Hardware removal, right 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.,

both-bone forearm fracture
forearm
hardware
hardware removal
retained hardware
surgery
ulnar


Chest pain and non-Q-wave MI with elevation of troponin I only. Left heart catheterization, left ventriculography, and left and right coronary arteriography.

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.

angiograms
arteriography
coronary arteriography
heart catheterization
surgery
ventriculography


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.

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.


Pyogenic granuloma, left lateral thigh. Excision of recurrent pyogenic granuloma.

PREOPERATIVE DIAGNOSIS: , Pyogenic granuloma, left lateral thigh.,POSTOPERATIVE DIAGNOSIS: , Pyogenic granuloma, left lateral thigh.,ANESTHESIA:, General.,PROCEDURE: , Excision of recurrent pyogenic granuloma.,INDICATIONS: , The patient is 12-year-old young lady, who has a hand-sized congenital vascular malformation on her left lateral thigh below the greater trochanter, which was described by her parents as a birthmark. This congenital cutaneous vascular malformation faded substantially over the first years of her life and has regressed to a flat, slightly hyperpigmented lesion. Although no isolated injury event can be recalled, the patient has developed a pyogenic granuloma next to the distal portion of this lesion on her mid thigh, and it has been treated with topical cautery in her primary care doctor's office, but with recurrence. She is here today for excision.,OPERATIVE FINDINGS: , The patient had what appeared to be a classic pyogenic granuloma arising from this involuted vascular malformation.,DESCRIPTION OF OPERATION: ,The patient came to the operating room, had an uneventful induction of general anesthesia. We conducted a surgical time-out, reiterated her important and unique identifying information and confirmed that the excision of the left thigh pyogenic granuloma was the procedure planned for today. Preparation and draping was __________ ensued with a chlorhexidine based prep solution. The pyogenic granuloma was approximately 6 to 7 mm in greatest dimension and to remove it required creating an elliptical incision of about 1 to 1.2 cm. This entire area was infiltrated with 0.25% Marcaine with dilute epinephrine to provide a wide local field block and then an elliptical incision was made with a #15 scalpel blade, excising the pyogenic granuloma, its base, and a small rim of surrounding normal skin. Some of the abnormal vessels in the dermal and subdermal layer were cauterized with the needle-tip electrocautery pencil. The wound was closed in layers with a deep dermal roll of 5-0 Monocryl stitches supplemented by 5-0 intradermal Monocryl and Steri-Strips for final skin closure. The patient tolerated the procedure well. This nodule was submitted to pathology for confirmation of its histology as a pyogenic granuloma. Blood loss was less than 5 mL and there were no complications.

granuloma
malformation
pyogenic
pyogenic granuloma
surgery
thigh
trochanter
vascular
vascular malformation


PREOPERATIVE DIAGNOSIS:, Neurologic devastation secondary to nonaccidental trauma.,POSTOPERATIVE DIAGNOSES: , Neurologic devastation secondary to nonaccidental trauma.,PROCEDURE: , Laparoscopic G-tube placement (14-French 1.2-cm MIC-Key).,INDICATIONS FOR PROCEDURE: , This patient is a 5-month-old baby boy who presented unfortunately because of nonaccidental trauma. The patient suffered neurologic devastation. In order to facilitate enteral feedings, the plan is to place a G-tube as the patient cannot take by mouth. Consent was obtained by court order as the patient is a ward of the state.,DESCRIPTION OF PROCEDURE: ,The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia. The patient's abdomen was prepped and draped in the usual sterile fashion. An incision was made through the umbilicus. Peritoneal cavity entered bluntly. A 5-mm trocar was introduced. Abdomen was insufflated with a 5-mm scope. No obvious pathology noted. We visualized the stomach. We chose the spot in the left upper quadrant for future G-tube site. I made a small incision on the skin there, put another 5-mm trocar at that site. Using a Babcock, we grasped the stomach along the greater curvature site for further G-tube. I pulled a knuckle of stomach through the incision and secured with 4-0 Vicryl. I then used 3-0 Prolene sutures as tacking sutures on either side of the future G-tube site taking full-thickness abdominal wall through stomach and back out the abdominal wall. I then pulled the knuckle of stomach back up through the incision, made a gastrotomy, and then put a 4-0 pursestring around the gastrotomy site, introduced the 14, 1.2- cm MIC-Key into the stomach. The gastrotomy site insufflated with 5 mL of saline. We then tied down the pursestring. On the laparoscopy, the G-tube looked to be in good position. I insufflated the stomach through the G-tube, which I did and removed air subsequently. I then placed 2 x 2 underneath the G-tube and tied down tacking sutures around the G-tube itself, placed the G-tube to gravity, desufflated the abdomen, closed the umbilical port site fascia with 3-0 Vicryl, closed skin with 5-0 Monocryl, and dressed with bacitracin, 2 x 2, and Steri-Strips. The patient was extubated in the operating room and taken back to recovery room. The patient tolerated the procedure well.

abdominal wall
babcock
g-tube placement
g-tube site
gastrotomy
gastrotomy site
laparoscopic g-tube placement
mic key
mic-key
neurologic devastation
nonaccidental trauma
stomach
surgery
tube


Gastroscopy. A short-segment Barrett esophagus, hiatal hernia, and incidental fundic gland polyps in the gastric body; otherwise, normal upper endoscopy to the transverse duodenum.

PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSIS: , Gastroesophageal reflux disease.,POSTOPERATIVE DIAGNOSIS:, Barrett esophagus.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum to the transverse duodenum. The preparation was excellent and all surfaces were well seen. The hypopharynx appeared normal. The esophagus had a normal contour and normal mucosa throughout its distance, but at the distal end, there was a moderate-sized hiatal hernia noted. The GE junction was seen at 40 cm and the hiatus was noted at 44 cm from the incisors. Above the GE junction, there were three fingers of columnar epithelium extending cephalad, to a distance of about 2 cm. This appears to be consistent with Barrett esophagus. Multiple biopsies were taken from numerous areas in this region. There was no active ulceration or inflammation and no stricture. The hiatal hernia sac had normal mucosa except for one small erosion at the hiatus. The gastric body had normal mucosa throughout. Numerous small fundic gland polyps were noted, measuring 3 to 5 mm in size with an entirely benign appearance. Biopsies were taken from the antrum to rule out Helicobacter pylori. A retroflex view of the cardia and fundus confirmed the small hiatal hernia and demonstrated no additional lesions. The scope was passed through the pylorus, which was patent and normal. The mucosa throughout the duodenum in the first, second, and third portions was entirely normal. The scope was withdrawn and the patient was sent to the recovery room. He tolerated the procedure well.,FINAL DIAGNOSES:,1. A short-segment Barrett esophagus.,2. Hiatal hernia.,3. Incidental fundic gland polyps in the gastric body.,4. Otherwise, normal upper endoscopy to the transverse duodenum.,RECOMMENDATIONS:,1. Follow up biopsy report.,2. Continue PPI therapy.,3. Follow up with Dr. X as needed.,4. Surveillance endoscopy for Barrett in 3 years (if pathology confirms this diagnosis).

barrett
barrett esophagus
duodenum
endoscopy
esophagus
gastroesophageal reflux disease
gastroscope
gastroscopy
hernia
hiatal
hiatal hernia
olympus
surgery
transverse duodenum


Gangrene osteomyelitis, right second toe. The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The patient has history of previous right foot infection requiring first ray resection.

PREOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,POSTOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,OPERATIVE REPORT: ,The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The patient has history of previous right foot infection requiring first ray resection. The patient has ulcerations of right second toe dorsally at the proximal interphalangeal joint, which has failed to respond to conservative treatment. The patient now has exposed bone and osteomyelitis in the second toe. The patient has been on IV antibiotics as an outpatient and has failed to respond to these and presents today for surgical intervention.,After an IV was started by the Department of Anesthesia, the patient was taken back to the operating room and placed on the operative table in the supine position. A restraint belt was placed around the patient's waist using copious amounts of Webril and an ankle pneumatic tourniquet was placed around the patient's right ankle and the patient was made comfortable by the Department of Anesthesia. After adequate amounts of sedation had been given to the patient, we administered a block of 10 cc of 0.5% Marcaine plain in proximal digital block around the second digit. The foot and ankle were then prepped in the normal sterile orthopedic manner. The foot was elevated and an Esmarch bandage applied to exsanguinate the foot. The tourniquet was then inflated to 250 mmHg and the foot was brought back onto the table. Using Band-Aid scissors, the stockinet was cut and reflected and using a wet and dry sponge, the foot was wiped, cleaned, and the second toe identified.,Using a skin scrape, a racket type incision was planned around the second toe to allow also remodelling of previous operative site. Using a fresh #10 blade, skin incision was made circumferentially in the racket-shaped manner around the second digit. Then, using a fresh #15 blade, the incision was deepened and was taken down to the level of the second metatarsophalangeal joint. Care was taken to identify bleeders and cautery was used as necessary for hemostasis. After cleaning up all the soft tissue attachments, the second digit was disarticulated down to the level of the metatarsophalangeal joint. The head of the second metatarsal was inspected and was noted to have good glistening white cartilage with no areas of erosion evident by visual examination. Attention was then directed to closure of the wound. All remaining tissue was noted to be healthy and granular in appearance with no necrotic tissue evident. Areas of subcutaneous tissue were then removed through a sharp dissection in order to allow better approximation of the skin edges. Due to long-standing lower extremity lymphedema and postoperative changes on previous surgery, I thought that we were unable to close the incision in entirety. Therefore, after copious amounts of irrigation using sterile saline, it was determined to use modified dental rolls using #4-0 gauze to remove tension from the skin. Deep vertical mattress sutures were used in order to reapproximate more closely, the skin edges and bring the plantar flap of skin up to the dorsal skin. This was obtained using #2-0 nylon suture. Following this, the remaining exposed tissue from the wound was covered using moist to dry saline soaked 4 x 4 gauze. The wound was then dressed using 4 x 4 gauze fluffed with abdominal pads, then using Kling and Kerlix and an ACE bandage to provide compression. The tourniquet was deflated at 42 minutes' time and hemostasis was noted to be achieved. The ACE bandage was extended up to just below the knee and no bleeding striking to the bandages was appreciated. The patient tolerated the procedure well and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact, as was evidenced by capillary bleeding, which was present during the procedure. Sedation was given postoperative introductions, which include to remain nonweightbearing to her right foot. The patient was instructed to keep the foot elevated and to apply ice behind her knee as necessary, no more than 20 minutes each hour. The patient was instructed to continue her regular medications. The patient was to continue IV antibiotic course and was given prescription for Vicoprofen to be taken q.4h. p.r.n. for moderate to severe pain #30. The patient will followup with Podiatry on Monday morning at 8:30 in the Podiatry Clinic for dressing change and evaluation of her foot at that time.,The patient was instructed as to signs and symptoms of infection, was instructed to return to the Emergency Department immediately if these should present. The second digit was sent to Pathology for gross and micro.

ace bandage
digital
dorsally
foot
foot infection
gangrene
gangrene osteomyelitis
infection
metatarsophalangeal joint
ray resection
surgery
toe
ulcerations


Esophagitis, minor stricture at the gastroesophageal junction, hiatal hernia. Otherwise normal upper endoscopy to the transverse duodenum.

