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INDICATIONS: , This is a 55-year-old female who is having a colonoscopy to screen for colon cancer. There is no family history of colon cancer and there has been no blood in the stool.,PROCEDURE PERFORMED: ,Colonoscopy.,PREP: , Fentanyl 100 mcg IV and 3 mg Versed IV.,PROCEDURE:, The tip of the endoscope was introduc...
Surgery
PREOPERATIVE DIAGNOSIS:, Prior history of polyps.,POSTOPERATIVE DIAGNOSIS:, Small polyps, no evidence of residual or recurrent polyp in the cecum.,PREMEDICATIONS: , Versed 5 mg, Demerol 100 mg IV.,REPORTED PROCEDURE:, The rectal chamber revealed no external lesions. Prostate was normal in size and consistency.,The ...
Surgery
PREOPERATIVE DIAGNOSIS:, History of colitis.,POSTOPERATIVE DIAGNOSIS: , Small left colon polyp.,PROCEDURE PERFORMED: , Total colonoscopy and polypectomy.,ANESTHESIA:, IV Versed 8 mg and 175 mcg of IV fentanyl.,CLINICAL HISTORY: , This patient had a tough time with colitis 10 years ago and has intermittent problems wi...
Surgery
PROCEDURE: , Colonoscopy.,INDICATIONS: , Hematochezia, Personal history of colonic polyps.,MEDICATIONS:, Midazolam 2 mg IV, Fentanyl 100 mcg IV,PROCEDURE:, A History and Physical has been performed, and patient medication allergies have been reviewed. The patient's tolerance of previous anesthesia has been reviewed....
Surgery
PROCEDURES PERFORMED:, Colonoscopy.,INDICATIONS:, Renewed symptoms likely consistent with active flare of Inflammatory Bowel Disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy.,PROCEDURE: , Informed consent was obtained prior to the procedure with special attention to be...
Surgery
PREOPERATIVE DIAGNOSIS:, Diarrhea, suspected irritable bowel.,POSTOPERATIVE DIAGNOSIS:, Normal colonoscopy., PREMEDICATIONS: , Versed 5 mg, Demerol 75 mg IV.,REPORTED PROCEDURE:, The rectal exam revealed no external lesions. The prostate was normal in size and consistency.,The colonoscope was inserted into the cecu...
Surgery
PREOPERATIVE DIAGNOSIS:, Prior history of neoplastic polyps.,POSTOPERATIVE DIAGNOSIS:, Small rectal polyps/removed and fulgurated.,PREMEDICATIONS:, Prior to the colonoscopy, the patient complained of a sever headache and she was concerned that she might become ill. I asked the nurse to give her 25 mg of Demerol IV....
Surgery
OPERATIVE PROCEDURES: , Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy.,PREOPERATIVE DIAGNOSES:,1. Colon cancer screening.,2. Family history of colon polyps.,POSTOPERATIVE DIAGNOSES:,1. Multiple colon polyps (5).,2. Diverticulosis, sigmoid colon.,3. Internal hemorrho...
Surgery
PREOPERATIVE DIAGNOSIS: , Possible inflammatory bowel disease.,POSTOPERATIVE DIAGNOSIS: , Polyp of the sigmoid colon.,PROCEDURE PERFORMED: ,Total colonoscopy with photography and polypectomy.,GROSS FINDINGS: , The patient had a history of ischiorectal abscess. He has been evaluated now for inflammatory bowel disease....
Surgery
PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES:, The patient is a 56-year-old female. She was referred for a screening colonoscopy. The patient has bowel movements every other day. There is no blood in the stool, no abdominal pain. She has hypertension, dyslipidemia, and gastroesophageal reflux disease. She has...
Surgery
PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES: , Rectal bleeding and perirectal abscess.,POSTOPERATIVE DIAGNOSIS: , Perianal abscess.,MEDICATIONS:, MAC.,DESCRIPTION OF PROCEDURE: ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum an...
