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PREOPERATIVE DIAGNOSIS: , Carious teeth and periodontal disease affecting all remaining teeth.,POSTOPERATIVE DIAGNOSIS: , Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth #32.,PROCEDURE: , Extraction of remaining teeth numbers 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 1...
Surgery
PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,TITLE OF THE PROCEDURE: , Right carpal tunnel release.,COMPLICATIONS:, There were no complications during the procedure.,SPECIMEN: ,The specimen was sent to pathology.,INSTRUMENTS: , All counts were correc...
Surgery
HISTORY: , The patient is an 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation who was admitted yesterday with the recurrence of such in a setting of hypokalemia, incomplete compliance with obstructive sleep apnea therapy with CPAP, chocolate/caffeine ingestion...
Surgery
EXAM: , Cardiac catheterization and coronary intervention report.,PROCEDURES:,1. Left heart catheterization, coronary angiography, left ventriculography.,2. PTCA/Endeavor stent, proximal LAD.,INDICATIONS: , Acute anterior ST-elevation MI.,ACCESS: , Right femoral artery 6-French.,MEDICATIONS:,1. IV Valium.,2. IV Ben...
Surgery
PRECATHETERIZATION DIAGNOSIS (ES):, Hypoplastic left heart, status post Norwood procedure and Glenn shunt.,POSTCATHETERIZATION DIAGNOSIS (ES):,1. Hypoplastic left heart.,A. Status post Norwood.,B. Status post Glenn.,2. Left pulmonary artery hypoplasia.,3. Diminished right ventricular systolic function.,4. Trivial neo-a...
Surgery
INDICATIONS FOR PROCEDURE:, This is a 61-year-old, white male with onset of chest pain at 04: 30 this morning, with history of on and off chest discomfort over the past several days. CPK is already over 1000. There is ST elevation in leads II and aVF, as well as a Q wave. The chest pain is now gone, mild residual short...
Surgery
PROCEDURE PERFORMED:,1. Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.,2. Right femoral selective angiogram.,3. Closure device the seal the femoral arteriotomy using an Angio-Seal.,INDICATIONS FOR PROCEDURE: ,The patient with known...
Surgery
INDICATIONS FOR PROCEDURE:, The patient has presented with crushing-type substernal chest pain, even in the face of a normal nuclear medicine study. She is here for catheterization.,APPROACH:, Right common femoral artery.,ANESTHESIA:, IV sedation per cardiac catheterization protocol. Local sedation with 1% Xylocaine.,C...
Surgery
PREOPERATIVE DIAGNOSIS: , Coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.,DESCRIPTION OF PROCEDURE:,LEFT HEART CATHETERIZATION WITH ANGIOGRAPHY AND MID ABDOMINAL AORTOGRAPHY:,Under local anesthesia with 2% li...
Surgery
EXAM: , Left Heart Catheterization,REASON FOR EXAM:, Chest pain, coronary artery disease, prior bypass surgery.,INTERPRETATION: , The procedure and complications were explained to the patient in detail and formal consent was obtained. The patient was brought to the cath lab. The right groin was draped in the usual s...
Surgery
EXAMINATION: , Cardiac catheterization.,PROCEDURE PERFORMED: , Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.,INDICATION: , Syncope with severe aortic stenosis.,COMPLICATIONS:, None.,D...
Surgery
INDICATIONS FOR PROCEDURE:, The patient has presented with atypical type right arm discomfort and neck discomfort. She had noninvasive vascular imaging demonstrating suspected right subclavian stenosis. Of note, there was bidirectional flow in the right vertebral artery, as well as 250 cm per second velocities in the r...
Surgery
PROCEDURES PERFORMED:,1. Left heart catheterization with coronary angiography and left ventricular pressure measurement.,2. Left ventricular angiography was not performed.,3. Right posterior descending artery percutaneous transluminal coronary angioplasty followed by stenting.,4. Right femoral artery angiography.,5. Pe...
Surgery
PROCEDURE:, Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.,INDICATIONS: , Atherosclerotic coronary artery disease.,PATIENT HISTORY: , This is a 55-year-old male. He presented with 3 hours of unstable angina.,PAST CARDIAC HISTORY: , History of previous arteriosclerotic c...