PREOPERATIVE DIAGNOSES: , Dysphagia and esophageal spasm.,POSTOPERATIVE DIAGNOSES: , Esophagitis and esophageal stricture.,PROCEDURE:, Gastroscopy.,MEDICATIONS:, MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum, to the third portion of the duodenum. The hypopharynx was normal and the upper esophageal sphincter was unremarkable. The esophageal contour was normal, with the gastroesophageal junction located at 38 cm from the incisors. At this point, there were several linear erosions and a sense of stricturing at 38 cm. Below this, there was a small hiatal hernia with the hiatus noted at 42 cm from the incisors. The mucosa within the hernia was normal. The gastric lumen was normal with normal mucosa throughout. The pylorus was patent permitting passage of the scope into the duodenum, which was normal through the third portion. During withdrawal of the scope, additional views were obtained of the cardia, confirming the presence of a small hiatal hernia. It was decided to attempt dilation of the strictured area, so an 18-mm TTS balloon was placed across the stricture and inflated to the recommended diameter. When the balloon was fully inflated, the lumen appeared to be larger than 18 mm diameter, suggesting that the stricture was in fact not a significant one. No stretching of the mucosa took place. The balloon was deflated and the scope was withdrawn. The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Esophagitis.,2. Minor stricture at the gastroesophageal junction.,3. Hiatal hernia.,4. Otherwise normal upper endoscopy to the transverse duodenum.,RECOMMENDATIONS: ,Continue proton pump inhibitor therapy.

duodenum
endoscopy
esophageal
esophagitis
esophagus
gastroesophageal
gastroesophageal junction
gastroscope
gastroscopy
hernia
hiatal
hiatal hernia
stomach
surgery
transverse duodenum
upper endoscopy


Gastrostomy, a 6-week-old with feeding disorder and Down syndrome.

PREOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,POSTOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,OPERATION PERFORMED: , Gastrostomy.,ANESTHESIA: , General.,INDICATIONS: ,This 6-week-old female infant had been transferred to Children's Hospital because of Down syndrome and congenital heart disease. She has not been able to feed well and in fact has to now be NG tube fed. Her swallowing mechanism does not appear to be very functional, and therefore, it was felt that in order to aid in her home care that she would be better served with a gastrostomy.,OPERATIVE PROCEDURE: ,After the induction of general anesthetic, the abdomen was prepped and draped in usual manner. Transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection. The muscle was divided and the peritoneal cavity entered. The greater curvature of the stomach was grasped with a Babcock clamp and brought into the operative field. The site for gastrostomy was selected and a pursestring suture of #4-0 Nurolon placed in the gastric wall. A 14-French 0.8 cm Mic-Key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube. Following this, the stomach was returned to the abdominal cavity and the posterior fascia was closed using a #4-0 Nurolon affixing the stomach to the posterior fascia. The anterior fascia was then closed with #3-0 Vicryl, subcutaneous tissue with the same, and the skin closed with #5-0 subcuticular Monocryl. The balloon was inflated to the full 5 mL. A sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition.,

congenital heart disease
down syndrome
fascia
feeding disorder
gastrostomy
mic-key tubeless
nurolon
stomach
subcutaneous tissue
surgery
syndrome


OPERATION PERFORMED:, Full mouth dental rehabilitation in the operative room under general anesthesia.,PREOPERATIVE DIAGNOSIS: , Severe dental caries.,POSTOPERATIVE DIAGNOSES:,1. Severe dental caries.,2. Non-restorable teeth.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY: , 43 minutes.,BRIEF HISTORY: ,The patient was first seen by me on 04/26/2007. She had a history of open heart surgery at 11 months' of age. She presented with severe anterior caries with most likely dental extractions needed. Due to her young age, I felt that she would be best served in the safety of the hospital operating room. After consultation with the mother, she agreed to have her treated in the safety of the hospital operating room at Children's Hospital.,OPERATIVE PREPARATION: ,This child was brought to Hospital Day Surgery and is accompanied by her mother. There I met with them and discussed the needs of the child, types of restorations to be performed, the risks and benefits of the treatment as well as the options and alternatives of the treatment. After all their questions and concerns were addressed, I gave the informed consent to proceed with the treatment. The patient's history and physical examination was reviewed. Once she was cleared by Anesthesia and the child was taken back to the operating room.,OPERATIVE PROCEDURE: ,The patient was placed on the surgical table in the usual supine position with all extremities protected. Anesthesia was induced by mask. The patient was then intubated with a nasal endotracheal tube and the tube was stabilized. The head was wrapped and the eyes were taped shut for protection. An angiocatheter was placed in the left hand and an IV was started. The head and neck were draped with sterile towels, and the body was covered with a lead apron and sterile sheath. A moist continuous throat pack was placed beyond the tonsillar pillars. Plastic lip and cheek retractors were then placed. Preoperative clinical photographs were taken. Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiography. After the radiographs were taken, the lead shield was removed. Prophylaxis was then performed using prophy cup and fluoridated prophy paste. The teeth were then rinsed well and the patient's oral cavity was suctioned clean. Clinical and radiographic examinations followed and areas of decay were noted. During the restorative phase, these areas of decay were entered into and removed. Entry was made to the level of the dental-enamel junction and beyond as necessary to remove it. Final caries was removed and was confirmed upon reaching hard, firm sounding dentin. Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement. Non-restorable primary teeth would be extracted.,Upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris. The original treatment plan was verified with the actual treatment provided. Postoperative clinical photographs were then taken. The continuous gauze throat pack was removed with continuous suction with visualization. Topical fluoride was then placed on the teeth.,At the end of the procedure, the child was undraped, extubated, and awakened in the operating room and taken to the recovery room breathing spontaneously with stable vital signs.,FINDINGS: ,This young patient presented with mild generalized marginal gingivitis secondary to light generalized plaque accumulation and fair oral hygiene. All primary teeth were present. Dental caries were present on the following teeth: Tooth D, E, F, and G caries on all surfaces; teeth J, lingual caries. The remainder of her teeth and soft tissues were within normal limits. The following restorations and procedures were performed: Tooth D, E, F, and G were extracted and four sutures were placed one at each extraction site and tooth J lingual amalgam.,CONCLUSION: ,The mother was informed of the completion of the procedure. She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care. They will contact to my office in the event of immediate postoperative complications. After full recovery, she was discharged from the recovery room in the care of her mother.

