Practicode IV (301-400)

CaseID: OPD7053 Primary Diagnosis: K56.609, L89.152, E86.0, R82.81 Secondary Diagnosis: Z93.3, Z87.01, Z85.038, Z87.440, Z80.9 E/M Level: 99285

"> MEDICAL RECORD EMERGENCY DEPARTMENTSex: FemaleAge: 83DOS: 1/01/20XXCHIEF COMPLAINT: Vomiting.HISTORY OF PRESENT ILLNESS: Female brought by her son with history of nausea, vomiting, decreased intake of food and fluids and worry about her being dehydrated. There was some question of small amount of loose stool, diarrheal type today. No one has seen black or bloody stools or hematemesis, coffee grounds emesis. The patient was a poor historian. She has been increasingly confused and fatigued appearing, according to the son progressively over the last 2 days.REVIEW OF SYSTEMS: Essentially negative.ALLERGIES: None known.MEDICATIONS REGULARLY:Fentanyl transdermal patch.Phenergan p.r.n. nausea.SOCIAL HISTORY: The patient denies smoking cigarettes, denies drinking alcohol.PAST MEDICAL HISTORY: Positive for history of prior pneumonia, large colon cancer, frequent UTIs, poor vision. She has had partial colectomy because of the colon cancer, and colostomy, and she also had an incarcerated hernia in the area of the colostomy with resection with primary revision in 20XX.FAMILY HISTORY: Positive for cancer in the family.PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure initially 143/70; pulse rate 98; temperature is afebrile at 99.4 tympanic; respirations 18 and nonlabored. Pulse oximetry reading good on room air at 95%. GENERAL: The patient is elderly. Skin turgor is poor. HEENT: Exam shows dried mucous membranes. EYES: PERRLA. EOMI. No scleral icterus noted. NECK: Supple without meningismus or lymphadenopathy. CHEST: Clear to auscultation. CARDIAC: Regular without murmur, rub, or gallop. ABDOMEN: Benign. Subjective tenderness diffusely, but no rebound tenderness. No rigidity on exam noted.LABORATORY AND X-RAY FINDINGS:Acute abdominal series shows multiple air fluid levels and ileums versus small bowel obstruction.The labs show w

CaseID: OPD7461 Primary Diagnosis: I25.5, R42, I10, E11.9, Z45.02 Secondary Diagnosis: Z79.4 CPT: 93289 E/M Level: 99214-25

">MEDICAL RECORD OFFICE - ESTABLISHEDCARDIOLOGYSEX: MALEAGE: 85Date: 01/01/20XXCHIEF COMPLAINT: He is here for BiV/ICD implantable cardioverter defibrillator followup and yearly check.PROBLEM LIST:1. Patient is 1-1/2 years S/P BiV/AICD for ischemic cardiomyopathy, ejection fraction 30-35% and left bundle-branch block (01/01/20XX).2. Left heart cath (01/01/20XX) shows patent LIMA to LAD SVG to circ and SVG to PDA.3. S/P CABG (20XX); recent onset nocturnal dyspnea, possibly cardiac in origin.4. Hypertension.5. Type 2 diabetes mellitus, now insulin dependent, with suboptimal control.ALLERGIES: No known drug allergies, although he is allergic to eggs.MEDICATIONS:Atenolol 12.5 mg b.i.d.Lexapro 10 mg q.d.Lantus insulinLovastatin 80 mg q.d.NovoLog insulinLisinopril 5 mg q.d.Gabapentin 400 mg q.d.Nexium 20 mg q.d.Elavil 25 mg q.d.INTERVAL HISTORY:It has been 1-1/2 years since the patient's last office visit. He presents today for BiV/ ICD interrogation. He has had increasing falls lately with no significant injury thus far.Due to lightheadedness and dizziness, his atenolol was decreased by PCP, but there has been no improvement in symptoms. He has had no chest pain. Breathing is stable. No new health issues.Interrogation today by me shows:1. Ventricular-paced rhythm with occasional intrinsic beats.2. Boston Scientific BiV/ICD with ERI estimated 5.5 years.3. He is atrial pacing 53% and ventricular pacing 88%.4. There were eight high ventricular rates that appeared to be supraventricular tachycardia.ROBERT JONES, MD 1/1/20XXPHYSICAL EXAMINATION:VITAL SIGNS: Weight 168-1/2 lbs, BP 122/68 in the left arm, pulse is 79 and regular, oxygen saturation is 96% on room air.CONSTITUTIONAL: He is slightly weak and pale-appearing. In no acute distress.HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous memb

CaseID: OPD7047 Primary Diagnosis: Z48.812 Secondary Diagnosis: I87.2 E/M Level: 99024

">MEDICAL RECORD OFFICE - POST OPSex: FemaleAge: 67DOS: 1/1/20XXSUBJECTIVE: The patient is status post numerous episodes of sclerotherapy for venous insufficiency, at least three now. The last one two days ago. She has also had one microthrombectomy. She states that overall, the veins treated individually feel okay but there has been no significant improvement in the overall swelling of her legs and the right remains the same as the left. Measurements today demonstrate 41 cm symmetric bilaterally. There is some discoloration along the treated segments of veins. These are somewhat tender to touch but there is no evidence for inflammation. It appears to me that there is some improvement overall in the telangiectatic and reticular pattern of the right compared to the left leg; however, because she has no significant improvement in the swelling, which was the goal, I am reticent to continue further with extensive sclerotherapy. I discussed with her the option of targeting those individual varicose veins that are painful and closing those down. She states the one along the lateral left thigh and calf region is large and painful on occasion. After further discussion, it was decided to target that vein next week. I would like to wait an additional week before continuing treatment.PLAN: Sclerotherapy follow-up. Treatment to continue next weekElectronically signed by 1/1/20XX

CaseID: OPD7077 Primary Diagnosis: M25.522 Secondary Diagnosis: Y93.83 E/M Level: 99283

Emergency Department ReportPatient: Dovie SmithCHIEF COMPLAINT: Elbow pain.HISTORY OF PRESENT ILLNESS: This is a female who was seen over at one of our prompt cares after persistent left elbow pain from an injury while horsing around with her brother yesterday. Her brother, who apparently is 7, was twisting her arm last night and she has not wanted to move her arm since that time. She seemed to be quite tender last night and bothered by it. Today she continues to not want to use it. They apparently went to Prompt Care over at Hospital and had an x-ray done and was sent over here for further evaluation as there was some concern that she may have had a dislocation. The family makes comments that after the x-ray was done and the manipulative process of that the patient seemed to be remarkably improved almost instantaneously. She since that time has had no signs of distress, has been using her arm normally, and without any discomfort. She has not taken any medication for this today. She was sent over here for further evaluation. She did not have any other injuries. She has not had any other complaints.PAST MEDICAL HISTORY: None.MEDICATIONS: None.ALLERGIES: NONE.SOCIAL HISTORY: She lives locally, she is here with mom and dad.REVIEW OF SYSTEMS: As above.PHYSICAL EXAM: GENERAL APPEARANCE: Well-developed 4 year old female resting quietly in no distress.PSYCH: She is alert and oriented.VITAL SIGNS: Temperature 98, pulse 100, respiratory rate 16, O2 sat 100% on room air.MUSCULOSKELETAL: No C, T, or L spine tenderness. There is no chest tenderness. She has no tenderness over the shoulders. No tenderness over the right arm at all. Focused exam of the left arm shows no reproducible tenderness at the wrist, throughout the forearm, or over the humerus. There is no tenderness over the elbow or supracondylar region that I can appreciat

CaseID: OPD7244 Primary Diagnosis: S02.832A, S02.641A, S09.90XA Secondary Diagnosis: Y04.8XXA E/M Level: 99284

