ADMITTING DIAGNOSIS: Cystocele with urinary incontinence.
FINAL DIAGNOSIS: Cystocele with urinary incontinence.
PROCEDURE: Anterior repair.
COMPLICATIONS: None
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.
Thursday, April 23, 2009
Opta 7 HISTORY AND PHYSICAL EXAMINATION
HISTORY AND PHYSICAL EXAMINATION
PREOPERATIVE DIAGNOSIS:
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.
PHYSICAL FINDINGS:
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.
PREOPERATIVE DIAGNOSIS:
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.
PHYSICAL FINDINGS:
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.
Pulmo 5 EMERGENCY ROOM REPORT
EMERGENCY ROOM REPORT
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.
PHYSICAL EXAMINATION
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.
EMERGENCY ROOM DIAGNOSES
1. Acute laryngotracheobronchitis.
2. Bronchial asthma.
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.
PHYSICAL EXAMINATION
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.
EMERGENCY ROOM DIAGNOSES
1. Acute laryngotracheobronchitis.
2. Bronchial asthma.
Pulmo 8 CONSULTATION
CONSULTATION
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.
RECOMMENDATIONS:
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.
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.
RECOMMENDATIONS:
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.
ENT7 EMERGENCY ROOM REPORT
EMERGENCY ROOM REPORT
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.
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.
Thursday, February 19, 2009
EMERGENCY ROOM REPORT
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.
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.
MEDICAL REPORTS
EMERGENCY SERVICES ADMISSION
PATIENT: Brenda Seggerman
Hospital Number: 903321
DATE OF ADMISSION: March 27, 2008
ADMITTING PHYSICIAN: Linda L. Kingston, DO
ADMITTING DIAGNOSIS: Ectopic pregnancy
CHIEF COMPLAINTS: The patient presents to the emergency room this morning complaining of lower abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient states that she has been having vaginal bleeding more like spotting over the past month. She denies the chance of pregnancy although she state that she is sexually active and using no birth control.
GYNECOLOGIC HISTORY: Patient is gravida 2, para 1, abortus 1. Her only child is a 15-year-old daughter who lives in Texas with her grandmother.
PAST MEDICAL HISTORY: Positive for Hepatitis-B.
PAST SURGICAL HISTORY: Pilonidal cyst, remove in the remote past. Had plastic surgery on her ears as a child.
SOCIAL HISTORY: Married, has one daughter, patient works as a substitute teacher. Smokes one pack of cigarettes on a daily basis. Denies ETOH. Smoked marijuana last night. No IV drug abuse.
ALLERGIES: Tightness.
MEDICATION: None.
REVIEW OF SYSTEM
Patient complaints of a lower abdominal pain for the past week that apparently got much worst last night and by this morning was intolerable. The patient is also having some nausea and vomiting. Denies hematemesis, hematokesia and melena. The patient has had vaginal spotting over the past month with questionable vaginal discharge as well. Denies urinary frequency, urgency, and hematuria. Denies arthralgias. Review of system is otherwise essentially negative.
PHYSICAL EXAMINATION
VITAL SIGNS: Shows temperature 97degrees, pulse 53, respirations 22, blood pressure 108/60.
GENERAL: Physical examination reveals a well developed, well-nourish, 35-year-old white female in a moderate amount of distress at the time of the examinations.
HEENT: Unremarkable except for poor dentition.
NECK: Soft and supple.
CHEST: Lungs are clear in all fields.
HEART: Regular rate and Rhythm.
ABDOMEN: Soft with positive tenderness of her lower abdominal area. Fundus was not palpable above the pubic area. Left adnexa are more tender than the right.
VAGINAL EXAMINATION: The cervix is close. A moderate amount of mucopurulent vaginal discharge is noted. The patient would not allow me to perform a bi-manual examination due to the patient pain. So the speculum was withdrawn.
EXTREMITIES: No clot. No edema.
NEUROLOGIC EXAMINATION: Intact. Oriented x3, No neurologic deficits.
DIAGNOSTIC DATA
ADMISSION: Hemoglobin 12.8 g and Hematocrit 36.6%.
URINALYSIS: Essentially Negative.
BETA HCG: Positive with WBC count of 23,278.
RADIOLOGY
Pelvic Ultrasound shows a 7 week 4 day old viable ectopic pregnancy per radiology. The patient was given Demerol 25 mg, and Phenergan 25 mg. IV for the pain after her report was obtained. The patient also given claperan 1g IV.