amalgam
anesthesia
dental
dental caries
dental extractions
dental rehabilitation
full mouth
full mouth dental rehabilitation
mouth
non-restorable teeth
oral
oral cavity
primary teeth
prophylaxis
rehabilitation
restorative phase
surgery
throat pack
tooth


Excision of ganglion of the left wrist. A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.

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.

curved incision
dorsal
excision
ganglion
superficial vessels
surgery
tourniquet
wrist


OPERATION PERFORMED:, Full mouth dental rehabilitation in the operating room under general anesthesia.,PREOPERATIVE DIAGNOSES: ,1. Severe dental caries.,2. Hemophilia.,POSTOPERATIVE DIAGNOSES: ,1. Severe dental caries.,2. Hemophilia.,3. Nonrestorable teeth.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY: ,1 hour and 22 minutes.,BRIEF HISTORY: ,The patient was first seen by me on 08/23/2007, who is 4-year-old with hemophilia, who received infusion on Tuesdays and Thursdays and he has a MediPort. Mom reported history of high fever after surgery and he has one seizure previously. He has history of trauma to his front teeth and physician put him on antibiotics. He was only cooperative for having me do a visual examination on his anterior teeth. Visual examination revealed severe dental caries and dental abscess from tooth #E and his maxillary anterior teeth needed to be extracted. Due to his young age and hemophilia, I felt that he would be best served to be taken to the hospital operating room.,OTHER PREPARATION: ,The child was brought to the Hospital Day Surgery accompanied by his mother. There, I met with her and discussed the needs of the child, types of restoration to be performed, and the risks, and benefits of the treatment as well as the options and alternatives of the treatment. After all her questions and concerns were addressed, she gave her informed consent to proceed with treatment. The patient's history and physical examination was reviewed. He was given factor for appropriately for his hemophilia prior to being taken back to the operating room. Once he was cleared by Anesthesia, the child was taken back to the operating room.,OPERATIVE PROCEDURE: ,The patient was placed on the surgical table in the usual supine position with all extremities protected. Anesthesia was induced by mask. The patient was then intubated with an oral tube and the tube was stabilized. The head was wrapped and IV was started. The head and neck were draped with sterile towels and the body was covered with a lead apron and sterile sheath. A moist continuous throat pack was placed beyond tonsillar pillars. Plastic lip and cheek retractors were then placed. Preoperative clinical photographs were taken. Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiograph. After the radiographs were taken, the lead shield was removed.,Prophylaxis was then performed using a prophy cup and fluoridated prophy paste. The patient's teeth were rinsed well. The patient's oral cavity was suctioned clean. Clinical and radiographic examination followed and areas of decay were noted. During the restorative phase, these areas of decay were incidentally removed. Entry was made to the level of the dental-enamel junction and beyond as necessary to remove it. Final caries removal was confirmed upon reaching hard, firm and sound dentin.,Teeth restored with composite ___________ bonded with a one-step bonding agent. Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement. Non-restorable primary teeth would be extracted. The caries were extensive and invaded the pulp tissues, pulp therapy was initiated using ViscoStat and then IRM pulpotomies. Teeth treated in such a manner would then be crowned with stainless steel crowns.,Upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris. The original treatment plan was verified with the actual treatment provided. Postoperative clinical photographs were then taken. The continuous gauze throat pack was removed with continuous suction with visualization. Topical fluoride was then placed on the teeth. At the end of the procedure, the child was undraped, extubated, and awakened in the operating room, was taken to the recovery room, breathing spontaneously with stable vital signs.,FINDINGS: , This young patient presented with mild generalized marginal gingivitis, secondary to light generalized plaque accumulation and fair oral hygiene. All primary teeth were present. Dental carries were present on the following teeth: Tooth B, OL caries, tooth C, M, L, S caries, tooth B, caries on all surfaces, tooth E caries on all surfaces, tooth F caries on all surfaces, tooth T caries on all surfaces, tooth H, lingual and facial caries, tooth I, caries on all surfaces, tooth L caries on all surfaces, and tooth S, all caries. The remainder of his teeth and soft tissues were within normal limits. The following restoration and procedures were performed. Tooth B, OL amalgam, tooth C, M, L, S composite, tooth D, E, F, and G were extracted, tooth H, and L and separate F composite. Tooth I is stainless steel crown, tooth L pulpotomy and stainless steel crown and tooth S no amalgam. Sutures were also placed at extraction site D, E, S, and G.,CONCLUSION: ,The mother was informed of the completion of the procedure. She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care. She is to contact to myself with an event of immediate postoperative complications and after full recovery, he was discharged from recovery room in the care of his mother. She was also given prescription for Tylenol with Codeine Elixir for postoperative pain control.,


Dysphagia, possible stricture. Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.

PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSES: , Dysphagia, possible stricture.,POSTOPERATIVE DIAGNOSIS: , Gastroparesis.,MEDICATION: , MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus, stomach, and duodenum. The hypopharynx was normal. The esophagus had a normal upper esophageal sphincter, normal contour throughout, and a normal gastroesophageal junction viewed at 39 cm from the incisors. There was no evidence of stricturing or extrinsic narrowing from her previous hiatal hernia repair. There was no sign of reflux esophagitis. On entering the gastric lumen, a large bezoar of undigested food was seen occupying much of the gastric fundus and body. It had 2 to 3 mm diameter. This was broken up using a scope into smaller pieces. There was no retained gastric liquid. The antrum appeared normal and the pylorus was patent. The scope passed easily into the duodenum, which was normal through the second portion. On withdrawal of the scope, additional views of the cardia were obtained, and there was no evidence of any tumor or narrowing. The scope was withdrawn. The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Normal postoperative hernia repair.,2. Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.,3. Otherwise normal upper endoscopy to the descending duodenum.,RECOMMENDATIONS:,1. Continue proton pump inhibitors.,2. Use Reglan 10 mg three to four times a day.


Gastroscopy. Dysphagia and globus. No evidence of inflammation or narrowing to explain her symptoms.

PROCEDURE:, Gastroscopy.,PREOPERATIVE DIAGNOSIS:, Dysphagia and globus.,POSTOPERATIVE DIAGNOSIS: , Normal.,MEDICATIONS:, MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced through the oropharynx and passed carefully through the esophagus and stomach, and then through the gastrojejunal anastomosis into the efferent jejunal loop. The preparation was good and all surfaces were well seen. The hypopharynx was normal with no evidence of inflammation. The esophagus had a normal contour and normal mucosa throughout with no sign of stricturing or inflammation or exudate. The GE junction was located at 39 cm from the incisors and appeared normal with no evidence of reflux, damage, or Barrett's. Below this there was a small gastric pouch measuring 6 cm with intact mucosa and no retained food. The gastrojejunal anastomosis was patent measuring about 12 mm, with no inflammation or ulceration. Beyond this there was a side-to-side gastrojejunal anastomosis with a short afferent blind end and a normal efferent end with no sign of obstruction or inflammation. The scope was withdrawn and the patient was sent to recovery room. She tolerated the procedure well.,FINAL DIAGNOSES:,1. Normal post-gastric bypass anatomy.,2. No evidence of inflammation or narrowing to explain her symptoms.

dysphagia
esophagus
gastric
gastric pouch
gastrojejunal
gastrojejunal anastomosis
gastroscopy
globus
inflammation
mucosa
olympus gastroscope
surgery


PREOPERATIVE DIAGNOSIS: , Prostate cancer.,POSTOPERATIVE DIAGNOSIS: , Prostate cancer.,OPERATION: , Cystoscopy and removal of foreign objects from the urethra.,BRACHYTHERAPY:, Iodine 125.,ANESTHESIA: , General endotracheal. The patient was given Levaquin 500 mg IV preoperatively.,Total seeds were 59. Activity of 0.439, 30 seeds in the periphery with 10 needles and total of 8 seeds at the anterior of the fold, 4 needles. Please note that the total needles placed on the top were actually 38 seeds and 22 seeds were returned back.,BRIEF HISTORY: , This is a 72-year-old male who presented to us with elevated PSA and prostate biopsy with Gleason 6 cancer on the right apex. Options such as watchful waiting, brachytherapy, radical prostatectomy, cryotherapy, and external beam radiation were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, incontinence, erectile dysfunction, urethral stricture, dysuria, burning pain, hematuria, future procedures, and failure of the procedure were all discussed. The patient understood all the risks, benefits, and options and wanted to proceed with the procedure. The patient wanted to wait until he came back from his summer vacations, so a one dose of Zoladex was given. Prostate size measured about 15 g in the OR and about 22 g about two months ago. Consent was obtained.,DETAILS OF THE OPERATION: ,The patient was brought to the OR and anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient had a Foley catheter placed sterilely. The scrotum was taped up using Ioban. Transrectal ultrasound was done. The prostate was measured 15 g. Multiple images were taken. A volume study was done. This was given to the physicist, Dr. X was present who is radiation oncologist who helped with implanting of the seeds. Total of 38 seeds were placed in the patient with 10 peripheral needles and then 4 internal needles. Total of 30 seeds were placed in the periphery and total of 8 seeds were placed in the inside. They were done directly under transrectal ultrasound vision. The seeds were placed directly under ultrasound guidance. There was a nice distribution of the seeds. A couple of more seeds were placed on the right side due to the location of the prostate cancer. Subsequently at the end of the procedure, fluoroscopy was done. Couple of images were obtained. Cystoscopy was done at the end of the procedure where a seed was visualized right in the urethra, which was grasped and pulled out using grasper, which was difficult to get the seed off of the spacers, which was actually pulled out. There were no further seeds visualized in the bladder. The bladder appeared normal. At the end of the procedure, a Foley catheter was kept in place of 18 French and the patient was brought to recovery in stable condition.

cystoscopy
endotracheal
foley catheter
foreign objects
prostate
prostate cancer
surgery
transrectal ultrasound
ultrasound
urethra


Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma. Acute subdural hematoma, right, with herniation syndrome.