MEDICAL RECORD EMERGENCY DEPARTMENTSEX: MALEAGE: 22DOS: 01/01/20XXCHIEF COMPLAINT: Facial injury.HISTORY OF PRESENT ILLNESS: This is a male who was assaulted by assailant who struck him on the face with his fists and knees. He states he was also struck on his chest but has no pain in his chest. His only complaint is pain and swelling to his face. He has pain to the right side of his jaw and around both of his eyes. He had no loss of consciousness. He has a mild headache. No neck pain. No chest pain or shortness of breath. No abdominal pain.PAST MEDICAL HISTORY: Unremarkable.MEDICATIONS: None.ALLERGIES: NO KNOWN DRUG ALLERGIES.SOCIAL HISTORY: The patient denies any tobacco use. He drinks alcohol moderately.REVIEW OF SYSTEMS: Prior to the onset of the symptoms the patient was feeling well. A 9 point review of systems was done and was negative or noncontributory.PHYSICAL EXAMINATION: GENERAL: The patient is awake, alert and in no acute distress. VITAL SIGNS: Temperature 99.8, pulse 82, respirations 20, O2 saturation 97%. Blood pressure 126/82. HEENT: He has significant swelling. He has bilateral periorbital edema, more on the left than the right. His pupils are equal, round, reactive to light. Extraocular movements are intact. TMs are normal. He has a little bit of swelling of his nasal bridge. No septal hematoma. He has significant swelling to the right side of his mandible. He has a little bit of swelling of his tongue and there was a little blood along the right lower molars although I cannot see an acute laceration. NECK: Supple, full range of motion without adenopathy. LUNGS: Clear to auscultation without wheezes or rales or rhonchi. COR: Regular rate and rhythm. ABDOMEN: Positive bowel sounds. Soft, nontender. CHEST: Nontender. EXTREMITIES: Without clubbing, cyanosis or edema. NEURO: Awake, alert and oriented x3. No

CaseID: OPD7117 Primary Diagnosis: I45.10, I47.20 Secondary Diagnosis: Z79.02 CPT: 93227

MEDICAL RECORD MEDICAL RECORD HOLTER MONITOR FINDINGSCARDIOLOGYAGE: 79 SEX: MaleDate: 01/01/20XXINDICATION: PalpitationsMEDICATIONS: Celebrex, Plavix, Toprol XL, lisinopril, Flomax, HCTZ.PROCEDURE: The patient was monitored on a three-channel monitor for a period of 24 hours and then reviewed and interpreted by me.FINDINGS:Rhythm is sinus rhythm with right bundle branch block.The average heart rate is 64 b.p.m.The minimum heart rate is 57 b.p.m. at 0213 hours while sleeping.The maximum heart rate is 92 b.p.m. at 1446 hours with no diary entry.Occasional to frequent PACs, occasional PVCs. Unifocal ventricular couplet at 1601 hours. Six- beat run of ventricular tachycardia at 2306 hours with no diary entry. The patient remained asymptomatic throughout.ASSESSMENT:1. Right bundle branch block, with rates from 57 to 92 b.p.m2. Ventricular tachycardia with ventricular couplet and 6-beat run3. Plavix dailyElectronically signed by 1/1/20XX

CaseID: OPD7182 Primary Diagnosis: D25.2 CPT: 58545, 58350-50

MEDICAL RECORD AGE: 28SEX: FEMALEDATE OF OPERATION: 01/13/xxPREOPERATIVE DIAGNOSIS: CHRONIC PELVIC PAIN.PROCEDURES: LAPAROSCOPIC MYOMECTOMY WITH CHROMOPERTUBATION.POSTOPERATIVE DIAGNOSIS: FIBROID UTERUS.SURGEON: Pasquale M. Kramer, M.D.FIRST ASSISTANT:ANESTHESIA: GENERAL, ENDOTRACHEAL.ESTIMATED BLOOD LOSS: BELOW 20 CC.IV FLUIDS: 1000 CC OF LACTATED RINGER'S.URINE OUTPUT: 100 CC OF CLEAR URINE AT THE END OF THE PROCEDURE.COMPLICATIONS: NONE.PROCEDURE: After an informed consent, the patient was taken to the operating room where general endotracheal anesthesia was induced. The patient was in the dorsal lithotomy position. The exam under anesthesia revealed an anteverted uterus of about 6 to 7-week size. No adnexal mass palpated. The patient was prepped and draped in the normal sterile fashion.A weighted speculum was placed into the patient's vagina. A single tooth tenaculum was advanced through anterior portion of the cervix. The uterus was sounded and a HUMI manipulator was placed into the cervical os. A Foley catheter was inserted into the bladder. The speculum was removed.Attention was turned into the patient's abdomen where a 10-mm skin incision was made at the umbilical fold. A Veress needle was carefully introduced into the peritoneal cavity at a 45-degree angle while tenting up the abdominal wall. Intraperitoneal placement was confirmed by the use of CO2 insufflation with opening pressure below 10 mm. The trocar and sleeve were advanced without difficulty into the abdomen where intraabdominal placement was confirmed by the laparoscope. Pneumoperitoneum was obtained with 4 liters of CO2 gas. Two extra ports were inserted. One supraumbilical and one on the left lateral side. Two more trocar and sleeves were inserted. Both incisions were about 5-mm. The survey of the abdomen revealed one small subserosal myoma antever

CaseID: OPD6983 Primary Diagnosis: K60.311 Secondary Diagnosis: K60.1 CPT: 46270

MEDICAL RECORD AGE: 28SEX: MALEDATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: CHRONIC ANAL FISSURE.PROCEDURES: EXAM UNDER ANESTHESIA, RIGID PROCTOSCOPY, FISTULOTOMYPOSTOPERATIVE DIAGNOSIS: CHRONIC ANAL FISSURE AND ANAL FISTULA.SURGEON: M.D.ANESTHESIA: LOCAL WITH SEDATION.ANESTHESIOLOGIST: M.D.ESTIMATED BLOOD LOSS: MINIMAL.SPECIMEN: FISTULAR TRACT.COMPLICATIONS: NONE.PROCEDURE: The patient was placed in the prone position and the area was prepped and draped in the standard fashion. Approximately 0.5 ml of 1:1 mixture of 0.5% Marcaine and sodium bicarb were infiltrated as a ring block for local anesthesia.Upon initial inspection, a small fistula opening approximately 3 cm from the anal verge in the posterior midline was noted and a fissure in the posterior midline was also noted. No sign of hemorrhoids or any other lesions. Rigid proctoscopy was performed to10 cm and then limited by stool in the vault but revealed normal mucosa to that level. Using a fistula probe, the fistula opening was entered, and the fistula tract was identified opening up into the posterior midline fissure. A fistulotomy was then performed with electrocautery. The base of the fistula tract was bluntly excised and sent to pathology as a specimen. Hemostasis was achieved. The area was irrigated, and a sterile dressing was applied.The patient tolerated the procedure well and was transferred to recovery room in stable condition, will be discharge home that day. All instrument, sharp and sponge count was found to be correct.Electronically signed by: MD 1/1/20XX

CaseID: OPD6993 Primary Diagnosis: K40.90 Secondary Diagnosis: D17.6 CPT: 49505-RT