Surgery
PREOPERATIVE DIAGNOSIS: , Colon polyps.,POSTOPERATIVE DIAGNOSES:,1. Universal diverticulosis.,2. Nonsurgical internal hemorrhoids.,PROCEDURE PERFORMED:, Total colonoscopy with photos.,ANESTHESIA:, Demerol 100 mg IV with Versed 3 mg IV.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE: ,...
Surgery
PREOPERATIVE DIAGNOSIS: , History of polyps.,POSTOPERATIVE DIAGNOSES:,1. Normal colonoscopy, left colonic diverticular disease.,2. 3+ benign prostatic hypertrophy.,PROCEDURE PERFORMED: , Total colonoscopy and photography.,GROSS FINDINGS: , This is a 74-year-old white male here for recheck colonoscopy for a history of...
Surgery
PROCEDURE IN DETAIL: , Following instructions and completion of an oral colonoscopy prep, the patient, having been properly informed of, with signature consenting to total colonoscopy and indicated procedures, the patient received premedications of Vistaril 50 mg, Atropine 0.4 mg IM, and then intravenous medications of...
Surgery
PREOPERATIVE DIAGNOSIS: , Screening. ,POSTOPERATIVE DIAGNOSIS:, Tiny Polyps.,PROCEDURE PERFORMED: , Colonoscopy.,PROCEDURE: , The procedure, indications, and risks were explained to the patient, who understood and agreed. He was sedated with Versed 3 mg, Demerol 25 mg during the examination. ,A digital rectal exam...
Surgery
PREOPERATIVE DIAGNOSES:, Prior history of anemia, abdominal bloating.,POSTOPERATIVE DIAGNOSIS:, External hemorrhoids, otherwise unremarkable colonoscopy.,PREMEDICATIONS:, Versed 5 mg, Demerol 50 mg IV.,REPORT OF PROCEDURE:, Digital rectal exam revealed external hemorrhoids. The colonoscope was inserted into the re...
Surgery
MEDICATIONS:,1. Versed intravenously.,2. Demerol intravenously.,DESCRIPTION OF THE PROCEDURE: , After informed consent was obtained, the patient was placed in the left lateral decubitus position and sedated with the above medications. The Olympus video colonoscope was inserted through the anus and was advanced in re...
Surgery
INDICATION: , Iron deficiency anemia.,PROCEDURE: ,Colonoscopy with terminal ileum examination.,POSTOPERATIVE DIAGNOSIS:, Normal examination.,WITHDRAWAL TIME: , 15 minutes.,SCOPE: , CF-H180AL.,MEDICATIONS: , Fentanyl 100 mcg and versed 10 mg.,PROCEDURE DETAIL: ,Following the preprocedure patient assessment the proced...
Surgery
PREOPERATIVE DIAGNOSES: , Colon cancer screening and family history of polyps.,POSTOPERATIVE DIAGNOSIS:, Colonic polyps.,PROCEDURE:, Colonoscopy.,ANESTHESIA:, MAC,DESCRIPTION OF PROCEDURE: ,The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon into the ce...
Surgery
PROCEDURE:, Colonoscopy.,PREOPERATIVE DIAGNOSES: , Change in bowel habits and rectal prolapse.,POSTOPERATIVE DIAGNOSIS: , Normal colonoscopy.,PROCEDURE: ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve...
Surgery
PREPROCEDURE DIAGNOSIS: , History of colon polyps and partial colon resection, right colon.,POSTPROCEDURE DIAGNOSES: ,1. Normal operative site. ,2. Mild diverticulosis of the sigmoid colon. ,3. Hemorrhoids.,PROCEDURE: ,Total colonoscopy.,PROCEDURE IN DETAIL: ,The patient is a 60-year-old of Dr. ABC's being evaluat...
Surgery
PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,PROCEDURE: , Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.,ANESTHESIA: , Local infiltrate with IV sedation.,INDICATIONS FOR SURGERY: , The patient has had a longstanding h...