Surgery
The patient and his wife had the opportunity to ask questions, all of which were answered for them and the patient stated in a clear, competent and coherent fashion that he wished to go forward with cardiac catheterization which I felt was appropriate.,PROCEDURE NOTE: ,The patient was brought to the Cardiac Catheteriz...
Surgery
PREOPERATIVE DIAGNOSIS: , Post infarct angina.,TYPE OF PROCEDURE: , Left cardiac catheterization with selective right and left coronary angiography.,PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory, and the groin was prepped in the usual fashion. Using...
Surgery
PREOPERATIVE DIAGNOSES:, Left calcaneal valgus split.,POSTOPERATIVE DIAGNOSES:, Left calcaneal valgus split.,PROCEDURES: ,1. Left calcaneal lengthening osteotomy with allograft.,2. Partial plantar fasciotomy.,3. Posterior subtalar and tibiotalar capsulotomy.,4. Short leg cast placed.,ANESTHESIA: , Surgery perfor...
Surgery
PREOPERATIVE DIAGNOSIS: , Breast assymetry, status post previous breast surgery.,POSTOPERATIVE DIAGNOSIS: ,Breast assymetry, status post previous breast surgery.,OPERATION: , Capsulotomy left breast, flat advancement V to Y left breast for correction lower pole defect.,ANESTHESIA:, LMA.,FINDINGS AND PROCEDURE: ,The ...
Surgery
PREOPERATIVE DIAGNOSIS: , Angina and coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Angina and coronary artery disease.,NAME OF OPERATION: , Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal ...
Surgery
PREOPERATIVE DIAGNOSES:,1. Ischemic cardiomyopathy.,2. Status post redo coronary artery bypass.,3. Status post insertion of intraaortic balloon.,POSTOPERATIVE DIAGNOSES:,1. Ischemic cardiomyopathy.,2. Status post redo coronary artery bypass.,3. Status post insertion of intraaortic balloon.,4. Postoperative coagu...
Surgery
INDICATIONS FOR PROCEDURE:, A 51-year-old, obese, white female with positive family history of coronary disease and history of chest radiation for Hodgkin disease 20 years ago with no other identifiable risk factors who presents with an acute myocardial infarction with elevated enzymes. The chest pain occurred early Tu...
Surgery
OPERATIVE PROCEDURE:,1. Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade f...
Surgery
PREOPERATIVE DIAGNOSES: , Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.,POSTOPERATIVE DIAGNOSES:, Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.,OPERATIVE PROCEDU...
Surgery
PREOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,POSTOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,OPERATION PROCEDURE: , Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal. Total car...
Surgery
TITLE OF PROCEDURE: ,Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold bloo...
Surgery
PREOPERATIVE DIAGNOSES:,1. Hallux abductovalgus, right foot.,2. Hammer toe, right foot, second, third, fourth and fifth toes.,3. Tailor's bunionette, right foot.,4. Degenerative joint disease, right first metatarsophalangeal joint.,5. Rheumatoid arthritis.,6. Contracted fourth right metatarsophalangeal joint.,POS...
Surgery
PREOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,POSTOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,PROCEDURE PERFORMED:,1. Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left.,2. Arthroplasty left second toe.,HISTORY: ,This 3...
Surgery
PREOPERATIVE DIAGNOSIS: , Bunion, left foot.,POSTOPERATIVE DIAGNOSIS: ,Bunion, left foot.,PROCEDURE PERFORMED:,1. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation.,2. Akin osteotomy with internal wire fixation of left foot.,HISTORY: , This 19-year-old Caucasian female presents...
Surgery
PREOPERATIVE DIAGNOSIS:, Bunion, right foot.,POSTOPERATIVE DIAGNOSIS:, Bunion, right foot.,PROCEDURE PERFORMED:, Austin/akin bunionectomy, right foot.,HISTORY: , This 77-year-old African-American female presents to ABCD General Hospital with the above chief complaint. The patient states she has had a bunion deformi...
Surgery
S -, A 60-year-old female presents today for care of painful calluses and benign lesions.,O -, On examination, the patient has bilateral bunions at the first metatarsophalangeal joint. She states that they do not hurt. No pain appears to be produced by active or passive range of motion or palpation and direct pressur...