MEDICAL RECORD AGE: 37SEX: MALEDOS: 1/1/20XXPHYSICIAN: MDPREOPERATIVE DIAGNOSIS: Right inguinal hernia.POSTOPERATIVE DIAGNOSES:1. Right inguinal hernia (indirect).2. Small cord lipoma.OPERATIVE PROCEDURE:1. Open right inguinal hernia repair with mesh.2. Resection of cord lipoma.SURGEON: MDASSISTANT:ANESTHESIA: General and local.COMPLICATIONS: None.FINDINGS: He did have a small cord lipoma and an obvious medium sized indirect inguinal hernia. The defect was not very lax or large.INDICATIONS: The patient is a male that has developed a bulge, which is uncomfortable in his right groin. Exam confirms a right inguinal hernia. He now presents for repair of a right inguinal hernia.DESCRIPTION: After informed consent was obtained and after marking the area, the patient was brought back to the operating room and placed on operating table in supine fashion. After adequate monitors were placed, the patient underwent general anesthesia. The right groin was prepped with Hibiclens soap and sterilely draped. A time out was performed, confirming the patient and the procedure. A local anesthetic was infiltrated in the skin and a skin incision made. The dissection was taken down to the external oblique fascia and I divided the external oblique fascia in the direction of the fibers. I then swept my finger around the spermatic cord at the pubic tubercle and placed a Penrose drain around this. I then separated the cremasteric fibers and then eventually identified the indirect inguinal hernia sac. I slowly dissected this out. This was somewhat scarred, but I eventually was able to dissect it out. I entered into the hernia sac right at the apex and this was suture ligated using 2-0 Vicryl. I further skeletonized our hernia sac all the way down to its neck.I did identify a small cord lipoma, which was dissected off and removed. I then pushed t

CaseID: OPD6964 Primary Diagnosis: S42.464A CPT: 24579-RT

MEDICAL RECORD AGE: 48SEX: MALEDATE OF OPERATION: 01/01/20XXPREOPERATIVE DIAGNOSIS: RIGHT MEDIAL COLUMN INTRAARTICULAR DISTAL HUMERUS FRACTURE.PROCEDURES: RIGHT ELBOW ORIF, MEDIAL COLUMN IN INTRAARTICULAR PORTION WITH ANTERIOR ULNAR NERVE TRANSPOSITION.POSTOPERATIVE DIAGNOSIS: NONDISPLACED RIGHT MEDIAL COLUMN INTRAARTICULAR DISTAL HUMERUS FRACTURE.SURGEON: M.D.ANESTHESIA: GENERAL VIA ENDOTRACHEAL TUBE.ESTIMATE BLOOD LOSS: 20 CC.TOURNIQUET TIME: 90 MINUTES.ANTIBIOTICS: ANCEF 1 GM PREOP, 1 GM ANCEF POSTOP.COMPLICATIONS: NONE.INDICATIONS: This patient is a right-dominant male who fell at work getting off his truck, sustained a closed right medial column nondisplaced intraarticular fracture of the distal humerus. Options, risks and benefits were discussed with the patient and he agreed with open reduction internal fixation and ulnar nerve transposition and possible olecranon osteotomy.PROCEDURE: The patient was brought to the operating room and anesthesia was induced via endotracheal tube. The patient was placed in the left lateral decubitus position on a bean bag and the right upper extremity was prepped and draped in sterile fashion. His limb was exsanguinated and the tourniquet was inflated to 250.A longitudinal incision was made over the olecranon and extended proximally and distally. The ulnar nerve was identified along the medial triceps and traced up to the medial intermuscular septum. It was traced distally down to the first branch to the flexor carpi ulnaris. A Penrose drain was placed around the ulnar nerve and that was used to protect the nerve throughout the case. The fracture surfaces were subperiosteally dissected irrigated out and curetted.The trochlear fragment was reduced to the medial column and held with 1.3 K-wires. It was reduced to the capitellum and viewed by performing a partial triceps slide from m

CaseID: OPD7379 Primary Diagnosis: N81.3 Secondary Diagnosis: N39.3 CPT: 58260, 57288

MEDICAL RECORD AGE: 50SEX: FEMALEDATE OF OPERATION: 11/30/xxPREOPERATIVE DIAGNOSIS: COMPLETE UTERINE PROLAPSE, STRESS URINARY INCONTINENCE.PROCEDURES: TOTAL VAGINAL HYSTERECTOMY, RIGHT SACROSPINOUS FIXATION, TRANSOBTURATOR SLING PLACEMENT AND CYSTOSCOPY.POSTOPERATIVE DIAGNOSIS: COMPLETE UTEROVAGINAL PROLAPSE, STRESS URINARY INCONTINENCE.SURGEON: Gregorio M. Kramer, M.D.FIRST ASSISTANT: Eri Andrews, M.D.ANESTHESIA: GENERAL, ENDOTRACHEAL.ANESTHESIOLOGIST: ESTIMATE BLOOD LOSS: 100 CC.IV FLUIDS: 2300 CC OF LR.URINE OUTPUT: 350 CC OF CLEAR URINE AT THE END OF THE PROCEDURE.COMPLICATIONS: NONE.FINDINGS: Atrophic uterus with complete uterovaginal prolapse. Normal ovaries status post tubal ligation.INDICATIONS: The risks, benefits, indications and alternatives of the procedure were reviewed with the patient and informed consent was obtained.PROCEDURE: The patient was taken to the operating room with IV running. General anesthesia was applied without difficulty. The patient was placed in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. A Foley catheter was placed.The cervix was grasped with the tooth tenaculum. The cervix was injected circumferentially with normal saline. The cervix was circumferentially incised with the Bovie and the bladder dissected off the pubovesicocervical fascia anteriorly with Metzenbaum scissors.The same procedure was performed posteriorly and the Heaney clamp was placed bilaterally and transected and suture ligated with 0-chromic. Hemostasis was assured. The uterosacral ligaments were clamped and transected the same way. The cardinal ligament was clamped on both sides, transected and suture ligated in a similar fashion. The anterior cul-de-sac and posterior cul-de-sac were sharply entered with the Metzenbaum scissors. Excellent hemostasis was again obtained. The uter

CaseID: OPD6947 Primary Diagnosis: M16.11 Secondary Diagnosis: M85.451, Q27.30 CPT: 27130-RT

MEDICAL RECORD Age 68Sex: MALEDate of Service: 1/1/20XXService Department: Orthopedic Group GeneralPREOPERATIVE DIAGNOSIS: Arteriovenous malformation with severe primary osteoarthritis of the right hip.POSTOPERATIVE DIAGNOSIS: Same.NAME OF PROCEDURE: Right total hip arthroplasty.SURGEON:ANESTHESIA: GeneralDESCRIPTION OF PROCEDURE: The patient was taken to the operating room and after satisfactory general anesthesia the patient had an intrathecal block performed for postoperative pain control he was placed in the lateral decubitus position with his right hip uppermost. The right hip was then thoroughly scrubbed, prepped and draped in the usual sterile manner. The hip was incised longitudinally down to the fascia lata which was also split. This was retracted and the hip identified. The anterior half of the abductors were incised at the insertion of the greater trochanter. The leg was externally rotated. The capsule was then identified and a t-shaped incision was made in the capsule. The hip was dislocated anterolaterally. The femoral neck was the transected at the appropriate location to hold the medial neck prosthesis. The acetabulum was curetted. The labrum was removed and the acetabulum was then prepared with the combination reamers to hold a size 60 Press-Fit bone ingrowth prosthesis. The dome of the acetabulum had a large bone cyst. This was curetted. Kessel's node harvested from the patient's femoral head. The Press-Fit 60 mm prosthesis was then impacted in position. The Polyethylene liner was then inserted with the 10 degree buildup at the 10 o'clock position. The femur was then prepared with the Stryker instrument to hold a size 10 Press-Fit bone ingrowth prosthesis. This was impacted down the femoral canal. Trial reduction was performed with the -5 to -2.5 and 0 head and neck length. The -2.5 was selected. This