Surgery
HISTORY: , The patient is a 4-month-old who presented with respiratory distress and absent femoral pulses with subsequent evaluation including echocardiogram that demonstrated severe coarctation of the aorta with a peak gradient of 29 mmHg and associated dilated cardiomyopathy with fractional shortening of 16%. A bicu...
Surgery
PREOPERATIVE DIAGNOSIS: , Closed type-III supracondylar fracture, left distal humerus.,POSTOPERATIVE DIAGNOSES:,1. Closed type-III supracondylar fracture, left distal humerus.,2. Tethered brachial artery, left elbow.,PROCEDURE PERFORMED: , Closed reduction percutaneous pinning, left distal humerus.,SPECIFICATIONS: , ...
Surgery
INDICATION: , Rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.,PREMEDICATION: ,See procedure nurse NCS form.,PROCEDURE: ,
Surgery
PREOPERATIVE DIAGNOSIS: , Left upper extremity amputation.,POSTOPERATIVE DIAGNOSIS: , Left upper extremity amputation.,PROCEDURES:,1. Left abdominal flap 5 x 5 cm to left forearm.,2. Debridement of skin, subcutaneous tissue, muscle, and bone.,3. Closure of wounds, simple closure approximately 8 cm.,4. Placement of ...
Surgery
PREOPERATIVE DIAGNOSIS:, Iron deficiency anemia.,POSTOPERATIVE DIAGNOSIS:, Diverticulosis.,PROCEDURE:, Colonoscopy.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and th...
Surgery
PREOPERATIVE DIAGNOSIS:, Multiple complex lacerations of the periorbital area.,POSTOPERATIVE DIAGNOSIS:, Multiple complex lacerations of the periorbital area.,PROCEDURE PERFORMED:, Closure of multiple complex lacerations.,ANESTHESIA: , Local 1% with epinephrine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , None.,COM...
Surgery
PREOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,POSTOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,PROCEDURE PERFORMED: , Repair of bilateral cleft of the palate with vomer flaps.,ESTIMATED BLOOD LOSS: , 40 mL.,COMPLICATIONS: , None.,ANESTHESIA: , General ...
Surgery
PREOPERATIVE DIAGNOSES:,1. Trimalleolar ankle fracture.,2. Dislocation right ankle.,POSTOPERATIVE DIAGNOSES:,1. Trimalleolar ankle fracture.,2. Dislocation right ankle.,PROCEDURE PERFORMED: , Closed open reduction and internal fixation of right ankle.,ANESTHESIA: ,Spinal with sedation.,COMPLICATIONS: ,None.,ESTIM...
Surgery
CLEAR CORNEAL TEMPORAL INCISION (NO STITCHES),DESCRIPTION OF OPERATION: , Under satisfactory local anesthesia, the patient was appropriately prepped and draped. A lid speculum was placed in the fissure of the right eye.,The secondary incision was then made through clear cornea using 1-mm diamond keratome at surgeon's ...
Surgery
PREOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,INDICATIONS:, Mr. ABC is a 10-year-old boy who suffered a fall resulting in a right distal both-bone forearm fracture. Upon evaluation by Orthopedic Surgery team in the emergency depa...
Surgery
PREOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,PROCEDURE:, Closed reduction with splint application with use of image intensifier.,INDICATIONS: , Mr. ABC is an 11-year-old boy who sustained a fall on 07/26/2008. Evaluation in the em...
Surgery
PREOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,POSTOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,PROCEDURE: ,Closed reduction of mandible fracture with MMF.,ANESTHESIA: , General anesthesia via nasal endot...
Surgery
PROCEDURE: , Newborn circumcision.,INDICATIONS: , Parental preference.,ANESTHESIA:, Dorsal penile nerve block.,DESCRIPTION OF PROCEDURE:, The baby was prepared and draped in a sterile manner. Lidocaine 1% 4 mL without epinephrine was instilled into the base of the penis at 2 o'clock and 10 o'clock. The penile fores...