Surgery
PREOPERATIVE DIAGNOSIS: , Left buccal mucosal verrucous squamous cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Left buccal mucosal verrucous squamous cell carcinoma.,PROCEDURE PERFORMED:,1. Wide local excision of left buccal mucosal lesion with full thickness skin graft closure in the left supraclavicular region.,2. Adj...
Surgery
PREOPERATIVE DIAGNOSES:,1. Hallux valgus, right foot.,2. Hallux interphalangeus, right foot.,POSTOPERATIVE DIAGNOSES:,1. Hallux valgus, right foot.,2. Hallux interphalangeus, right foot.,PROCEDURES PERFORMED:,1. Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2. Akin b...
Surgery
PREOPERATIVE DIAGNOSES:,1. Pregnancy at 38 weeks and three days.,2. Previous cesarean section x2.,3. Refusing trial of labor.,4. Multiparity, seeking family planning.,POSTOPERATIVE DIAGNOSES:,1. Pregnancy at 38 weeks and three days.,2. Previous cesarean section x2.,3. Refusing trial of labor.,4. Multiparity, se...
Surgery
PREOPERATIVE DIAGNOSES:,1. Hallux abductovalgus, right foot.,2. Hammertoe, bilateral third, fourth, and fifth toes.,POSTOPERATIVE DIAGNOSES:,1. Hallux abductovalgus, right foot.,2. Hammertoe, bilateral third, fourth, and fifth toes.,PROCEDURE PERFORMED:,1. Bunionectomy with distal first metatarsal osteotomy and in...
Surgery
PREOPERATIVE DIAGNOSES:,1. Lumbar osteomyelitis.,2. Need for durable central intravenous access.,POSTOPERATIVE DIAGNOSES:,1. Lumbar osteomyelitis.,2. Need for durable central intravenous access.,ANESTHESIA:, General.,PROCEDURE:, Placement of left subclavian 4-French Broviac catheter.,INDICATIONS: ,The patient is...
Surgery
PREOPERATIVE DIAGNOSES:,1. Eyebrow ptosis.,2. Dermatochalasia of upper and lower eyelids with tear trough deformity of the lower eyelid.,3. Cervical facial aging with submental lipodystrophy.,OPERATION:,1. Hairline biplanar temporal browlift.,2. Quadrilateral blepharoplasty with lateral canthopexy with arcus margi...
Surgery
PREOPERATIVE DIAGNOSIS: , Foreign body in airway.,POSTOPERATIVE DIAGNOSIS:, Plastic piece foreign body in the right main stem bronchus.,PROCEDURE: , Rigid bronchoscopy with foreign body removal.,INDICATIONS FOR PROCEDURE: , This patient is 7-month-old baby boy who presented to emergency room today with increasing stri...
Surgery
PREOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,POSTOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,PROCEDURE:, Bronchoscopy with brush biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was taken...
Surgery
PREOPERATIVE DIAGNOSIS: ,Carcinoma of the left upper lobe.,PROCEDURES PERFORMED:,1. Bronchoscopy with aspiration.,2. Left upper lobectomy.,PROCEDURE DETAILS: ,With patient in supine position under general anesthesia with endotracheal tube in place, the flexible bronchoscope was then placed down through the endotrac...
Surgery
PREOPERATIVE DIAGNOSIS:, Refractory pneumonitis.,POSTOPERATIVE DIAGNOSIS: , Refractory pneumonitis.,PROCEDURE PERFORMED: , Bronchoscopy with bronchoalveolar lavage.,ANESTHESIA: , 5 mg of Versed.,INDICATIONS: , A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requir...
Surgery
PROCEDURE:, Diagnostic fiberoptic bronchoscopy.,ANESTHESIA: , Plain lidocaine 2% was given intrabronchially for local anesthesia.,PREOPERATIVE MEDICATIONS:, ,1. Lortab (10 mg) plus Phenergan (25 mg), p.o. 1 hour before the procedure.,2. Versed a total of 5 mg given IV push during the procedure.,INDICATIONS: ,
Surgery
OPERATIVE PROCEDURE:, Bronchoscopy brushings, washings and biopsies.,HISTORY: , This is a 41-year-old woman admitted to Medical Center with a bilateral pulmonary infiltrate, immunocompromise.,INDICATIONS FOR THE PROCEDURE:, Bilateral infiltrates, immunocompromised host, and pneumonia.,Prior to procedure, the patient ...