CaseID: OPD7183 Primary Diagnosis: O00.101 CPT: 59120

MEDICAL RECORD Age: 39SEX: FEMALEDATE OF OPERATION: 11/02/20xxPREOPERATIVE DIAGNOSIS: RIGHT SIDE TUBAL PREGNANCY.PROCEDURES: PRIMARY LOW TRANSVERSE INCISION VIA PFANNENSTIEL MINI LAPAROTOMY. RIGHT SALPINGECTOMYPOSTOPERATIVE DIAGNOSIS: RIGHT SIDE TUBAL PREGNANCY.SURGEON: Ezequiel M. Kramer, M.D.FIRST ASSISTANT:ANESTHESIA: GENERAL, ENDOTRACHEAL.ESTIMATED BLOOD LOSS: 300 CC. AND FLUID WAS EVACUATED FROM THE PERITONEAL CAVITY.URINE OUTPUT: 150 CC CLEAR URINE AT THE END OF THE PROCEDURE.COMPLICATIONS: NONE.ESTIMATED BLOOD LOSS: ABOUT 300 CC.URINE OUTPUT: AT THE END OF THE PROCEDURE ABOUT 200 TO 250 CC CLEAR URINE.FINDINGS: Normal anteverted uterus with closed os.INDICATION: Right-sided tubal pregnancy.HISTORY: The patient is a 39-year-old gravida IV, para 1-1-2-1 presenting for a laparotomy, right salpingectomy for right tubal pregnancy. The patient's history is significant for prior bilateral tubal ligation also prior tubal reversal anastomosis. The patient also has a history of diabetes controlled with p.o. Sulfonylurea. The patient presented to the emergency room with right-sided abdominal pain beta hCG in the ER showed very low 596. Ultrasound showed ectopic pregnancy. The patient was counseled about ectopic pregnancy with the risks and benefits were explained. The patient opted for operative management of the ectopic pregnancy. The patient was consulted for possible laparotomy. The consent was voluntarily obtained.PROCEDURE: The patient was taken to the operating room where general anesthesia via the endotrachea was found to be adequate. The patient was then draped and prepped in the normal sterile fashion in the dorsal supine position. The patient was also examined under anesthesia.A Mini Laparotomy 4cm Pfannenstiel skin incision was then made with a scalpel and carried through to the underlying layer of fascia with t

CaseID: OPD6949 Primary Diagnosis: M19.011 Secondary Diagnosis: M75.41 CPT: 29824-RT, 29826-RT

MEDICAL RECORD Age: 46 Sex: FEMALEDate of Service: 1/1/20XXService Department: Orthopedic Group GeneralPREOPERATIVE DIAGNOSIS: Right shoulder chronic impingement, AC joint primary arthritis.POSTOPERATIVE DIAGNOSIS: Same.NAME OF PROCEDURE: Right shoulder examination under anesthesia, arthroscopy, acromioplasty, distal clavicle excision.SURGEON: Dr. MDANESTHESIA: General with scalene block.ESTIMATED BLOOD LOSS: Minimal.COMPLICATIONS: None.DESCRIPTION OF PROCEDURE: After appropriate pre-operative marking and time out the patient was given a scalene block. After time out the patient was placed under endotracheal intubation and general anesthesia. The shoulder was examined. There was full range of motion and all ligaments were stable. The shoulder was then prepped and draped free in the usual manner.A posterior portal was established after insufflating the joint with 50 mL of sterile saline. Within the shoulder joint we found completely normal cartilage on both articular surfaces. The inferior recess was clear. The subscapularis inserted normally without tearing. The biceps tendon proper was intact. The supraspinatus was intact with no signs of degeneration or tearing. The infraspinatus and posterior bare area were normal. We established a portal anteriorly in the interval above the subscapularis. There was a normal insertion of the bicep tendon to the superior glenoid. The labrum was attached solidly to bone.We placed the arthroscope into the subacromial space. There were significant impingement findings with a lot of degeneration and abrasion along the anterior edge of the acromion and superior cuff. There was extensive adhesions and bursitis. There was no tearing of the bursal side of the cuff. We established a lateral portal and debrided the undersurface of the acromion of soft tissue and performed an acromioplasty. We

CaseID: OPD7513 Primary Diagnosis: I67.9 CPT: 93308-26, 93321-26, 93325-26

MEDICAL RECORD CARDIOLOGYSEX: MALEAGE: 67Transthoracic Echocardiography ReportLimited 2D Study with M-Mode, Limited Spectral Doppler, and Color Doppler01/01/20XXAccount: Status: InpatientLocation: Tape: Ht 69 in (175.3 cm)Wt 211.2 lb (96 kg)BSA 2.12 m squaredDiagnoses: - CEREBROVASC DISEASE NOSEcho Attending: Echo Technologist: Attending Ordering: SummaryLeft ventricle: Systolic function was normal. Ejection fraction was estimated in the range of 55% to 65%. There were no regional wall motion abnormalities. COMPARISONS: No previous study is available for comparison.HISTORY: PRIOR HISTORY: Risk factors: hypertension, oral hypoglycemic-treated diabetes, and medication-treated hypercholesterolemia. PROCEDURE: The procedure was performed at the bedside. This was a routine study. The transthoracic approach was used. Limited or follow-up 2D echocardiography study was performed with M-mode, limited spectral Doppler, and color Doppler. The heart rate was 91 b.p.m. at start. Systolic blood pressure was 106 mmHg at start. Diastolic blood pressure was 60 mmHg at start. Images were obtained from the parasternal and apical acoustic windows. Echocardiographic views were limited by restricted patient mobility and poor patient compliance. This was a technically difficult study.LEFT VENTRICLE: Size was normal. Systolic function was normal. Ejection fraction was estimated in the range of 55% to 65%. There were no regional wall motion abnormalities. Wall thickness was normal. DOPPLER: The ratio of early ventricular filling to atrial contraction velocities was within the normal range.AORTIC VALVE: The valve was not well visualized.AORTA: Not well visualized.MITRAL VALVE: Valve structure was normal. There was normal leaflet separation. DOPPLER: The transmitral velocity was within the normal range. There was no evidence for stenosis. There

CaseID: OPD6973 Primary Diagnosis: I49.5, I45.5 Secondary Diagnosis: CPT: 33208, 99152, 99153 x3 E/M Level:

MEDICAL RECORD CARDIOPULMONARY REPORT:ADMISSION DATE: 01/01/20XX PT ROOM: W.2S04DISCHARGE DATE: DATE OF SERVICE: 01/01/20XXSURGEON PHYSICIAN: INDICATIONS: Sick sinus syndrome with sinus arrest. ANESTHESIA: Conscious Sedation - Time: 60 mins. administered by MD PROCEDURES PERFORMED: Dual-chamber pacemaker with A and B lead insertion, and an axillary venogram. DESCRIPTION OF PROCEDURE: After informed consent was obtained, and preoperative antibiotics given, the patient was brought to the procedure laboratory in a fasting state. The patient was prepped and draped in the usual sterile fashion. After local anesthesia with lidocaine and administration of conscious sedation by me, an incision was made in the infraclavicular area. Electrocautery was carried out to the level of the prepectoral fascia, and all bleeding was controlled with electrocautery. The pacemaker pocket was fashioned using electrocautery along the fascial planes. An axillary venogram was the performed, the axillary vein was then entered using a sterile Seldinger technique. The pacemaker leads were placed through the peelaway sheaths to the level of the IVC, the peelaway sheaths were removed and hemostasis was obtained using manual pressure. The leads were then manipulated into position under fluoroscopic guidance, where the active fixation device was deployed. Appropriate sensing and capturing values were obtained and 10-volt pacing did not result in any diaphragmatic stimulation. The leads were then anchored to the prepectoral fascia using nonabsorbable sutures. The pocket was irrigated with antibiotic solution and the device generator was brought to the field. The generator was connected to the leads and the generator and the leads were delivered in the pocket where the generator was anchored to the prepectoral fascia using a single nonabsorbable suture.