Surgery
PREOPERATIVE DIAGNOSIS: , Cleft soft palate.,POSTOPERATIVE DIAGNOSIS: , Cleft soft palate.,PROCEDURES:,1. Repair of cleft soft palate, CPT 42200.,2. Excise accessory ear tag, right ear.,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , The patient was placed supine on the operating room table. After anesthesia was ...
Surgery
PREOPERATIVE DIAGNOSES: , Phimosis and adhesions.,POSTOPERATIVE DIAGNOSES: ,Phimosis and adhesions.,PROCEDURES PERFORMED: , Circumcision and release of ventral chordee.,ANESTHESIA: ,Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid. The patient was given antibiotics preop.,BRIEF HISTORY: , This is a ...
Surgery
PROCEDURE:, Circumcision.,ANESTHESIA: , EMLA.,FINDINGS: , Normal penis. The foreskin was normal in appearance and measured 1.6 cm. There was no bleeding at the circumcision site.,PROCEDURE:, Patient was placed on the circumcision restraint board. EMLA had been applied approximately 90 minutes before. A time-out w...
Surgery
PROCEDURE: , Circumcision.,PRE-PROCEDURE DIAGNOSIS: , Normal male phallus.,POST-PROCEDURE DIAGNOSIS: , Normal male phallus.,ANESTHESIA: ,1% lidocaine without epinephrine.,INDICATIONS: , The risks and benefits of the procedure were discussed with the parents. The risks are infection, hemorrhage, and meatal stenosis. ...
Surgery
PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,DETAILS OF PROCEDURE: ,The child was placed in a Circumstraint board and restrained in the usual fashion. The area of the penis and scrotum were prepared with povidone iodine solution. The area was draped with sterile drapes,...
Surgery
PROCEDURES:,1. Release of ventral chordee.,2. Circumcision.,3. Repair of partial duplication of urethral meatus.,INDICATIONS: , The patient is an 11-month-old baby boy who presented for evaluation of a duplicated urethral meatus as well as ventral chordee and dorsal prepuce hooding. He is here electively for surgic...
Surgery
CIRCUMCISION,After informed consent was obtained the baby was placed on the circumcision tray. He was prepped in a sterile fashion times 3 with Betadine and then draped in a sterile fashion. Then 0.2 mL of 1% lidocaine was injected at 10 and 2 o'clock. A ring block was also done using another 0.3 mL of lidocaine. G...
Surgery
CIRCUMCISION - OLDER PERSON,OPERATIVE NOTE:, The patient was taken to the operating room and placed in the supine position on the operating table. General endotracheal anesthesia was administered. The patient was prepped and draped in the usual sterile fashion. A 4-0 silk suture is used as a stay-stitch of the glan...
Surgery
The patient tolerated the procedure well and was sent to the Recovery Room in stable condition.
Surgery
REASON FOR CATHETERIZATION:, ST-elevation myocardial infarction.,PROCEDURES UNDERTAKEN,1. Left coronary system cineangiography.,2. Right coronary system cineangiography.,3. Left ventriculogram.,4. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncom...
Surgery
PROCEDURES UNDERTAKEN,1. Left coronary system cineangiography.,2. Right coronary system cineangiography.,3. Cineangiography of SVG to OM.,4. Cineangiography of LIMA to LAD.,5. Left ventriculogram.,6. Aortogram.,7. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angi...
Surgery
PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,The child was placed in a Circumstraint board and restrained in the usual fashion. The area of the penis and scrotum were prepared with povidone iodine solution. The area was draped with sterile drapes, and the remainder of t...
Surgery
PREOPERATIVE DIAGNOSIS:, Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,PROCEDURE:, Placement of cholecystostomy tube under ultrasound guidance.,ANESTHESIA: , Xylocaine 1% With Epinephrine.,INDICATIONS: , Patient is a pleasant 75-year-old gentleman who is about one week sta...