PREOPERATIVE DIAGNOSES: , Acute subdural hematoma, right, with herniation syndrome.,POSTOPERATIVE DIAGNOSES: , Acute subdural hematoma, right, with herniation syndrome.,OPERATION PERFORMED: ,Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma.,ANESTHESIA: , General endotracheal.,PREPARATION: , Povidone.,INDICATION:, This is an 83-year-old male with herniation syndrome with large subdural hematoma 100%. This procedure is being done as an emergency procedure in an attempt to save his life and maximize the potential for recovery.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room intubated. The patient previously was given fresh frozen plasma plus recombinant activated factor VII. The patient had a roll placed on his right shoulder, head was maintained three point fixation with a Mayfield headholder. The right side of the head was shaved, thoroughly prepped and draped, a large ? scalp incision was marked, infiltrated with local and incised with a scalpel, Raney clips were applied to the scalp margins, hemostasis, temporalis muscle and fascia, pericranium opened and aligned with incision, flap was reflected anteriorly. Burr holes are placed low in the temporal bone at the keyhole posteriorly and then superiorly with a perforator, then using Midas Rex drill with a B1 foot plate a free flap was turned. The dura was opened in a cruciate fashion, acute subdural hematoma was evacuated. There was a small arterial bleeder in the anterior parietal region, which was controlled with bipolar electrocautery. Using suction and biopsy forceps, acute clot was resected from the frontotemporoparietal and occipital poles, subdural space was irrigated, no further bleeders were encountered. Dura was closed with 4-0 Nurolon. A subdural Camino ICP catheter was placed in the subdural space. Bone flaps secured in place with neuro clips with 5 mm screws, central pack up suture was placed, dural tack up sutures were placed using 4-0 Nurolon prior to placement of the bone flap. The wound was irrigated with saline, temporalis muscle and fascia closed with 2-0 Vicryl, subgaleal Hemovac was placed, galea was closed with 2-0 Vicryl, and scalp with staples. ICP monitor and the Hemovac were sutured in place with 2-0 Vicryl. The patient was taken out of the head holder, a sterile dressing placed. The head was wrapped. The patient was taken directly to ICU, still intubated in guarded condition. Brain was nicely soft and pulsatile. At the termination of the procedure, no significant contusion of the brain was identified. Final sponge and needle counts are correct. Estimated blood loss 400 cc.

craniotomy
frontotemporoparietal
hematoma
herniation
subdural
subdural hematoma
surgery
temporalis


Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot.

S -, An 84-year-old diabetic female, 5'7-1/2" tall, 148 pounds, history of hypertension and diabetes. She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot. She also has a left great toenail that is giving her problems as well.,O - ,Plantar to the left first metatarsal head is a very panful hyperkeratotic lesion that measures 1.1 cm in diameter. There is a second lesion plantar to the fifth plantarflex metatarsal head which also measures 1.1 cm in diameter. These lesions have become so painful that the patient is now having difficulty walking wearing shoes or even doing gardening. The first and fifth metatarsal heads are plantarflexed. Vibratory sensation appears to be absent. Dorsal pedal pulses are nonpalpable. Varicose veins are visible to the skin on the patient's feet that are very thin, almost transparent. The medial aspect of the left great toenail has dried blood under the nail. The nail itself is very opaque, loose from the nailbed almost rotten, opaque, discolored, hypertrophic. All of the patient's toenails are elongated and discolored and opaque as well. There is dried blood under the medial aspect of the left great toenail.,A - ,1. Painful feet.,

foot
hyperkeratotic lesion
lesions
metatarsal
metatarsal head
metatarsal heads
nail matrix
painful
painful left foot
plantar
surgery
toenail


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.

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.

ankle
ankle tourniquet
excision of foreign body
foot
foreign body
foreign body removal
plantar
plantar aspect
surgery
wound


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.

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.

abscess
cellulitis
debridement
foot
foreign body
irrigation
kerlix
metatarsal
purulent
purulent material
removal of foreign body
surgery


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

benign prostatic hyperplasia
cystoscopy
flexible cystoscopy
hematuria
lateral lobe obstruction
microscopic hematuria
obstruction
surgery
urethra


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.

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.

biopsy
bronchoalveolar
bronchoalveolar lavage
bronchoscope
bronchoscopy
cytology
endobronchial
endobronchial biopsy
fiberoptic bronchoscopy
flexible fiberoptic bronchoscopy
hemorrhage
lavage
lobe
microbiology
oropharynx
pulmonary hypertension
submucosal
surgery
tracheobronchitis
varicosities
vascular
venous engorgement


Removal of foreign body of right thigh. Foreign body of the right thigh, sewing needle.