CaseID: OPD6974 Primary Diagnosis: I48.3, I50.9, I87.1 CPT: 33249, 99152, 99153 x4, 93641

MEDICAL RECORD CARDIOPULMONARY REPORT:ADMISSION DATE: 01/01/20XXDISCHARGE DATE: DATE OF SERVICE: 01/01/20XXSIGNING PHYSICIAN: MD REFERRING PHYSICIAN: MD FLUOROSCOPY TIME: 6.8 minutes. PROCEDURES PERFORMED: Aborted EP study; the patient did undergo dual-chamber ICD implantation and DFT testing. INDICATIONS: Typical Atrial flutter and CHF. OPERATOR: MD ANESTHESIA: Conscious Sedation - Time: 70 min. COMPLICATIONS: None. DESCRIPTION OF PROCEDURE: The patient entered the lab in a fasting state. He was prepped and draped in the usual sterile manner. Then 1% lidocaine was used to infiltrate the skin over the right femoral vein. Afterwards, a Seldinger percutaneous technique was used to gain access into what was presumed to be the right femoral vein. However, the wire would not advance. Contrast was flushed into the vein demonstrating that the patient had had a prior DVT here and now and collateral flow and, thus, no access was possible from the right femoral vein. Attention was then turned to the left femoral vein. A puncture was made, a Woolley wire was passed away up into the inferior vena cava at the mid-thorax region. However, at this point, the Woolley wire would pass no further and again, a sheath was placed near that area. Again, contrast was flushed through the area, demonstrating that the patient's inferior vena cava was completely obstructed, and he had collateral flow. Therefore, there was no access from the inferior vena cava and attempts at the atrial flutter ablation were aborted. Then 1% lidocaine was used to infiltrate the skin below the left clavicle. After that, an incision with a scalpel through the skin. Electrocautery was then used to cut down to the level of the prepectoral fascia. All hemostasis was obtained with electrocautery. The pocket was fashioned with electrocautery. Afterward, a Seldinger percut

CaseID: OPD6976 Primary Diagnosis: Z45.010 Secondary Diagnosis: I44.30 CPT: 33228

MEDICAL RECORD CARDIOPULMONARY REPORT:AGE: 80 SEX: FemalePT LOCATION: W.CLDATE OF SERVICE: 01/01/20XX SIGNING PHYSICIAN: MD ELECTROPHYSIOLOGY PROCEDURE REFERRING PHYSICIAN: MD FLUOROSCOPY TIME: 0 minutes PROCEDURE PERFORMED: Pacemaker generator change and pocket revision. INDICATIONS: AV block with device at ERI OPERATOR: MD ANESTHESIA: Conscious Sedation - Time: 45 mins COMPLICATIONS: None. DESCRIPTION OF PROCEDURE: The patient entered the lab in a fasting state. She was prepped and draped in the usual sterile manner. Lidocaine 1% was used to infiltrate the skin 2 cm below the left clavicle over the previous device. An incision was made through the skin, electrocautery was cut down to the level of the pre-existing can. The leads and the can were freed from the pocket and a partial capsulectomy was performed. The pocket was revised to the size of the new pacemaker and it was moved more laterally for patient comfort. The leads were then tested and found to be functioning normally. The pocket was flushed with antibiotic solution and the device generator was attached to leads and delivered in the pocket and sewn into position using a nonabsorbable suture. The device was then closed with standard 3-layer closure. Device information is as follows: The right atrial lead is a St. Jude Medical model #1688T/46, serial # DNxxxxxx. The generator is a St. Jude Medical model PM2110, serial # xxxxxxx. The right atrial lead is sensing 1.6 millivolt, P waves has a threshold of 1.2 V at 0.4 milliseconds, and an impedance of 540 ohms. The right ventricular lead has no R waves, it has a threshold of 0.8 V at 0.4 milliseconds, and an impedance of 570 ohms. CONCLUSIONS: Successful device generator change, successful pocket revisions and there are no complications.CWT/hs Conf #: 664749 DID: 1261287 D; 01/01/20XX 08:45:50 T: 01/01/20XX 10:11

CaseID: OPD7498 Primary Diagnosis: Z22.322 CPT: 81002 E/M Level: 99202

MEDICAL RECORD CLINIC VISIT - NEW PATIENT SEX: FEMALEAGE: 31DATE OF ADMISSION: 09/4/20XXPRIMARY CARE PROVIDER: Dr. Ed Kramer, M.D.CHIEF COMPLAINT: Patient reports exposure to MSRA ALLERGIES: NKDA CURRENT MEDICATIONS: NoneHPI: Patient is a 31 year old female with recent MSRA to bladder infection. Patient's son also has bacterial infection to phimotic foreskin. Patient requests to provide with pelvic examination for perineal lesions as well as nasal swab cultures to make sure she does not have any other MSRA infection prior to her son's circumcision.PAST SURGICAL HISTORY: No information available.PAST MEDICAL HISTORY: Supervision of normal pregnancy.CURRENT MEDICATIONS: NoneVITAL SIGNS: BP is 128/88, pulse 74, resp 18, temp 102.1, O2 sat 99% on room air.REVIEW OF SYSTEMS:SYSTEMIC: Feeling tired. No fever or ChillsHEAD: No headacheEYES: No vision problemsCARDIOVASCULAR: No chest pain or discomfortPULMONARY: No dyspneaGASTROINTESTINAL: No vomiting and no abdominal painGENITOURINARY: No Hematuria. Urine is unchanged in appearance. No changes in urinary habits. No dysuria. ENDOCRINE: No hot flashesPSYCHOLOGICAL: No anxiety or depressionSKIN: No lesions or rashQUESTIONAIRE AUA System Index for BPH1. Not at all2. Less than 1 time in 53. Less than half the time4. More than half the time5. Almost alwaysPage Two- Sylvia JonesIncomplete Emptying: Over the last month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? 5Frequency: During the last month, how often have you had to urinate again less than 2 hours after you finished urinating? 2Intermittency: During the last month, how often have you stopped and started again several times when you urinated? 5Urgency: During the last month, how often have you found it difficult to postpone urination? 3Weak Stream: During the last mon

CaseID: OPD7385 Primary Diagnosis: R87.612 Secondary Diagnosis: Z32.02 CPT: 57454, 81025

MEDICAL RECORD DATE: 11/21/20xxSEX: FEMALEAGE: 39HISTORY: She came in for a colposcopy and ECC due to an abnormal pap smear with LGSIL. Procedure was explained to patient. Questions were answered. Urine pregnancy test done, results negative.COLPOSCOPY: Patient was put in lithotomy position and speculum was inserted. At the time that we did the ECC and did the colposcopy via Gynecor making sure that we got good diagnostic tissue. Specimen obtained at 12-1 o'clock and at 1-4 o'clock. After the procedure was terminated no bleeding was noted. Patient was sent home.PLAN: Patient to call back in 7-10 days for results.signed Dr. Kramer

CaseID: OPD7259 Primary Diagnosis: S82.842A Secondary Diagnosis: W03.XXXA, Y93.61 CPT: 27840-LT, 99152 E/M Level: 99284-57

MEDICAL RECORD EMERGENCY DEPARTMENT Age 26 Sex: M DOS: 1/1/20XX CHIEF COMPLAINT: Left ankle pain. HPI: This is a male who was playing football when another player landed on his left ankle and he fell to the ground. He heard a pop and saw his leg deformed. He denies any other injuries and was wearing a helmet. He otherwise feels well. He comes in with a splint on his leg, but no pain medication prior to arrival. PAST MEDICAL HISTORY: Denies. MEDICATIONS: Denies. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient does not smoke or drink alcohol. REVIEW OF SYSTEMS: As per the HPI, otherwise unremarkable. He specifically also does not have any distal paresthesias, though he does have some numbness about the ankle. PHYSICAL EXAM: VITAL SIGNS: Temperature 99.4, pulse 76, respiratory rate 16, pulse oximetry 100%, blood pressure 126/75. GENERAL: He is a well-developed, well-nourished, pleasant young man appearing his stated age and appearing to be in a good bit of pain. HEENT: Pupils are equal, round and reactive to light. Oropharynx, clear. NECK: No vertebral tenderness. RESPIRATORY: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops or rubs. GI: Soft, nontender, nondistended with normal bowel sounds. EXTREMITIES: The patient's left leg is in a splint. You can see that there is notable deformity. Capillary refill distally is intact and less than 2. NEURO: Distal sensation and motion are intact. EMERGENCY ROOM COURSE: X-ray reveals a bimalleolar fracture with a posterior and lateral malleolus fracture as well as dislocation of the ankle. I discussed the findings with the patient and the need for conscious sedation as well as manipulation and need for ultimate surgery. Discussion occurred before pain medications were received by the patient. Risks and benefits of sedatio