Surgery
CIRCUMCISION - NEONATAL,PROCEDURE:,: The procedure, risks and benefits were explained to the patient's mom, and a consent form was signed. She is aware of the risk of bleeding, infection, meatal stenosis, excess or too little foreskin removed and the possible need for revision in the future. The infant was placed on...
Surgery
PREOPERATIVE DIAGNOSIS:, Phimosis.,POSTOPERATIVE DIAGNOSES:, Phimosis.,OPERATIONS:, Circumcision.,ANESTHESIA: , LMA.,EBL:, Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , This is a 3-year-old male, who was referred to us from Dr. X's office with phimosis. The patient had spraying of urine and ballooning of the fo...
Surgery
PREOPERATIVE DIAGNOSIS: ,Gallstone pancreatitis.,POSTOPERATIVE DIAGNOSIS: , Gallstone pancreatitis.,PROCEDURE PERFORMED: , Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal and local injectable Marcaine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Gallbladder.,COMPLICATIONS: ,None.,OPERATIVE FINDINGS: ...
Surgery
PREOPERATIVE DIAGNOSIS (ES):,1. Cholelithiasis.,2. Cholecystitis.,POSTOPERATIVE DIAGNOSIS (ES):,1. Acute perforated gangrenous cholecystitis.,2. Cholelithiasis.,PROCEDURE:,1. Attempted laparoscopic cholecystectomy.,2. Open cholecystectomy.,ANESTHESIA:, General endotracheal anesthesia.,COUNTS:, Correct.,COMPLICATIONS:, ...
Surgery
PROCEDURE:, Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.,INDICATION FOR THE PROCEDURE:, Patient with a history of chronic abdominal pain and CT showing evidence of chronic pancreatitis, with a recent upper endoscopy showing an abnormal-appearing ampulla.,MEDICATIONS:, General anesthesi...
Surgery
PREOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology.,POSTOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology with pathology pending.,PROCEDURE: ,Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruc...
Surgery
PREOPERATIVE DIAGNOSES:,1. Cholelithiasis.,2. Acute cholecystitis.,POSTOPERATIVE DIAGNOSES:,1. Acute on chronic cholecystitis.,2. Cholelithiasis.,PROCEDURE PERFORMED: , Laparoscopic cholecystectomy with cholangiogram.,ANESTHESIA: , General.,INDICATIONS: , This is a 38-year-old diabetic Hispanic female patient, with...
Surgery
PREOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,POSTOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,OPERATION: , Left chest tube placement.,IV SEDATION: , 5 mg of Versed total given under pulse ox monitoring, 1% lidocaine local infiltration.,PROCEDURE: , With the patie...
Surgery
PROCEDURE:, Delayed primary chest closure.,INDICATIONS: , The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation. Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected...
Surgery
PREOPERATIVE DIAGNOSIS:, Chest wall mass, left.,POSTOPERATIVE DIAGNOSIS: , Chest wall mass, left.,PROCEDURE:, Removal of chest wall mass.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was brought to the operating room where he underwent a general endotracheal anesthetic. The time-out ...
Surgery
PREOPERATIVE DIAGNOSES:,1. Right spontaneous pneumothorax secondary to barometric trauma.,2. Respiratory failure.,3. Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1. Right spontaneous pneumothorax secondary to barometric trauma.,2. Respiratory failure.,3. Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained....
Surgery
PREOPERATIVE DIAGNOSIS: , Right hemothorax.,POSTOPERATIVE DIAGNOSIS: , Right hemothorax.,PROCEDURE PERFORMED: , Insertion of a #32 French chest tube on the right hemithorax.,ANESTHESIA: , 1% Lidocaine and sedation.,INDICATIONS FOR PROCEDURE:, This is a 54-year-old female with a newly diagnosed carcinoma of the cervix....
Surgery
PREOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,POSTOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,PROCEDURE PERFORMED: ,Removal of bilateral #32-French chest tubes with closure of wound.,COMPLICATIONS:, None.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old African-American male who has been in the...