Surgery
HISTORY OF PRESENT ILLNESS:, A 67-year-old gentleman who presented to the emergency room with chest pain, cough, hemoptysis, shortness of breath, and recent 30-pound weight loss. He had a CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a ...
Surgery
PREOPERATIVE DIAGNOSES,1. Bilateral bronchopneumonia.,2. Empyema of the chest, left.,POSTOPERATIVE DIAGNOSES,1. Bilateral bronchopneumonia.,2. Empyema of the chest, left.,PROCEDURES,1. Diagnostic bronchoscopy.,2. Limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2.,DESCRI...
Surgery
PREOPERATIVE DIAGNOSIS: , Hypoxia and increasing pulmonary secretions.,POSTOPERATIVE DIAGNOSIS: , Hypoxia and increasing pulmonary secretions.,OPERATION: , Bronchoscopy.,ANESTHESIA: , Moderate bedside sedation.,COMPLICATIONS:, None.,FINDINGS:, Abundant amount of clear thick secretions throughout the main airways.,IND...
Surgery
INDICATIONS FOR PROCEDURE:, Persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis.,PREMEDICATION:,1. Demerol 50 mg.,2. Phenergan 25 m...
Surgery
PREOPERATIVE DIAGNOSIS: ,Tracheal stenosis and metal stent complications.,POSTOPERATIVE DIAGNOSIS: ,Tracheal stenosis and metal stent complications.,ANESTHESIA: ,General endotracheal.,ENDOSCOPIC FINDINGS:,1. Normal true vocal cords.,2. Subglottic stenosis down to 5 mm with mature cicatrix.,3. Tracheal granulation...
Surgery
PREOPERATIVE DIAGNOSIS: , Breast mass, left.,POSTOPERATIVE DIAGNOSIS:, Breast mass, left.,PROCEDURE:, Excision of left breast mass.,OPERATION: , After obtaining an informed consent, the patient was taken to the operating room where he underwent general endotracheal anesthesia. The time-out process was followed. Pre...
Surgery
PROCEDURE:, Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration.,DETAILS OF THE PROCEDURE: , The risks, alternatives, and benefits of the procedure were explained to the patient as well as conscious sedation and she agrees to proceed. T...
Surgery
PREOPERATIVE DIAGNOSIS:, Airway stenosis with self-expanding metallic stent complication.,POSTOPERATIVE DIAGNOSIS:, Airway stenosis with self-expanding metallic stent complication.,PROCEDURES:,1. Rigid bronchoscopy with removal of foreign body, prolonged procedure taking two hours to remove the stent piecemeal in a ...
Surgery
POSTOPERATIVE DIAGNOSIS: Fever.,PROCEDURES: Bronchoalveolar lavage.,INDICATIONS FOR PROCEDURE: The patient is a 28-year-old male, status post abdominal trauma, splenic laceration, and splenectomy performed at the outside hospital, who was admitted to the Trauma Intensive Care Unit on the evening of August 4, 2008. ...
Surgery
PREOPERATIVE DIAGNOSIS:, Right breast mass with abnormal mammogram.,POSTOPERATIVE DIAGNOSIS:, Right breast mass with abnormal mammogram.,PROCEDURE PERFORMED:, Right breast excisional biopsy with needle-localization.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,SPECIMEN: , Right breast mass and confirmat...
Surgery
PROCEDURE: , Fiberoptic bronchoscopy.,PREOPERATIVE DIAGNOSIS:, Right lung atelectasis.,POSTOPERATIVE DIAGNOSIS:, Extensive mucus plugging in right main stem bronchus.,PROCEDURE IN DETAIL:, Fiberoptic bronchoscopy was carried out at the bedside in the medical ICU after Versed 0.5 mg intravenously given in 2 aliquots....
Surgery
PREOPERATIVE DIAGNOSES:,1. Left breast mass.,2. Hypertrophic scar of the left breast.,POSTOPERATIVE DIAGNOSES:,1. Left breast mass.,2. Hypertrophic scar of the left breast.,PROCEDURE PERFORMED: ,Excision of left breast mass and revision of scar.,ANESTHESIA: ,Local with sedation.,SPECIMEN: , Scar with left breast ...