I page Dr. Gerard, patient’s GYN, physician, as soon as I receive the ultra-sound report at approximately 10a.m. He was not in North Miami office. I page the South Miami office and reach Dr. Gerard’s office at approximately 10:15a.m. His office personnel advice me that he is not on call, Dr. Bomback is on call. I spoke with Dr. Bomback at approximately 10:25a.m. and she will be here to take the patient to the operating room.
ADMITTING DIAGNOSIS: Left ectopic first trimester pregnancy.
Disposition: The patient receive and IV of lactated ringer upon arrival at the emergency room. This was switch to normal saline while we were awaiting Dr. Bomback’s arrival. The surgical procedure was explained to the patient and her husband. All risk and benefits were discussed. They understand the necessity for immediate surgery and informed consent was signed. No old records are available for review.
84
PATIENT: Brenda Seggerman
Hospital Number: 903321
DATE OF ADMISSION: March 27, 2008
ADMITTING PHYSICIAN: Linda L. Kingston, DO
ADMITTING DIAGNOSIS: Ectopic pregnancy
CHIEF COMPLAINTS: The patient presents to the emergency room this morning complaining of lower abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient states that she has been having vaginal bleeding more like spotting over the past month. She denies the chance of pregnancy although she state that she is sexually active and using no birth control.
GYNECOLOGIC HISTORY: Patient is gravida 2, para 1, abortus 1. Her only child is a 15-year-old daughter who lives in Texas with her grandmother.
PAST MEDICAL HISTORY: Positive for Hepatitis-B.
PAST SURGICAL HISTORY: Pilonidal cyst, remove in the remote past. Had plastic surgery on her ears as a child.
SOCIAL HISTORY: Married, has one daughter, patient works as a substitute teacher. Smokes one pack of cigarettes on a daily basis. Denies ETOH. Smoked marijuana last night. No IV drug abuse.
ALLERGIES: Tightness.
MEDICATION: None.
REVIEW OF SYSTEM
Patient complaints of a lower abdominal pain for the past week that apparently got much worst last night and by this morning was intolerable. The patient is also having some nausea and vomiting. Denies hematemesis, hematokesia and melena. The patient has had vaginal spotting over the past month with questionable vaginal discharge as well. Denies urinary frequency, urgency, and hematuria. Denies arthralgias. Review of system is otherwise essentially negative.
PHYSICAL EXAMINATION
VITAL SIGNS: Shows temperature 97degrees, pulse 53, respirations 22, blood pressure 108/60.
GENERAL: Physical examination reveals a well developed, well-nourish, 35-year-old white female in a moderate amount of distress at the time of the examinations.
HEENT: Unremarkable except for poor dentition.
NECK: Soft and supple.
CHEST: Lungs are clear in all fields.
HEART: Regular rate and Rhythm.
ABDOMEN: Soft with positive tenderness of her lower abdominal area. Fundus was not palpable above the pubic area. Left adnexa are more tender than the right.
VAGINAL EXAMINATION: The cervix is close. A moderate amount of mucopurulent vaginal discharge is noted. The patient would not allow me to perform a bi-manual examination due to the patient pain. So the speculum was withdrawn.
EXTREMITIES: No clot. No edema.
NEUROLOGIC EXAMINATION: Intact. Oriented x3, No neurologic deficits.
DIAGNOSTIC DATA
ADMISSION: Hemoglobin 12.8 g and Hematocrit 36.6%.
URINALYSIS: Essentially Negative.
BETA HCG: Positive with WBC count of 23,278.
RADIOLOGY
Pelvic Ultrasound shows a 7 week 4 day old viable ectopic pregnancy per radiology. The patient was given Demerol 25 mg, and Phenergan 25 mg. IV for the pain after her report was obtained. The patient also given claperan 1g IV.
I page Dr. Gerard, patient’s GYN, physician, as soon as I receive the ultra-sound report at approximately 10a.m. He was not in North Miami office. I page the South Miami office and reach Dr. Gerard’s office at approximately 10:15a.m. His office personnel advice me that he is not on call, Dr. Bomback is on call. I spoke with Dr. Bomback at approximately 10:25a.m. and she will be here to take the patient to the operating room.
ADMITTING DIAGNOSIS: Left ectopic first trimester pregnancy.
Disposition: The patient receive and IV of lactated ringer upon arrival at the emergency room. This was switch to normal saline while we were awaiting Dr. Bomback’s arrival. The surgical procedure was explained to the patient and her husband. All risk and benefits were discussed. They understand the necessity for immediate surgery and informed consent was signed. No old records are available for review.
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