Surgery
PREOPERATIVE DIAGNOSES:,1. Term pregnancy.,2. Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1. Term pregnancy.,2. Desires permanent sterilization.,PROCEDURE:,1. Repeat low-transverse cesarean section.,2. Bilateral tubal ligation.,3. Extensive anterior abdominal wall/uterine/bladder adhesiolysis.,ANES...
Surgery
PREOPERATIVE DIAGNOSIS: , Severe tricompartmental osteoarthritis, left knee with varus deformity.,POSTOPERATIVE DIAGNOSIS:, Severe tricompartmental osteoarthritis, left knee with varus deformity.,PROCEDURE PERFORMED: ,Left total knee cemented arthroplasty.,ANESTHESIA: , Spinal with Duramorph.,ESTIMATED BLOOD LOSS: ,...
Surgery
PREOPERATIVE DIAGNOSIS:, Cecal polyp.,POSTOPERATIVE DIAGNOSIS: , Cecal polyp.,PROCEDURE: , Laparoscopic resection of cecal polyp.,COMPLICATIONS: , None., ,ANESTHESIA: ,General oral endotracheal intubation.,PROCEDURE:, After adequate general anesthesia was administered the patient's abdomen was prepped and draped ase...
Surgery
PREOPERATIVE DIAGNOSIS:, Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,POSTOPERATIVE DIAGNOSIS: , Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,PROCEDURES PERFORMED:,1. Left hip cemented hemiarthroplasty.,2. Biopsy of the tissue from the...
Surgery
PREOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,POSTOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,OPERATION:, Right subclavian triple lumen central line placement.,ANESTHESIA: , Local Xylocaine.,INDICATIONS FOR OPERATION: ,...
Surgery
INDICATIONS FOR PROCEDURES: , Impending open-heart surgery for atrial septectomy and bilateral bidirectional Glenn procedure.,The patient was already under general anesthesia in the operating room. Antibiotic prophylaxis with cephazolin and gentamicin were already given. A strict aseptic technique was used including ...
Surgery
PREOPERATIVE DIAGNOSES,1. Empyema thoracis.,2. Need for intravenous antibiotics.,POSTOPERATIVE DIAGNOSES,1. Empyema thoracis.,2. Need for intravenous antibiotics.,PROCEDURE:, Central line insertion.,DESCRIPTION OF PROCEDURE: , With the patient in his room, after obtaining the informed consent, his left deltopector...
Surgery
PREOPERATIVE DIAGNOSIS: , Epistaxis and chronic dysphonia.,POSTOPERATIVE DIAGNOSES:,1. Atrophic dry nasal mucosa.,2. Epistaxis.,3. Atrophic laryngeal changes secondary to inhaled steroid use.,PROCEDURE PERFORMED:,1. Cauterization of epistaxis, left nasal septum.,2. Fiberoptic nasal laryngoscopy.,ANESTHESIA: , Neo-...
Surgery
PROCEDURE PERFORMED: , Ultrasound-guided placement of multilumen central venous line, left femoral vein.,INDICATIONS:, Need for venous access in a patient on a ventilator and on multiple IV drugs.,CONSENT: , Consent obtained from patient's sister.,PREOPERATIVE MEDICATIONS: , Local anesthesia with 1% plain lidocaine.,P...
Surgery
PREOPERATIVE DIAGNOSIS: , Facial and neck skin ptosis. Cheek, neck, and jowl lipotosis. Facial rhytides.,POSTOPERATIVE DIAGNOSIS:, Same.,PROCEDURE: , Temporal cheek-neck facelift (CPT 15825). Submental suction assisted lipectomy (CPT 15876).,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , This patient is a 65-yea...
Surgery
PREOPERATIVE DIAGNOSIS:, Refractory priapism.,POSTOPERATIVE DIAGNOSIS:, Refractory priapism.,PROCEDURE PERFORMED: , Cavernosaphenous shunt.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: ,400 cc.,FLUIDS: , IV fluids 1600 crystalloids, one liter packed red blood cells.,INDICATIONS FOR PROCEDURE: ,This is a 34-year-old...
