under anesthesia with control of bleeding via cautery.,ANESTHESIA:, General endotracheal.,INDICATION: , The patient is a 42-year-old gentleman who is ...
Surgery
PREOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,POSTOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,PROCEDURE: ,The patient with lef...
Surgery
PREOPERATIVE DIAGNOSIS:,1. Anal cancer.,2. Need for IV access.,POSTOPERATIVE DIAGNOSIS:,1. Anal cancer.,2. Need for IV access.,OPERATIVE PROCEDURE:,1. Placement of a Port-A-Cath.,2. Fluoroscopic guidance.,ANESTHESIA:, General LMA.,ESTIMATED BLOOD LOSS:, Minimum.,IV FLUIDS: , Per anesthesia.,RECURRENT COMPLICATI...
Surgery
PREOPERATIVE DIAGNOSES,1. Metastatic carcinoma of the bladder.,2. Bowel obstruction.,POSTOPERATIVE DIAGNOSES,1. Metastatic carcinoma of the bladder.,2. Bowel obstruction.,PROCEDURE: , Port insertion through the right subclavian vein percutaneously under radiological guidance.,PROCEDURE DETAIL: ,The patient was ele...
Surgery
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 perf...
Surgery
TITLE OF OPERATION: , Transnasal transsphenoidal approach in resection of pituitary tumor.,INDICATION FOR SURGERY: , The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor. She was started on Dostinex with increasing dosages. The most recent MRI dem...
Surgery
PREOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.,POSTOPERATIVE DIAGNOSES: , Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion, and potentially unstable cervical spine.,OPERAT...
Surgery
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 obtain...
Surgery
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% Marca...
Surgery
PREOPERATIVE DIAGNOSIS:, Plantar fascitis, left foot.,POSTOPERATIVE DIAGNOSIS: , Plantar fascitis, left foot.,PROCEDURE PERFORMED: , Partial plantar fasciotomy, left foot.,ANESTHESIA:, 10 cc of 0.5% Marcaine plain with TIVA.,HISTORY: ,This 35-year-old Caucasian female presents to ABCD General Hospital with above chi...
Surgery
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 rec...
Surgery
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 tis...
Surgery
S -, A 44-year-old, 250-pound male presents with extreme pain in his left heel. This is his chief complaint. He says that he has had this pain for about two weeks. He works on concrete floors. He says that in the mornings when he gets up or after sitting, he has extreme pain and great difficulty in walking. He als...
Surgery
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.,...
Surgery
PREOPERATIVE DIAGNOSIS: , Pilonidal cyst with abscess formation.,POSTOPERATIVE DIAGNOSIS:, Pilonidal cyst with abscess formation.,OPERATION: , Excision of infected pilonidal cyst.,PROCEDURE: , After obtaining informed consent, the patient underwent a spinal anesthetic and was placed in the prone position in the operat...
Surgery
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 in...
Surgery
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 ...
Surgery
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 th...
Surgery
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 quadripare...
Surgery
PREOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,POSTOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,PROCEDURE:, Right phacoemulsification of cataract with intraocular lens implantation.,DESCRIPTION OF THE OPERATION:, Under topical anesthesia with monitored anesthesia care, the patient was prepped, draped and positio...
Surgery
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, 34...
Surgery
PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,PROCEDURE: ,Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.,ANESTHESIA: ,Topical.,COMPLICATIONS: ,None.,PROCEDURE IN DETAIL: ,The patient was identified. The operative eye was treated ...
Surgery
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...
Surgery
TITLE OF OPERATION: , Phacoemulsification with posterior chamber intraocular lens implant in the right eye.,INDICATION FOR SURGERY: , The patient is a 27-year-old male who sustained an open globe injury as a child. He subsequently developed a retinal detachment in 2005 and now has silicone oil in the anterior chamber ...
Surgery
PREOPERATIVE DIAGNOSES:,1. Senile nuclear cataract, left eye.,2. Senile cortical cataract, left eye., ,POSTOPERATIVE DIAGNOSES:,1. Senile nuclear cataract, left eye.,2. Senile cortical cataract, left eye., ,PROCEDURES: , Phacoemulsification of cataract, extraocular lens implant in left eye., ,LENS IMPLANT USED:, A...
Surgery
PROCEDURE: , Phacoemulsification with posterior chamber intraocular lens insertion.,INTRAOCULAR LENS: , Allergan Medical Optics model S140MB XXX diopter chamber lens.,PHACO TIME:, Not known.,ANESTHESIA: , Retrobulbar block with local minimal anesthesia care.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS:, None.,DESCRIP...