PREPROCEDURE DIAGNOSIS:, Foreign body of the right thigh.,POSTOPERATIVE DIAGNOSIS: , Foreign body of the right thigh, sewing needle.,PROCEDURE: ,Removal of foreign body of right thigh.,HISTORY: ,This is a 71-year-old lady who has been referred because there is a mass in the right thigh. The patient comes with an ultrasound and apparently was diagnosed with a blood clot. On physical examination, blood pressure was 152/76 and temperature was 95.0. The patient is 5 feet 1 inch and weighs 170. On examination of her right thigh, there is a transverse area of ecchymosis in the upper third of the thigh. There is a palpation of a very sharp object just under the skin. The patient desires for this to be removed.,DESCRIPTION OF PROCEDURE: , After obtaining informed consent in our office, the area was prepped and draped in usual fashion. Xylocaine 1% was infiltrated in the end of the object that was the sharpest and a small incision was made there and then I pushed the foreign body through partially and then grabbed it with a hemostat and took it out and it was a 1-1/2-inch sewing needle.,Compression was applied for a few minutes and then a Band-Aid was applied.,The patient was given a tetanus toxoid 0.5 cc IM shot injection and then she was dismissed with instructions of return if inflammatory signs develop.

foreign body
removal of foreign body
sewing needle
surgery


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.

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.

carpi
fiberwire
flexor
flexor carpi radialis
kessler stitch
laceration
longus
palmaris
palmaris longus
radialis
repair
surgery


Flexible nasal laryngoscopy. Foreign body, left vallecula at the base of the tongue. Airway is patent and stable.

PREOPERATIVE DIAGNOSIS: ,Oropharyngeal foreign body.,POSTOPERATIVE DIAGNOSES:,1. Foreign body, left vallecula at the base of the tongue.,2. Airway is patent and stable.,PROCEDURE PERFORMED: , Flexible nasal laryngoscopy.,ANESTHESIA:, ______ with viscous lidocaine nasal spray.,INDICATIONS: , The patient is a 39-year-old Caucasian male who presented to ABCD General Hospital Emergency Department with acute onset of odynophagia and globus sensation. The patient stated his symptoms began around mid night after returning home _________ ingesting some chicken. The patient felt that he had ingested a chicken bone, tried to dislodge this with fluids and other solid foods as well as sticking his finger down his throat without success. The patient subsequently was seen in the Emergency Department where it was discovered that the patient had a left vallecular foreign body. Department of Otolaryngology was asked to consult for further evaluation and treatment of this foreign body.,PROCEDURE: , After verbal informed consent was obtained, the patient was placed in the upright position. The fiberoptic nasal laryngoscope was inserted in the patient's right naris and then the left naris. There was visualized some bilateral caudal spurring of the septum. The turbinates were within normal limits. There was some posterior nasoseptal deviation to the left. The nasal laryngoscope was then inserted back into the right naris and it was advanced along the floor of the nasal cavity. The nasal mucous membranes were pink and moist. There was no evidence of mass, ulceration, lesion, or obstruction.,The scope was further advanced to the level of the nasopharynx where the eustachian tubes were visualized bilaterally. There was evidence of some mild erythema in the right fossa Rosenmüller. There was no evidence of mass lesion or ulceration in this area, however. The eustachian tubes were patent without obstruction. The scope was further advanced to the level of the oropharynx where the base of the tongue, vallecula, and epiglottis were visualized. There was evidence of a 1.5 cm left vallecular white foreign body. The rest of the oropharynx was without abnormality. The epiglottis was within normal limits and was noted to be omega in shape. There was no edema or erythema to the epiglottis. The scope was then further advanced to the level of the hypopharynx to the level of the true vocal cords. There was no evidence of erythema or edema of the posterior commissure, arytenoid cartilage, or superior surface of the vocal cords. The laryngeal surface of the epiglottis was within normal limits. There was no evidence of mass lesion or nodularity of the vocal cords. The patient was asked to Valsalva and the piriform sinuses were observed without evidence of foreign body or mass lesion. The patient did have complete glottic closure upon phonation and the airway was patent and stable throughout the exam. The glottic aperture was completely patent with inspiration. The anterior commissure, epiglottic folds, false vocal cords, and piriform sinuses were all within normal limits. The scope was then removed without difficulty. The patient tolerated the procedure well and remained in stable condition.,FINDINGS:,1. A 1.5 cm white foreign body consistent with a chicken bone at the left vallecular region. There is no evidence of supraglottic or piriform sinuses foreign body.,2. Mild erythema of the right nasopharynx in the region of the fossa Rosenmüller. No mass is appreciated at this time.,PLAN:, The patient is to go to the operating room for direct laryngoscopy/microscopic suspension direct laryngoscopy for removal of foreign body under anesthesia this a.m. Airway precautions were instituted. The patient currently remained in stable condition.

epiglottis
erythema
flexible nasal laryngoscopy
foreign body
laryngoscopy
nasal
nasal spray
oropharyngeal
oropharyngeal foreign body
surgery
tongue


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.

arteriovenous
arteriovenous malformation
avm
conformality index
ct-guided
cyberknife
frameless stereotactic radiosurgery
malformation
occipital
occipital arteriovenous malformation
surgery


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.

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.

anastomosis
arteriovenous
bridge fistula
chronic renal failure
distal anastomosis
fogarty
fogarty thrombectomy
gore tex bridge
gore-tex bridge fistula
interposition
prolene
prolene suture
renal
renal failure
surgery
thrombectomy
thrombosed


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.

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.

biopsies
bronchoalveolar
bronchoscope
bronchoscopy
fiberoptic
flexible
flexible fiberoptic bronchoscopy
granulomatous
lavage
lobe
miliary tb
oropharynx
surgery
tb
tracheobronchitis
transbronchial


Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA. Normal cystoscopy with atrophic vaginitis.