CaseID: OPD7254 Primary Diagnosis: M70.22, M10.071, M85.471, M19.071 E/M Level: 99284

MEDICAL RECORD EMERGENCY DEPARTMENT SEX: Male AGE: 48 DOS: 1/1/20XX Time Seen: 1133. Arrived- By private vehicle. Historian- patient. HISTORY OF PRESENT ILLNESS Chief complaint- UPPER EXTREMITY PAIN and SWELLING and complaint; PROBLEM IN THE LEFT ELBOW; (and right ankle pain). This started several years ago and is still present and now worse. (for one week.). It was gradual in onset and has been constant and waxing/waning. Severity is described as being moderate in degree. It has become recently worse. The quality is noted to be aching and pain. No radiation. Modifying factors- worsened by movement. Made better by rest. Not made better by anything. Symptoms located in the area of the left elbow. He has had swelling, (over the left olecranon c/w bursitis. no sign of infection - not hot or red or painful). No chest pain or difficulty breathing. The patient has not had redness. Patient denies an injury. Similar symptoms previously: He has had similar symptoms previously (right ankle pain is chronic, just with increased pain and swelling in the past week.). Recent medical care: (no pmd). Not recently seen/assessed. REVIEW OF SYSTEMS: The patient has had a subjective fever (several days ago - gone). No chills or skin rash. All systems otherwise negative, except as recorded above. PAST HISTORY: Arthritis (ankles and knees). Surgeries: Right knee surgery. Medications: None. Allergies: Lortab. SOCIAL HISTORY: No drug use. No recent travel. ADDITIONAL NOTES: The nursing notes have been reviewed. PHYSICAL EXAM: Appearance: Alert. Oriented X3. No acute distress. Vital Signs: Have been reviewed and normal. Eyes: Pupils equal, round and reactive to light. CVS: Normal heart rate and rhythm. Heart sounds normal. Respiratory: No respiratory distress. Breath sounds normal. Skin: Skin intact. Skin warm and dry. Normal skin color. Extrem

CaseID: OPD7235 Primary Diagnosis: R07.9 CPT: 93010, 93042-59 E/M Level: 99284-25

MEDICAL RECORD EMERGENCY DEPARTMENTSEX: FEMALE AGE: 27DOS: 01/01/20XXTime Seen: 04:41 JAN 1 20XX. Arrived- By private vehicle. Historian- patient.HISTORY OF PRESENT ILLNESS: Chief Complaint: CHEST PAIN. This started about 4 hours ago and is still present. It was gradual in onset. Onset during rest. It is described as pain and it is described as located in the left chest area and radiating to the left shoulder. At its maximum, severity described as moderate. When seen in the E.D., severity described as moderate. Modifying factors- Not worsened by anything. Not relieved by anything. She has had mild difficulty breathing. No nausea, vomiting or diaphoresis. No additional chest pain. Similar symptoms previously: She has had similar symptoms previously.REVIEW OF SYSTEMS: No fever, chills, cough, pedal edema or calf pain. No abnormal bleeding, vaginal discharge, fainting episodes, headache or sore throat. No blurred vision, abdominal pain, black stools, difficulty with urination or skin rash. No enlarged lymph nodes or joint pain. All systems otherwise negative, except as recorded above.PAST HISTORY: anxiety. No history of hypertension or diabetes mellitus.Risk factors for heart disease- no; for abdominal aortic aneurysm- no. Denies the following risk factors for heart disease - hypertension, diabetes and elevated cholesterol. Denies the following risk factors for thoracic aortic dissection - hypertension, pregnancy, connective tissue disorder, prior history of thoracic aortic dissection and coarctation of the aorta. Denies the following risk factors for thoracic aortic dissection - Turner's syndrome. Denies the following risk factors for abdominal aortic aneurysm - connective tissue disorder, hypertension and prior abdominal aortic aneurysm. Denies the following risk factors for DVT/PE - history of DVT and pulmonary embolis

CaseID: OPD7248 Primary Diagnosis: I48.91 Secondary Diagnosis: Z79.02 E/M Level: 99285

MEDICAL RECORD EMERGENCY DEPARTMENTSEX: FEMALE AGE: 91DOS: 1/1/20XXTime Seen: 09:55 Arrived- By private vehicle. Historian- patient and family.HISTORY OF PRESENT ILLNESS:Chief Complaint: NAUSEA and WEAKNESS. This started several days ago and is still present. At its maximum, severity is described as severe. When seen in the E.D., severity is described as severe. Modifying factors- Not worsened by anything. Not relieved by anything. She has had loss of appetite, fatigue and weakness. No weight loss, headache, visual disturbance or muscle aches. Denies sleep problem. No decreased urine output. Similar symptoms previously: None.Recent medical care: Not recently seen/assessed.REVIEW OF SYSTEMS:The patient has had nausea. No fever, sore throat, sinus drainage, nasal congestion or cough. No difficulty breathing, chest pain, abdominal pain, vomiting or diarrhea. No black stools, bloody stools, chills, difficulty with urination or skin rash. No back pain, calf pain, headache, blackouts or double vision. No difficulty with ambulation. All systems otherwise negative, except as recorded above.PAST HISTORY: I suspect this pt has a-fib history.Medications:Hydrocodone Bitartrate ran out 3 days ago.Plavix Oral.Allergies: NKDA.SOCIAL HISTORY: Nonsmoker. No alcohol use.ADDITIONAL NOTES: The nursing notes have been reviewed.Weight: 49.9 kg measured. Height: 67 inches Per Patient. BMI: 17.2.PHYSICAL EXAM:Appearance: Alert. No acute distress.Vital Signs: Have been reviewed.Eyes: Pupils equal, round and reactive to light. Eyes normal inspection.ENT: Nose normal. Pharynx normal. Neck: Normal inspection. Neck supple.CVS: Tachycardia. Abnormal rhythm, which is irregularly irregular.Respiratory: No respiratory distress. Breath sounds normal.Abdomen: No visible injury. Soft and nontender.Back: Normal inspection.Skin: Skin warm. Normal skin colo

CaseID: OPD7231 Primary Diagnosis: I44.2 Secondary Diagnosis: R19.7, E11.9, I10 CPT: 93010, 93010-76 E/M Level: 99285-25

MEDICAL RECORD EMERGENCY DEPARTMENTSEX: FEMALE AGE: 98DOS: 01/01/20XXTime Seen: 0808. Arrived- By private vehicle. Historian- patient and family.HISTORY OF PRESENT ILLNESS:Chief Complaint: CHEST PAIN. This started today and is still present. It was abrupt in onset and has been constant. Onset during rest. At its maximum, severity described as mild. When seen in the E.D., severity described as mild. Modifying factors- Not worsened by anything. Not relieved by anything. She has had nausea and vomiting. Similar symptoms previously: None.Recent medical care: Not recently seen/assessed.REVIEW OF SYSTEMS: The patient has had moderate diarrhea (since yesterday). This has occurred several times. No bloody diarrhea. No fever, chills, cough, pedal edema or calf pain. No abdominal pain. All systems otherwise negative, except as recorded above.PAST HISTORY: Diabetes mellitus II.Risk factors for heart disease- hypertension and diabetes; for thoracic aortic dissection- hypertension; for abdominal aortic aneurysm- hypertension. Denies the following risk factors for heart disease - smoking. Denies the following risk factors for thoracic aortic dissection - pregnancy and connective tissue disorder. Denies the following risk factors for abdominal aortic aneurysm - connective tissue disorder and smoking. Denies the following risk factors for DVT/PE - history of DVT, recent surgery and congestive heart failure.Additional Problems: Diabetes Mellitus. Hypertension.Additional Surgeries: Hip Prosthesis. Knee Surgery.Medications: DIABETES PILLS.Allergies: Unknown.SOCIAL HISTORY: Nonsmoker. No alcohol use. No recent travel.ADDITIONAL NOTES: The nursing notes have been reviewed.Weight: 42.1 kg measured. Height: 59 inches Per Patient. BMI: 18.8.PHYSICAL EXAM:Appearance: Alert. Oriented X3. No acute distress.Vital Signs: Have been reviewed and app

