Thursday, April 23, 2009


ADMITTING DIAGNOSIS: Cystocele with urinary incontinence.

FINAL DIAGNOSIS: Cystocele with urinary incontinence.

PROCEDURE: Anterior repair.


HISTORY: This is a 65-year-old woman who had had a previous hysterectomy, who developed urinary incontinence, and was found to have a large cystocele.

Physical examination was unremarkable except for the cycstocele.

Lab work, including a panel, CBC, EKG, and chest x-ray, was essentially within normal limits. Following surgery the patient has done well. The vaginal pack was removed this date and the Foley catheter. She will be checked for residual. IF the residual is over 150 cc, the Foley will be replaced and the patient taught to use the catheter plug, and she will be discharged. She will be seen in the office in approximately one week for follow-up.



1. Cataract of left eye.
2. Pseudophakia of the right eye.
3. Dermatomyositis.
4. Rheumatoid arthritis.

HISTORY OF PRESENT ILLNESS: Patient is a 71-year-old woman who had an uncomplicated cataract extraction with lens implant of the right eye and had a good improvement in her visual function. She is also bothered by blurred vision from a cataract in the left eye and enters for a similar procedure on the left eye. She has had dry eyes and uses artificial tears frequently. She had had ectropion repair of the right lower lid. She has had dermatomyositis and rheumatoid arthritis for many years and has used cortisone for this. She is presently taking Persantine twice daily and Inderal 40 mg twice daily. She is allergic to penicillin, aspirin, codeine, and does not tolerate Tylenol because of constipation.

VITAL SIGNS: Blood pressure 110/80, pulse 76 and regular.
HEENT: Eyes; Recent eye examination showed best vision of 20/50+ in the right eye and 20/200 in the left. Pupils and extraocular motility were normal. Intraocular pressures where 18. Slit-lamp exam showed the eyelids in good position with weakness of the orbicularis and facial muscles. There was a clear corneal epithelium and the normal pseudophakia of the right eye and a dense nuclear cataract on the left. Fundus examination in each eye was normal.
EARS, NOSE, AND THROAT: Tympanic membranes are normal. The oral cavity showed dentures in place, and the pharynx had no lesions.
NECK: The neck showed a slight right carotid bruit, and the left was normal.
CHEST: The chest was clear to auscultation.
HEART: Heart had a regular sinus rhythm without murmur.
EXTREMITIES: Extremities showed ulnar deviations of the hands and mild ecchymoses in the legs.

PLAN: Plan is a cataract extraction with lens implant of the left eye under local anesthetic as an outpatient. The risks of the procedure, including possible loss of the eye, were discussed.



HISTORY OF PRESENT ILLNESS: Patient is a one-year-old female that has been congested for several days. The child has sounded hoarse, has had a croupy cough, and was seen 2 days ago. Since that time she has been on Alupent breathing treatments via machine, amoxicillin, Ventolin, cough syrup, and Slo-bid 100 mg b.i.d. but is not improving. Today the child is not taking food or fluids, has been unable to rest, and has been struggling in her respirations.

GENERAL: Physical exam in the ER showed an alert child in moderate respirator distress.
VITAL SIGNS: Respiratory rate was 40, pulse 20, temperature 99.6.
HEENT: Within normal limits.
NECK: Positive for mild to moderate stridor.
CHEST: Chest showed a diffuse inspirator and expiratory wheezing. No rales were noted. Viewing the chest wall, patient had subcostal-intercostal retractions.
HEART: Regular rhythm without murmur, gallop, or rub.
ABDOMEN: Soft, nontender, bowel sounds normal.
EXTREMITIES: Within normal limits.

The child was sent for a PA and lateral chest x-rays to rule out pneumonia. No pneumonia was seen on the films.
It was agreed to admit the patient to the pediatric unit for placement in a croup tent with respiratory therapy treatments q.3 h. The child was also placed on Decadron besides the amoxicillin and continuation of the Slo-bid.

1. Acute laryngotracheobronchitis.
2. Bronchial asthma.



This is a 32-year-old white male, lifelong nonsmoker, referred to me. He complains of a less than 2-weeks history of dry cough associated with dull substernal discomfort and dyspnea, particularly on exertion. Otherwise, he has been remarkably free of any other associated symptoms. In particular, he denies any preceding cold or flu or allergic exposure, and denies any associated fevers, chills, sweats, or weight loss. He does admit to having childhood asthma but felt he grew out this by the time he was a teenager. He was traveled extensively outside the U.S., including travel to the California deserts and Central Valley. He has not had pneumonia vaccine. He did have TB skin test 10 years ago and did have flue vaccine 3 years ago.

PAST MEDICAL HISTORY: Past medical history is remarkably negative.

PHYSICAL EXAMINATION: Blood pressure 140/80, pulse 85, respiratory rate 22, temperature 99.3.Chest exam is complete normal. There are no rales, wheezes, rhonchi, rubs. Even on forced exhalation, there was no cough or prolongation. Cardiac exam showed a regular rate and rhythm with no murmur or gallop.

LABORATORY DATA: PA chest x-ray is striking for a new interstitial infiltrate seen on both midlung zones with some shagging of the cardiac borders, indicating involvement of the lingual and right middle lobe. Surprisingly, the lowest part of the lung fields and the apices appear to be spared. Spirometry before and after bronchodilator performed in my office show a vital capacity of 3.79 or 69% after an 11% improvement with bronchodilator. FEV-1 achieves 3.24 L or 72% of predicted after 12% improvement wih bronchodilator. FEV-1/FVC ratio was mildly increased at 85 instead of predicted 82.

ASSESSMENT AND PLAN: Differential diagnosis includes the following:
1. Hypersensitivity pneumonitis.
2. Mycoplasma pneumonia.
3. Less likely candidates appear to be Wegener’s granulomatosis, Goodpasture’s syndrome, sarcoidosis, alveolar proteinosis, and allergic bronchopulmonary aspergillosis.

1. CBC, differential, chemistry-20, Wintrobe sed rate, angiotensin converting enzyme, urinalysis, and Mycoplasma titers.
2. Full pulmonary function test within 2 weeks
3. Vibramycin 100 mg q. day for 14 days. If he still has significant symptoms and restriction on PFTs within 2 weeks, he will have to be evaluated for one of the more chronic diagnoses, which may ultimately require open lung biopsy. Otherwise we should hope that within 2 weeks the patient will be improved and his x-ray will have cleared.



He was brought to the emergency room with a right epistaxis with clots in the nose. Patient is on Coumadin.

EXAMINATION: Clots were removed from the right nostril, and an active venous bleeder on the right anterior septum was identified. This was cauterized with silver nitrate and an anterior pack placed. The left side appeared to have no active bleeding. He was observed for a few minutes, and no further bleeding of an active nature was identified. Some tape as couterpressure was applied to the nose, and the throat checked also. There is just an old clot posterior that’s sticking down just enough so that you can see it but cannot reach it with an instrument. This was left in place. I recommend that we leave the pack in until Wednesday morning if patient tolerates it. He is apparently already on antibiotics, pain medicines, and oxygen, so no additional orders are indicated at this time.