PREOPERATIVE DIAGNOSIS:, Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA.,POSTOPERATIVE DIAGNOSIS: , Normal cystoscopy with atrophic vaginitis.,PROCEDURE PERFORMED: , Flexible cystoscopy.,FINDINGS:, Atrophic vaginitis.,PROCEDURE: ,The patient was brought in to the procedure suite, prepped and draped in the dorsal lithotomy position. The patient then had flexible scope placed through the urethral meatus and into the bladder. Bladder was systematically scanned noting no suspicious areas of erythema, tumor or foreign body. Significant atrophic vaginitis is noted.,IMPRESSION: , Atrophic vaginitis with overactive bladder with urge incontinence.,PLAN: , The patient will try VESIcare 5 mg with Estrace and follow up in approximately 4 weeks.

atrophic vaginitis
bladder infections
cystoscopy
flexible cystoscopy
frequency
incontinence
overactive bladder
surgery
urge incontinence
vaginitis
vesicare


Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.

PREOPERATIVE DIAGNOSES,1. Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2. Bilateral breast asymmetry.,3. Right breast macromastia.,4. Right abdominal scar deformity.,5. Left abdominal scar deformity.,6. A 1.3 cm lesion right inferior breast.,7. Lesion measuring 0.5 cm right inferior breast lateral.,POSTOPERATIVE DIAGNOSES,1. Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2. Bilateral breast asymmetry.,3. Right breast macromastia.,4. Right abdominal scar deformity.,5. Left abdominal scar deformity.,6. A 1.3 cm lesion right inferior breast.,7. Lesion measuring 0.5 cm right inferior breast lateral.,PROCEDURES,1. Left breast flap revision.,2. Right breast flap revision.,3. Right breast reduction mammoplasty.,4. Right nipple reconstruction.,5. Left abdominal scar deformity.,6. Right abdominal scar deformity.,7. Excision of right breast medial lesion enclosure.,8. Excision of right breast lateral lesion enclosure.,ANESTHESIA:, General.,COMPLICATIONS:, None.,DRAINS:, None.,SPECIMENS:, Right breast skin and lesions x2.,COMPLICATIONS:, None.,INDICATIONS:, This patient is a 54-year-old white female who presents for a revision of her previous bilateral breast reconstruction. The patient had asymmetry as well as right breast hypertrophy, and therefore, the procedures named above were indicated. The patient was informed about the possible risks and complications of the above procedures and gave an informed consent.,PROCEDURE:, The patient was brought to the operating room, placed supine on the operative table. After adequate endotracheal anesthesia was established and IV prophylactic antibiotics were given, the chest and abdomen were prepped and draped in standard surgical fashion.,Attention was first turned to the left breast where liposuction was performed laterally to allow for better contour and minimize the outer quadrant. The incision was made for this and was then closed with 5-0 Prolene interrupted suture.,Attention was then turned to the right breast where liposuction was also performed to reduce the medial superior and lateral quadrants. Once this was performed, the vertical reduction mammoplasty was outlined. Prior to that, the nipple reconstruction was performed with a keyhole pattern flap. The flap was elevated with 15-blade and hemostasis was then obtained with the Bovie. The flap was then sutured onto itself and secured with 5-0 Prolene interrupted sutures. Then the lateral and medial limbs were undermined to close the defect and this was performed with 3-0 Monocryl interrupted sutures. Subsequently, the reduction mastectomy skin was then excised sharply and passed up the table marked and sent to Pathology. ,Hemostasis was then obtained with the Bovie and then undermining was performed in the medial, superior, and lateral skin to allow for closure of the reduction incisions. Once this was performed, a 3-0 Monocryl interrupted sutures were used to close the inferior limb. Subsequently 2-0 PDS continuous suture was then placed in the periareolar area to close the defect, with a diameter that equaled the new nipple areolar complex. Once this was performed, the remaining incision was then closed with 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures. Subsequently, the 2 lesions were excised, the larger one which was medial and the lateral one that was smaller that were excised sharply, passed up the table and sent to Pathology. They were closed in 2 layers using 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the abdominal scars where liposuction and tumescent solution of diluted epinephrine were used to minimize the amount of excision that was required. Subsequently the extra skin was excised sharply in an elliptical fashion on the right side measuring approximately 10 x 3 cm, this was the superior and inferior skin, was when undermined and closure was performed after hemostasis was obtained with 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the contralateral left side where there was a larger defect. There was a larger excision required measuring approximately 15 x 3 cm. The superior and inferior edges of skin were undermined and closed primarily using 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures. Steri-Strips were placed on all incisions followed by surgical bra.,The patient tolerated the procedure well and was extubated without complications and transferred to the recovery room in stable condition. All instruments, needle counts, and sponges were correct at the end of the case.


Flexible sigmoidoscopy. The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.

PROCEDURE IN DETAIL: , Following a barium enema prep and lidocaine ointment to the rectal vault, perirectal inspection and rectal exam were normal. The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon. Withdrawal notes an otherwise normal descending, rectosigmoid and rectum. Retroflexion noted no abnormality of the internal ring. No hemorrhoids were noted. Withdrawal from the patient terminated the procedure.

: 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.


Flexible bronchoscopy to evaluate the airway (chronic wheezing).

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.

airway
arytenoids
bronchomalacia
bronchoscopy
chronic wheezing
endoscopy suite
epiglottis
flexible bronchoscopy
lobe
mainstem
subglottic
surgery
tracheal
vocal cords
wheezing


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.

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.

atrovent
bronchoscope
bronchoscopy
brushings
carcinomatosis
chronic obstructive pulmonary disease
endobronchial
endobronchial mucosal biopsies
fiberoptic
fiberoptic flexible bronchoscopy
hemoptysis
lavage
mucosal
oropharynx
surgery
topical