Surgery
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 09/02/20...
Surgery
PREOPERATIVE DIAGNOSIS:, Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,OPERATION PERFORMED: , Phacoemulsification with IOL, right eye.,ANESTHESIA:, Topical with MAC.,COMPLICATIONS,: None.,ESTIMATED BLOOD LOSS: , None.,PROCEDURE IN DETAIL: After appropriate consent was obtained, the patient wa...
Surgery
OPERATION PERFORMED:, Phacoemulsification of cataract and posterior chamber lens implant, right eye., ,ANESTHESIA:, Retrobulbar nerve block, right eye, ,DESCRIPTION OF OPERATION: ,The patient was brought to the operating room where local anesthetic was administered to the right eye followed by a dilute drop of Betadine...
Surgery
PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,PROCEDURE:, Phacoemulsification with intraocular lens placement, right eye.,ANESTHESIA: , Monitored anesthesia care,ESTIMATED BLOOD LOSS: , None,COMPLICATIONS:, None,SPECIMENS:, None,PROCEDURE IN DETAIL: , The patient had ...
Surgery
PREOPERATIVE DIAGNOSIS: ,Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,PROCEDURE: , Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation. ME 30, AC 25.0 diopter lens was used.,COMPLICATIONS: ,None.,ANESTHESIA: , Local 2%, peribulbar lidocaine.,PROCED...
Surgery
PROCEDURE PERFORMED: , Phacoemulsification with intraocular lens placement.,ANESTHESIA TYPE: ,Topical.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrine eye drops. Topical anesthetic drops were applied t...
Surgery
PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,TITLE OF OPERATION: ,Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Retrobulbar block.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room where retrobul...
Surgery
PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: ,Cataract, right eye.,PROCEDURE PERFORMED: ,Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation. An Alcon MA30BA lens was used, * diopters, #*.,ANESTHESIA: ,Topical 4% lidocaine with 1% nonpreserved i...
Surgery
PREOPERATIVE DIAGNOSIS:, Visually significant nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with posterior chamber intraocular lens implantation, right eye.,ANESTHESIA:, Monitored anesthesia car...
Surgery
PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,TITLE OF OPERATION: , Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room where tetracaine drops w...
Surgery
PREOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,ANESTHESIA: , Topical/MAC.,PROCEDURE: , Phacoemulsification cataract extraction with intraocular lens implantation, left eye (Alcon AcrySof, SN60AT, 23.0 D, serial #***).,COMPLICATIONS:...
Surgery
PREOPERATIVE DIAGNOSIS:, Cataract, nuclear sclerotic, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, nuclear sclerotic, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with intraocular lens implantation, right eye.,ANESTHESIA: , Topical tetracaine, intracameral lidocaine, monitored anesthesia care.,IOL: , AMO ...
Surgery
DIAGNOSIS:, Nuclear sclerotic and cortical cataract, right eye.,OPERATION:, Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.,PROCEDURE:, The patient was taken to the operating room and placed on the table in the supine position. Cardiac monitor and oxygen at 5...
Surgery
PREOPERATIVE DIAGNOSES: ,1. Nasolabial mesiolabial fold.,2. Mid glabellar fold.,POSTOPERATIVE DIAGNOSES: ,1. Nasolabial mesiolabial fold.,2. Mid glabellar fold.,TITLE OF PROCEDURES: ,1. Perlane injection for the nasolabial fold.,2. Restylane injection for the glabellar fold.,ANESTHESIA: ,Topical with Lasercai...
Surgery
PREOPERATIVE DIAGNOSES:,1. Nonfunctioning inflatable penile prosthesis.,2. Peyronie's disease.,POSTOPERATIVE DIAGNOSES:,1. Nonfunctioning inflatable penile prosthesis.,2. Peyronie's disease.,PROCEDURE PERFORMED: , Ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesi...
Surgery
PREOPERATIVE DIAGNOSIS: , Renal failure.,POSTOPERATIVE DIAGNOSIS:, Renal failure.,OPERATION PERFORMED: , Insertion of peritoneal dialysis catheter.,ANESTHESIA: , General.,INDICATIONS: ,This 14-year-old young lady is in the renal failure and in need of dialysis. She had had a previous PD catheter placed, but it becam...