CaseID: OPD7407 Primary Diagnosis: T43.221A Secondary Diagnosis: F33.1 E/M Level: 99284

MEDICAL RECORD EMERGENCY DEPARTMENTSEX: FEMALEAGE: 44DOS: 1/1/20XXTime Seen: 19:52; initial patient contact. Arrived- By private vehicle. Historian- patient. HISTORY OF PRESENT ILLNESSChief Complaint: DIZZINESS. This started 2 weeks and is still present. Described as feeling light-headed (intermittent). Described as feeling mildly weak all over. Severity described as mild at its maximum. When seen in the E.D., severity described as mild. Modifying factors- relieved by nothing. Not worsened by anything. She has had nausea (intermittent). (Pt reports feeling depressed. States she hasn't felt like she has gotten the attention she needs from VMH regarding her mental condition. Was concerned that she may need to switch meds. Thought she would try taking 30 to 40 mg of Celexa/day rather than 20. States she still feels some depression and anhedonia. Describes this as an ongoing condition. States she feels weak in general. No HI/SI. Denies hearing voices. Eating and drinking ok. Hasn't done anything to harm self purposefully.). Similar symptoms previously: None. Recent medical care: Not recently seen/assessed.REVIEW OF SYSTEMS: The patient has had weakness. No headache, double vision, fainting episodes, head injury or chest pain. No palpitations, black stools, abnormal vaginal bleeding, numbness or bloody stools. No fever, sore throat, cough, difficulty breathing or abdominal pain. No diarrhea, difficulty with urination, skin rash, enlarged lymph nodes or chills. No joint pain. No difficulty walking.PAST HISTORY: Hypertension. Sleep apnea. Depression moderate. C-section, tubalSOCIAL HISTORY Non smoker, little alcohol​ADDITIONAL NOTES The nursing notes have been reviewed.PHYSICAL EXAM: Appearance: Alert. No acute distress. Vital Signs: (BP: 158/95 sitting R arm (reg adult cuff). HR: 58 (regular, normal rate and strong). RR: 16

CaseID: OPD7218 Primary Diagnosis: R07.2 E/M Level: 99284

MEDICAL RECORD EMERGENCY DEPARTMENTSEX: MALE AGE: 64DOS:1/1/20XXArrived- By private vehicle. Historian- patient and family.HISTORY OF PRESENT ILLNESS:Chief Complaint: CHEST PAIN. This started several months ago and is still present and now worse. It was abrupt in onset and has been intermittent (episodes lasting minutes). Onset during light activity. It is described as pressure and well localized and it is described as located in the central chest area. No radiation. At its maximum, severity described as moderate. When seen in the E.D., severity described as mild. Modifying factors- Not worsened by anything. Not relieved by anything. No nausea, vomiting, difficulty breathing or diaphoresis.Similar symptoms previously: He has had similar symptoms previously. These occurred occasionally. The patient was seen recently at another facility in a clinic (PCP yesterday).REVIEW OF SYSTEMS: No fever, chills, or fainting episodes Respiratory: no cough. Eyes: blurred vision ENMT: sore throat, headache GI: No black stools, or abdominal pain GU: no difficulty with urination Skin: no rash, Lymph: no enlarged lymph nodes MS: no joint or leg pain.PAST HISTORY: Hypertension. Diabetes mellitus. Hyperlipidemia.SOCIAL HISTORY: No alcohol use or drug use.FAMILY HISTORY: Negative. No history of heart disease or aortic aneurysm or dissection.PHYSICAL EXAM:Appearance: Alert. Oriented X3. No acute distress. Oxygen being administered by nasal cannula. IV present X 1. EKG monitor and O2 sat monitor on the patient. (BP: 172 / 91 lying auto. HR: 83. O2 saturation: 96 %. (sinus rhythm with frequent PVCs).).Vital Signs: Abnormal and appear to be correct- hypertensive.Eyes: Eyes normal inspection. No scleral icterus or pale conjunctivae.ENT: Pharynx normal.Neck: Normal inspection. Neck supple.CVS: Normal heart rate and rhythm. Heart sounds normal. Pul

CaseID: OPD7420 Primary Diagnosis: S00.83XA Secondary Diagnosis: W20.8XXA, Y92.512 E/M Level: 99283

MEDICAL RECORD EMERGENCY DEPARTMENTSEX: MALEAGE: 4DOS: 1/1/20XXTime Seen: 1342. Arrived- By private vehicle. Historian- mother. HISTORY OF PRESENT ILLNESS: Chief Complaint- INJURY TO HEAD. Location of injuries- head. This occurred just prior to arrival. The patient sustained a blow. (store). (Had minor head injury with minimal swelling about a week ago from falling (Monday) cried 20 seconds and resumed normal activity. Has been fine since. When at department store she heard crash and there was mannequin on floor, mom thinks he pulled it onto himself. He now has swelling on forehead and is more fussy. Still alert, eye contact, no vomiting, is interactive). The patient complains of mild pain (fussing). The patient cried immediately. No loss of consciousness, seizure or neck pain. Not dazed. REVIEW OF SYSTEMS:The patient has been fussy. No chest pain, enlarged lymph nodes, weakness, abdominal pain or difficulty breathing. No laceration, fever or vomiting. Has not recently been ill. All systems otherwise negative, except as recorded above. PAST HISTORY(VSD Mitral valve defect). Immunizations received (missing 2 yo vaccines). SOCIAL HISTORY: Caregiver- mother. Does not attend daycare. ADDITIONAL NOTESWeight: 9.4 kg measured. Growth Chart Percentile: Weight: 0.1%. PHYSICAL EXAM:Appearance: Alert. Not lethargic. Strong cry on exam only. Attentive. The patient makes eye contact. Active. Vital Signs: Have been reviewed and normal. Head: Anterior fontanel closed. Forehead: moderate tenderness and swelling (3 x 3 cm swelling mid forehead, soft no step off, seems extracranial). Eyes: Pupils equal, round and reactive to light. EOM intact. ENT: No dental injury. Normal external inspection. No hemotympanum. No malocclusion. Neck: Neck non-tender. Painless ROM. CVS: Capillary refill normal. Strong peripheral pulses. Heart sounds norma

CaseID: OPD7213 Primary Diagnosis: S29.011A Secondary Diagnosis: N28.9, R07.1, Y93.F2, X50.0XXA E/M Level: 99284