Surgery
PREOPERATIVE DIAGNOSIS: , Atelectasis.,POSTOPERATIVE DIAGNOSIS: , Mucous plugging.,PROCEDURE PERFORMED: , Bronchoscopy.,ANESTHESIA: , Lidocaine topical 2%, Versed 3 mg IV. Conscious sedation.,PROCEDURE: , At bedside, a bronchoscope was passed down the tracheostomy tube under monitoring. The main carina was visualized...
Surgery
PROCEDURE PERFORMED: , Excisional breast biopsy with needle localization.,ANESTHESIA:, General.,PROCEDURE: , After informed consent was obtained, the patient was brought to the radiology suite where needle localization was performed with mammographic guidance. I reviewed the localizing films with the radiologist, and...
Surgery
PREOPERATIVE DIAGNOSIS,Left breast mass.,POSTOPERATIVE DIAGNOSIS,Left breast mass.,PROCEDURE PERFORMED,Needle localization and left breast biopsy.,ANESTHESIA,General.,FLUIDS,1000 cc.,ESTIMATED BLOOD LOSS,Minimal.,DRAINS,None.,COMPLICATIONS,None.,SPECIMEN,Breast biopsy specimen with localizing needle.,FINDINGS,Breast ti...
Surgery
PREOPERATIVE DIAGNOSIS:, Atypical ductal hyperplasia of left breast.,POSTOPERATIVE DIAGNOSIS: , Atypical ductal hyperplasia of left breast.,PROCEDURE: , Left excisional breast biopsy.,ANESTHESIA: , General.,INDICATIONS: , This is a 66-year-old female who has a history of a right lumpectomy for ductal carcinoma in situ...
Surgery
PREOPERATIVE DIAGNOSIS: , Right breast mass with atypical proliferative cells on fine-needle aspiration.,POSTOPERATIVE DIAGNOSIS:, Benign breast mass.,ANESTHESIA: , General,NAME OF OPERATION:, Excision of right breast mass.,PROCEDURE:, With the patient in the supine position, the right breast was prepped and draped ...
Surgery
PREOPERATIVE DIAGNOSIS:, Prostate cancer.,POSTOPERATIVE DIAGNOSIS:, Prostate cancer.,OPERATIONS: , Brachytherapy, iodine-125 seed implantation, and cystoscopy.,ANESTHESIA:, LMA.,ESTIMATED BLOOD LOSS: , Minimal.,Total number of seeds placed, 63. Needles, 24.,BRIEF HISTORY OF THE PATIENT: , This is a 57-year-old male...
Surgery
PREOPERATIVE DIAGNOSES: , Chronic otitis media and tonsillar adenoid hypertrophy.,POSTOPERATIVE DIAGNOSES:, Chronic otitis media and tonsillar adenoid hypertrophy.,PROCEDURES:, Bilateral myringotomy and tube placement, tonsillectomy and adenoidectomy.,INDICATIONS FOR PROCEDURE: , The patient is a 3-1/2-year-old child...
Surgery
PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS: ,Tailor's bunion, right foot.,PROCEDURE PERFORMED: , Removal of bone, right fifth metatarsal head.,ANESTHESIA: ,TIVA/local.,HISTORY: , This 60-year-old male presents to ABCD Preoperative Holding Area after keeping himself n.p.o., since mi...
Surgery
PREOPERATIVE DIAGNOSIS:, Completely bony impacted teeth #1, #16, #17, and #32.,POSTOPERATIVE DIAGNOSIS: , Completely bony impacted teeth #1, #16, #17, and #32.,PROCEDURE: , Surgical removal of completely bony impacted teeth #1, #16, #17, and #32.,ANESTHESIA: , General nasotracheal.,COMPLICATIONS: , None.,CONDITION: ,...
Surgery
PREOPERATIVE DIAGNOSIS: , Chronic otitis media.,POSTOPERATIVE DIAGNOSIS: , Chronic otitis media.,PROCEDURE PERFORMED: , Bilateral myringotomy tubes and adenoidectomy.,INDICATIONS FOR PROCEDURE:, The patient is an 8-year-old child with history of recurrent otitis media. The patient has had previous tube placement. Tu...