Surgery
PROCEDURE:, Permacath placement.,INDICATION: , Renal failure.,IMPRESSION: , Status post successful placement of a #4-French Permacath dialysis catheter.,DISCUSSION:, After informed consent was obtained at the request of Dr. Xyz, Permacath placement was performed.,The right neck and anterior chest were sterilely clean...
Surgery
PREOPERATIVE DIAGNOSIS:, Senile cataract OX,POSTOPERATIVE DIAGNOSIS: ,Senile cataract OX,PROCEDURE: ,Phacoemulsification with posterior chamber intraocular lens OX, model SN60AT (for Acrysof natural lens), XXX diopters.,INDICATIONS: ,This is a XX-year-old (wo)man with decreased vision OX.,PROCEDURE:, The risks and bene...
Surgery
PREOPERATIVE DIAGNOSIS:, Nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES:, Kelman phacoemulsification with posterior chamber intraocular lens, right eye.,ANESTHESIA:, Topical.,COMPLICATIONS:, None.,INDICATION: , This is a 40-year-old male...
Surgery
PREOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,POSTOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,PROCEDURE: ,Excision of penile skin bridges about 2 cm in size.,ABNORMAL FINDINGS: ,Same as above.,ANESTHESIA: ,General inhalation anesthetic with caudal block.,FLUIDS RECEIVED: , 300 ...
Surgery
PREOPERATIVE DIAGNOSIS: , Large left adnexal mass, 8 cm in diameter.,POSTOPERATIVE DIAGNOSIS: , Pelvic adhesions, 6 cm ovarian cyst.,PROCEDURES PERFORMED: ,1. Pelvic laparotomy.,2. Lysis of pelvic adhesions.,3. Left salpingooophorectomy with insertion of Pain-Buster Pain Management System by Dr. X.,GROSS FINDINGS: ...
Surgery
PREOPERATIVE DIAGNOSIS:, Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSIS: , Protein-calorie malnutrition.,PROCEDURE PERFORMED:, Percutaneous endoscopic gastrostomy (PEG) tube.,ANESTHESIA: , Conscious sedation per Anesthesia.,SPECIMEN: , None.,COMPLICATIONS: , None.,HISTORY: ,The patient is a 73-year-old male wh...
Surgery
TITLE OF OPERATION:,1. Pars plana vitrectomy.,2. Pars plana lensectomy.,3. Exploration of exit wound.,4. Closure of perforating corneal scleral laceration involving uveal tissue.,5. Air-fluid exchange.,6. C3F8 gas.,7. Scleral buckling, right eye.,INDICATION FOR SURGERY: , The patient was hammering and a piece of...
Surgery
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....
Surgery
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-si...
Surgery
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 ...
Surgery
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...
Surgery
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 S...
Surgery
PREOPERATIVE DIAGNOSIS:, Right superior parathyroid adenoma.,POSTOPERATIVE DIAGNOSIS:, Right superior parathyroid adenoma.,PROCEDURE: , Excision of right superior parathyroid adenoma.,ANESTHESIA:, Local with 1% Xylocaine and anesthesia standby with sedation.,CLINICAL HISTORY:, This 80-year-old woman has had some mi...
Surgery
PREOPERATIVE DIAGNOSIS: , Abdominal mass.,POSTOPERATIVE DIAGNOSIS: , Abdominal mass.,PROCEDURE:, Paracentesis.,DESCRIPTION OF PROCEDURE: ,This 64-year-old female has stage II endometrial carcinoma, which had been resected before and treated with chemotherapy and radiation. At the present time, the patient is under r...
Surgery
EXAM:, Ultrasound-guided paracentesis,HISTORY: , Ascites.,TECHNIQUE AND FINDINGS: ,Informed consent was obtained from the patient after the risks and benefits of the procedure were thoroughly explained. Ultrasound demonstrates free fluid in the abdomen. The area of interest was localized with ultrasonography. The ...
Surgery
PREOPERATIVE DIAGNOSIS: , Phimosis.,POSTOPERATIVE DIAGNOSIS: , Phimosis.,PROCEDURE: , Reduction of paraphimosis.,ANESTHESIA: ,General inhalation anesthetic with 0.25% Marcaine, penile block and ring block about 20 mL given.,FLUIDS RECEIVED: , 100 mL.,SPECIMENS:, No tissues sent to pathology.,COUNTS: , Sponge and need...
Surgery
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 w...
Surgery
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 subcla...
Surgery
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 ventric...
Surgery
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. Ve...
Surgery
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 fluor...
Surgery
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 ha...
Surgery
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. Bena...
Surgery
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 ...
Surgery
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:...
Surgery