Surgery
NORMAL CATARACT SURGERY,PROCEDURE DETAILS: , The patient was taken to the operating room where the Rand-Stein anesthesia protocol was followed using alfentanil and Brevital. Topical tetracaine drops were applied. The operative eye was prepped and draped in the usual sterile fashion. A lid speculum was inserted.,Unde...
Surgery
PREOPERATIVE DIAGNOSIS: , Cataract, left eye.,POSTOPERATIVE DIAGNOSIS: ,Cataract, left eye.,PROCEDURE PERFORMED: ,Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE: , After the inductio...
Surgery
PREOPERATIVE DIAGNOSIS: , Cataract to right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract to right eye.,PROCEDURE PERFORMED: ,Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.,LENS IMPLANT USED: ,See below.,COMPLICATIONS: , Posterior capsular hole, vitreous prolapse....
Surgery
PREOPERATIVE DIAGNOSES:,1. Right carpal tunnel syndrome.,2. Right index finger and middle fingers tenosynovitis.,POSTOPERATIVE DIAGNOSES:,1. Right carpal tunnel syndrome.,2. Right index finger and middle fingers tenosynovitis.,PROCEDURES PERFORMED:,1. Right carpal tunnel release.,2. Right index and middle fingers...
Surgery
PREOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,POSTOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,PROCEDURES:, Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.,AN...
Surgery
PROCEDURE PERFORMED: , Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification.,ANESTHESIA:, Peribulbar.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrin...
Surgery
PROCEDURE PERFORMED:, Cataract extraction with lens implantation, right eye.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room. The patient was identified and the correct operative site was also identified. A retrobulbar block using 5 ml of 2% lidocaine without epinephrine was done after adeq...
Surgery
PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Left carpal tunnel syndrome.,OPERATIVE PROCEDURE PERFORMED:, Left carpal tunnel release.,FINDINGS:, Showed severe compression of the median nerve on the left at the wrist.,SPECIMENS: ,None.,FLUIDS:, 500 mL of crystalloids.,URINE OUTPU...
Surgery
PREOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE: ,Open carpal tunnel release.,COMPLICATIONS: ,None.,PROCEDURE IN DETAIL: ,After administering appropriate antibiotics and general anesthesia the Left upper extremity was prepped and draped in the u...
Surgery
PREOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE:, Right carpal tunnel release.,ANESTHESIA:, Bier block to the right hand.,TOTAL TOURNIQUET TIME: , 20 minutes.,COMPLICATIONS: , None.,DISPOSITION: , Stable to PACU.,ESTIMATED BLOOD LOSS: , Less th...
Surgery
PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE PERFORMED: , Right carpal tunnel release.,PROCEDURE NOTE: ,The right upper extremity was prepped and draped in the usual fashion. IV sedation was supplied by the anesthesiologist. A local block ...
Surgery
PREOPERATIVE DIAGNOSIS: ,Bilateral carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Bilateral carpal tunnel syndrome.,PROCEDURES:,1. Right open carpal tunnel release.,2. Cortisone injection, left carpal tunnel.,ANESTHESIA: , General LMA.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:, None.,INDICATIONS:, This p...
Surgery
PREOPERATIVE DIAGNOSIS: ,Carpal tunnel syndrome, bilateral.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome, bilateral.,ANESTHESIA:, General,NAME OF OPERATION: , Bilateral open carpal tunnel release.,FINDINGS AT OPERATION: , The patient had identical, very thick, transverse carpal ligaments, with dull synovium.,PRO...
Surgery
PREOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE: , Endoscopic carpal tunnel release.,ANESTHESIA: , MAC,PROCEDURE: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fas...
Surgery
PREOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome (354.0).,2. Left ulnar nerve entrapment at the elbow (354.2).,POSTOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome (354.0).,2. Left ulnar nerve entrapment at the elbow (354.2).,OPERATIONS PERFORMED:,1. Left carpal tunnel release (64721).,2. Left ulnar nerv...