Surgery
PREOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,POSTOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,ANESTHESIA:, MAC (monitored anesthesia care) with local anesthesia.,TITLE OF PROCEDURES:,1. Left frontal craniotomy for placement of deep brain stimulator...
Surgery
An orbital block was done. An infraorbital block was also performed with a 25 gauge needle. A skin muscle flap was elevated by sharp dissection down to the orbital rim area. The herniated periorbital fat was removed by opening the orbital septum with sharp dissection using a 15 blade, teasing the periorbital fat out...
Surgery
PREOPERATIVE DIAGNOSIS: , Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.,POSTOPERATIVE DIAGNOSIS: , Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.,PROCEDURE:, Removal of benign cyst and extraction of full bone impacted tooth #17.,ANESTHESIA: ...
Surgery
PREOPERATIVE DX:, Dermatochalasis, mechanical ptosis, brow ptosis.,POSTOPERATIVE DX:, Same,PROCEDURE:,: Upper lid blepharoplasty and direct brow lift,ANESTHESIA:, Local with sedation,INDICATIONS FOR SURGERY: , In the preoperative evaluation the patient was found to have visually significant and symptomatic dermatochala...
Surgery
PREOPERATIVE DIAGNOSES:,1. Blepharochalasia.,2. Lower lid large primary and secondary bagging.,POSTOPERATIVE DIAGNOSES:,1. Blepharochalasia.,2. Lower lid large primary and secondary bagging.,PROCEDURE: , Quad blepharoplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,CONDITION: , The patient did well.,...
Surgery
PREOPERATIVE DIAGNOSES: ,1. Left back skin nevus 2 cm.,2. Right mid back skin nevus 1 cm.,3. Right shoulder skin nevus 2.5 cm.,4. Actinic keratosis left lateral nasal skin 2.5 cm.,POSTOPERATIVE DIAGNOSES: ,1. Left back skin nevus 2 cm.,2. Right mid back skin nevus 1 cm.,3. Right shoulder skin nevus 2.5 cm.,4. ...
Surgery
PREOPERATIVE DIAGNOSES:,1. Right axillary adenopathy.,2. Thrombocytopenia.,3. Hepatosplenomegaly.,POSTOPERATIVE DIAGNOSES:,1. Right axillary adenopathy.,2. Thrombocytopenia.,3. Hepatosplenomegaly.,PROCEDURE PERFORMED: ,Right axillary lymph node biopsy.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,DI...
Surgery
PREOPERATIVE DIAGNOSES:,1. Entropion, left upper lid.,2. Entropion and some blepharon, right lower lid.,TITLE OF OPERATION:,1. Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy.,2. Repairs of blepharon, entropion, right lower lid with mucous membrane graft.,PROCEDURE IN DETAIL: ...
Surgery
REFERRAL INDICATION AND PREPROCEDURE DIAGNOSES,1. Dilated cardiomyopathy.,2. Ejection fraction less than 10%.,3. Ventricular tachycardia.,4. Bradycardia with likely high degree of pacing.,PROCEDURES PLANNED AND PERFORMED,1. Implantation of biventricular automatic implantable cardioverter defibrillator.,2. Fluoros...
Surgery
PREOPERATIVE DIAGNOSIS:, Bladder lesions with history of previous transitional cell bladder carcinoma.,POSTOPERATIVE DIAGNOSIS: , Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.,OPERATION PERFORMED: ,Cystoscopy, bladder biopsies, and fulguration.,ANESTHESIA: , General....
Surgery
PREOPERATIVE DIAGNOSIS: , Cervical lymphadenopathy.,POSTOPERATIVE DIAGNOSIS:, Cervical lymphadenopathy.,PROCEDURE: , Excisional biopsy of right cervical lymph node.,ANESTHESIA: , General endotracheal anesthesia.,SPECIMEN: , Right cervical lymph node.,EBL: , 10 cc.,COMPLICATIONS: , None.,FINDINGS:, Enlarged level 2 ly...
Surgery
BLEPHAROPLASTY,The patient was prepped and draped. The upper lid skin was marked out in a lazy S fashion, and the redundant skin marked out with a Green forceps. Then the upper lids were injected with 2% Xylocaine and 1:100,000 epinephrine and 1 mL of Wydase per 20 mL of solution.,The upper lid skin was then excised ...