Surgery
PREOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,PROCEDURE: , Endoscopic release of left transverse carpal ligament.,ANESTHESIA:, Monitored anesthesia care with regional anesthesia provided by surgeon. ,TOURNIQUET TIME: , 12 minutes.,OPERATIVE PROCEDURE IN DETAIL: ,...
Surgery
PREOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome.,2. Stenosing tenosynovitis of right middle finger (trigger finger).,POSTOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome.,2. Stenosing tenosynovitis of right middle finger (trigger finger).,PROCEDURES:,1. Endoscopic release of left transverse carpal ligame...
Surgery
PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,OPERATIVE PROCEDURE:,1. Left endoscopic carpal tunnel release.,2. Endotracheal fasciotomy.,ANESTHESIA:, General.,COMPLICATIONS: , None.,INDICATION: , The patient is a 62-year-old lady with the aforementione...
Surgery
PREOPERATIVE DIAGNOSIS:, Right common, internal and external carotid artery stenosis.,POSTOPERATIVE DIAGNOSIS:, Right common, internal and external carotid artery stenosis.,OPERATIONS,1. Right common carotid endarterectomy.,2. Right internal carotid endarterectomy.,3. Right external carotid endarterectomy.,4. Hem...
Surgery
PROCEDURE PERFORMED: , Carpal tunnel release.,INDICATIONS FOR SURGERY: , Nerve conduction study tests diagnostic of carpal tunnel syndrome. The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.,PROCEDURE: ,The patient was brought to the operating...
Surgery
PROCEDURE:, Carpal tunnel release with transverse carpal ligament reconstruction.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 ...
Surgery
PREOPERATIVE DIAGNOSES:,1. Right carotid stenosis.,2. Prior cerebrovascular accident.,POSTOPERATIVE DIAGNOSES:,1. Right carotid stenosis.,2. Prior cerebrovascular accident.,PROCEDURE PERFORMED: ,Right carotid endarterectomy with patch angioplasty.,ESTIMATED BLOOD LOSS: ,250 cc.,OPERATIVE FINDINGS: , The common an...
Surgery
PROCEDURE: ,Direct-current cardioversion.,BRIEF HISTORY: ,This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years. He had a wide area of circumferential ablation done on November 9th for atrial fibrillation. He did develop recurrent atrial fibrillation the day before yesterday and...
Surgery
REASON FOR EXAM: , Atrial flutter/cardioversion.,PROCEDURE IN DETAIL: , The procedure was explained to the patient with risks and benefits. The patient agreed and signed the consent form. The patient received sedation prior to the cardioversion with a transesophageal echo as dictated earlier with a total of 50 mcg of...
Surgery
PROCEDURE: , Direct current cardioversion.,REASON FOR PROCEDURE: , Atrial fibrillation.,PROCEDURE IN DETAIL: ,The procedure was explained to the patient with risks and benefits including risk of stroke. The patient understands as well as her husband. The patient had already a transesophageal echocardiogram showing n...
Surgery
PREOPERATIVE DIAGNOSIS:, Critical left carotid stenosis.,POSTOPERATIVE DIAGNOSIS: , Critical left carotid stenosis.,PROCEDURE PERFORMED:, Left carotid endarterectomy with endovascular patch angioplasty.,ANESTHESIA:, Cervical block.,GROSS FINDINGS: ,The patient is a 57-year-old black female with chronic renal failur...
Surgery
HISTORY OF PRESENT ILLNESS: , Mr. A is a 50-year-old gentleman with a history of atrial fibrillation in the past, more recently who has had atrial flutter, who estimates he has had six cardioversions since 10/09, and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first eme...
Surgery
PROCEDURE PERFORMED:,1. Right femoral artery access.,2. Selective right and left coronary angiogram.,3. Left heart catheterization.,4. Left ventriculogram.,INDICATIONS FOR PROCEDURE:, A 50-year-old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery pres...
Surgery