Surgery
PREOPERATIVE DIAGNOSES: , Bladder laceration.,POSTOPERATIVE DIAGNOSES:, Bladder laceration.,NAME OF OPERATION: , Closure of bladder laceration.,FINDINGS:, The patient was undergoing a cesarean section for twins. During the course of the procedure, a bladder laceration was notices and urology was consulted. Findings...
Surgery
PREOPERATIVE DIAGNOSIS:, Stress urinary incontinence, intrinsic sphincter deficiency.,POSTOPERATIVE DIAGNOSES: , Stress urinary incontinence, intrinsic sphincter deficiency.,OPERATIONS: , Cystoscopy, cystocele repair, BioArc midurethral sling.,ANESTHESIA:, Spinal.,EBL: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY:...
Surgery
Initially a small incision was made in the right superior hemiscrotum and the incision was carried down to the vas deferens. This incision was carried down to the area of the previous vasectomy. A towel clip was placed around this. Next the scarred area was dissected free back to normal vas proximally and distally. ...
Surgery
PREOPERATIVE DIAGNOSES: ,1. Left chest actinic keratosis, 2 cm.,2. Left medial chest actinic keratosis, 1 cm.,3. Left shoulder actinic keratosis, 1 cm.,POSTOPERATIVE DIAGNOSES: ,1. Left chest actinic keratosis, 2 cm.,2. Left medial chest actinic keratosis, 1 cm.,3. Left shoulder actinic keratosis, 1 cm.,TITLE O...
Surgery
PREOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,POSTOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,PROCEDURES PERFORMED: , ,1. Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies.,2. Bone grafts.,3. Bilateral forehead reconstruction wit...
Surgery
PREOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,POSTOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,PROCEDURE PERFORMED: , Laparoscopic bilateral tubal occlusion with Hulka clips.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS: ,None.,FINDINGS: , On bimanual exam, the ...
Surgery
PREOPERATIVE DIAGNOSES,1. Recurrent acute otitis media, bilateral middle ear effusions.,2. Chronic rhinitis.,3. Recurrent adenoiditis with adenoid hypertrophy.,POSTOPERATIVE DIAGNOSES,1. Recurrent acute otitis media, bilateral middle ear effusions.,2. Chronic rhinitis.,3. Recurrent adenoiditis with adenoid hypert...
Surgery
PREOPERATIVE DIAGNOSES:, OM, chronic, serous, simple or unspecified. Adenoid hyperplasia. Hypertrophy of tonsils.,POSTOPERATIVE DIAGNOSIS: , Same as preoperative diagnosis.,OPERATION: , Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.,ANESTHESIA:, General.,COMPLICATIONS:, Non...
Surgery
PREOPERATIVE DIAGNOSIS: , Bilateral inguinal hernias.,POSTOPERATIVE DIAGNOSIS:, Bilateral inguinal hernias.,OPERATION PERFORMED: ,Bilateral inguinal herniorrhaphy.,ANESTHESIA: , General.,INDICATIONS: , This 3-1/2-year-old presents with bilateral scrotal swellings, which both reduce and are consistent with bilateral i...
Surgery
PREOPERATIVE DIAGNOSIS:, Bilateral upper eyelid dermatochalasis.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE: , Bilateral upper lid blepharoplasty, (CPT 15822).,ANESTHESIA: , Lidocaine with 1:100,000 epinephrine.,DESCRIPTION OF PROCEDURE: , This 65-year-old female demonstrates conditions described above of excess and r...
Surgery
PREOPERATIVE DIAGNOSES: , Bilateral chronic otitis media,POSTOPERATIVE DIAGNOSES:, Bilateral chronic otitis media,ANESTHESIA:, General mask,NAME OF OPERATION:, Bilateral Myringotomy with placement of PE tubes,PROCEDURE:, The patient was taken to the operating room and placed in the supine position. After adequate ...
Surgery
PREOPERATIVE DIAGNOSES:,1. Carotid artery occlusive disease.,2. Peripheral vascular disease.,POSTOPERATIVE DIAGNOSES:,1. Carotid artery occlusive disease.,2. Peripheral vascular disease.,OPERATIONS PERFORMED:,1. Bilateral carotid cerebral angiogram.,2. Right femoral-popliteal angiogram.,FINDINGS: , The right caro...
Surgery
PREOPERATIVE DIAGNOSIS: , Ruptured distal biceps tendon, right elbow.,POSTOPERATIVE DIAGNOSIS:, Ruptured distal biceps tendon, right elbow.,PROCEDURE PERFORMED: , Repair of distal biceps tendon, right elbow.,PROCEDURE: ,The patient was taken to OR, Room #2 and administered a general anesthetic. The right upper extre...
Surgery
PROCEDURE:, Belly button piercing for insertion of belly button ring.,DESCRIPTION OF PROCEDURE:, The patient was prepped after informed consent was given of risk of infection and foreign body reaction. The area was marked by the patient and then prepped. The area was injected with 2% Xylocaine 1:100,000 epinephrine...
Surgery
PREOPERATIVE DIAGNOSIS: , Hematemesis in a patient with longstanding diabetes. ,POSTOPERATIVE DIAGNOSIS: ,Mallory-Weiss tear, submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis.,PROCEDURE: , The procedure, indications explained and he understood and agreed. He was sedated with Versed...
Surgery
PREOPERATIVE DIAGNOSES,1. Basal cell carcinoma, right cheek.,2. Basal cell carcinoma, left cheek.,3. Bilateral ruptured silicone gel implants.,4. Bilateral Baker grade IV capsular contracture.,5. Breast ptosis.,POSTOPERATIVE DIAGNOSES,1. Basal cell carcinoma, right cheek.,2. Basal cell carcinoma, left cheek.,3. ...
Surgery
PREOPERATIVE DIAGNOSIS:, Cranial defect greater than 10 cm in diameter in the frontal region.,POSTOPERATIVE DIAGNOSIS: , Cranial defect greater than 10 cm in diameter in the frontal region.,PROCEDURE: , Bifrontal cranioplasty.,ANESTHESIA:, General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Nil.,INDICATIONS FOR ...
Surgery
PREOPERATIVE DIAGNOSIS: , Extremely large basal cell carcinoma, right lower lid.,POSTOPERATIVE DIAGNOSIS:, Extremely large basal cell carcinoma, right lower lid.,TITLE OF OPERATION: , Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large p...
Surgery
PREOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,POSTOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,OPERATION PERFORMED: , Excision of nasal tip basal carcinoma. Total area of excision, approximately 1 cm to 12 mm frozen section x2, final margins c...
Surgery
PREOPERATIVE DIAGNOSIS: , Basal cell carcinoma (0.8 cm diameter), right medial canthus.,POSTOPERATIVE DIAGNOSIS: , Basal cell carcinoma (0.8 cm diameter), right medial canthus.,OPERATION: , Excision basal cell carcinoma (0.8 cm diameter), right medial canthus with frozen section, and reconstruction of defect (1.2 cm di...
Surgery
PREOPERATIVE DIAGNOSIS:, End-stage renal disease with need for a long-term hemodialysis access.,POSTOPERATIVE DIAGNOSIS: , End-stage renal disease with need for a long-term hemodialysis access.,PROCEDURE: , Right basilic vein transposition.,ANESTHESIA: ,General endotracheal.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICAT...
Surgery
PREOPERATIVE DIAGNOSES,1. End-stage renal disease.,2. Left subclavian vein occlusion.,3. Status post chronic tracheostomy.,4. Status post coronary artery bypass grafting.,5. Right subclavian vein stenosis.,POSTOPERATIVE DIAGNOSES,1. End-stage renal disease.,2. Left subclavian vein occlusion.,3. Status post chro...
Surgery
PREOPERATIVE DIAGNOSIS:, Bilateral axillary masses, rule out recurrent Hodgkin's disease.,POSTOPERATIVE DIAGNOSIS: ,Bilateral axillary masses, rule out recurrent Hodgkin's disease.,PROCEDURE PERFORMED:,1. Left axillary dissection with incision and drainage of left axillary mass.,2. Right axillary mass excision and ...
Surgery
PREOPERATIVE DIAGNOSES,1. End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2. Ischemic cardiomyopathy, ejection fraction 20%.,POSTOPERATIVE DIAGNOSES,1. End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2. Ischemic cardiomyopathy, ejection...
Surgery