MEDICAL RECORD EMERGENCY DEPARTMENTSex: MAGE: 64DOS: 1/1/20XXCHIEF COMPLAINT: Chest pain.HPI: This is a male who comes in complaining of chest pain that he describes as squeezing from each shoulder toward the middle. It is pleuritic in nature. He states it feels like angina. It began 7 1/2 hours ago. He took 2 aspirin when it began, and then went to bed. This morning it seemed to feel worse, so he took 2 more aspirin, and a few hours later decided to come in to the hospital. He states in the past he was given a prescription for nitroglycerin, however, he never had any cardiac workup, including a stress test to really pinpoint the cause of his chest pain back then. He does complain of some mild shortness of breath. He denies rhinorrhea or cough. He had an episode of gastroenteritis last week, but otherwise has been well. He has not had any recent travel. Two days ago, he lifted an electric wheelchair into a car, and states that it was quite heavy.PAST MEDICAL HISTORY: (1) Chronic back pain. (2) Depression. (3) Migraines.PAST SURGICAL HISTORY: Back surgery.MEDICATIONS:Methadone.Over-the-counter headache relief.Bupropion.Hydrochlorothiazide.Lisinopril.ALLERGIES: NO KNOWN DRUG ALLERGIES.SOCIAL HISTORY: The patient quit smoking many years ago. He had smoked 15-20 years, 1 pack per day. He has not drank alcohol in 12 years.FAMILY HISTORY: Cancer. No one in the immediate family has coronary artery disease nor CVA history.REVIEW OF SYSTEMS: As per the HPI. Otherwise, unremarkable.PHYSICAL EXAMINATION: VITAL SIGNS: Pulse 85, blood pressure 154/88, pulse oximetry 95% on room air. GENERAL: Well-developed, well-nourished, pleasant man, appearing his stated age, appearing uncomfortable. HEENT: Pupils equal, round, reactive to light. Sclerae not injected, nonicteric. Oropharynx clear. NECK: Supple, nontender, no lymphadenopathy. No

CaseID: OPD7071 Primary Diagnosis: R07.89, R00.2, I25.10 Secondary Diagnosis: I25.2, Z79.02, Z79.82 E/M Level: 99284

MEDICAL RECORD Emergency Department ReportSex: FAGE: 90DOS: 01/01/20XXPatient arrived by private vehicle accompanied by family. Historian is Patient.A female who complains of difficulty breathing and weakness. She also complains of chest pain on and off for the last 3 weeks. She has been seen here in the past, but did not follow up with Dr. Kramer as recommended at that time.PHYSICAL ASSESSMENT: Alert. Oriented X 3. Appears in no acute distress. The patient has had new onset of generalized weakness. Pupils equal, round and reactive to light. No facial asymmetry noted. Respirations not labored. Chest nontender. Breath sounds within normal limits. Normal sinus rhythm noted. Abdomen soft and nontender and normal bowel sounds. Capillary refill less than 2 seconds. Pulses within normal limits. Skin intact. Mucous membranes are pink. Skin is warm and dry. Normal skin turgor.MEDICATIONS:ASA 81mg daily.CRESTOR 20MG AT NIGHT.METOPROLOL 12.5MG BID 1/2 TABLET.NTG 0.4 SUB L PRN.Pantoprazole 40mg daily.Plavix 75mg daily.PAST MEDICAL HX: CAD, Acute MI (July 20XX) and knee problems.SURGERY HX: Cholecystectomy. Hemorrhoidectomy. Tonsillectomy. (you should have them all on record. I'm just too tired. I can't even think).SOCIAL HX: Functional assessment performed: uses cane. The nutritional risk assessment revealed no deficiencies.ALLERGIES:MSG.PenicillinsLABS AND XRAYS:The X-rays were by the radiologistLaboratory Tests: Laboratory tests have been ordered, with results reviewed and considered in the medical decision making process. 0401:YJ:CG00077R: (COLL: 01/01/20XX 09:50) ( MsgRcvd 01/01/20XX 10:34) Final resultsCraig Kramer Electronically signed by CRAIG KRAMER 01/01/20XXLaboratory Test ValueHOLD TUBE FOR COAG SEE NOTERAD CHEST AP ONLY PORTABLE CHEST:1. ViewHISTORY: Difficulty breathing, chest painCompare December 1, 20XXThere are de

CaseID: OPD6966 Primary Diagnosis: T84.021A Secondary Diagnosis: T81.41XA, E86.0, Y92.129, Y93.E8 CPT: 27265-LT, 99152, 99153 E/M Level: 99285-57

MEDICAL RECORD Emergency Department ReportTime Seen: 16:41Arrived- By private vehicle. Historian- patient.HISTORY OF PRESENT ILLNESSChief Complaint- LEFT HIP INJURY. The injury occurred yesterday. Occurred at a nursing home. Patient reportedly had dislocation while having her Depends changed. The patient complains of moderate pain. No blow to the head, neck pain, loss of consciousness or seizure. Not dazed.REVIEW OF SYSTEMS: The patient has had fever. No numbness, hearing loss, headache, loss of vision or chest pain. No depression, weakness, nausea, bladder dysfunction or laceration. No vomiting. All systems otherwise negative, except as recorded above.PAST HISTORY: Hypertension. hip dislocation, recent operative repair (3/10 by Gomez).SOCIAL HISTORY: Nonsmoker. No alcohol use or drug use. Resides in a nursing home.ADDITIONAL NOTES: The nursing notes have been reviewed.PHYSICAL EXAMAppearance: Alert. Oriented X3. Patient in mild distress.Vital Signs: Have been reviewed (BP: 138 / 58. HR: 94. RR: 16. Temp: 100.5 F (oral). O2 saturation: 2 liters oxygen: 96%).Head: Head non-tender. No swelling of head.Eyes: EOM intact.ENT: Pharynx normal.Neck: Painless ROM. Non-tender.CVS: Heart sounds normal. Pulses normal.Respiratory: Breath sounds normal. Chest nontender.Abdomen: No visible injury. Soft and nontender. Bowel sounds normal. No organomegaly. No mass. Femoral pulses equal.Skin: (cellulitis to hip, otherwise unremarkable).Extremities: Left hip: moderate tenderness. The left leg is shortened. Limited ROM secondary to pain (patient with significant cellulitis around surgical site, moderate purulent drainage noted).Neuro: Oriented X 3. No sensory deficit.LABS, X-RAYS, AND EKGPelvis X-ray: (FINDINGS: The metallic a left femoral head is now in better relationship to the acetabulum previous tendon appears to be quite deformed wi

CaseID: OPD7215 Primary Diagnosis: R10.13, R11.2 E/M Level: 99283

MEDICAL RECORD Emergency DepartmentSex: F AGE: 30DOS: 1/1/20XXArrived- By private vehicle. Historian- patient.HISTORY OF PRESENT ILLNESS:Chief complaint- ABDOMINAL PAIN, NAUSEA and VOMITING. This started about 3 - 4 months ago and is still present. It is not improving. It was gradual in onset and has been waxing/waning. It is described as burning and it is described as located in the epigastric area. No radiation. At its maximum, severity described as severe. When seen in the E.D., severity described as severe. Modifying factors- worsened by food. Not relieved by anything. She has had nausea, loss of appetite and vomiting. No diarrhea. No additional abdominal pain.(s/p recent EGD in MT several mo ago, told she has erosions but not given any meds??).Similar symptoms previously: She has had similar symptoms previously. These are chronic.Recent medical care: Not recently seen/assessed.REVIEW OF SYSTEMS:No constipation, black stools, hematemesis, difficulty with urination or pain with urination. No urinary frequency, bloody stools, fever, headache or sore throat. No blurred vision, chest pain, difficulty breathing, cough or joint pain. No skin rash, chills or back pain. Denies current pregnancy. The patient has not had weight loss. All systems otherwise negative, except as recorded above.PAST HISTORY: Gastritis. Gastroesophageal reflux. Anxiety. Denies the following risk factors for ectopic pregnancy - current IUD and history of infertility, PID, tubal ligation and prior ectopic. Denies the following risk factors for ectopic pregnancy - elective abortion within the last two weeks.Surgeries: No history of previous surgery.Medications: Mood Stabilizer.Allergies: NKDA.SOCIAL HISTORY: No alcohol use or drug use.PHYSICAL EXAM:Appearance: Alert. Oriented X3. O2 sat monitor on the patient. Anxious. Appears to be in pain. Patient

CaseID: OPD7113 Primary Diagnosis: I49.3 CPT: 93227

MEDICAL RECORD HOLTER MONITORSEX: Male AGE: 51Attending Physician: Referring Physician:Date: 01/01/20XXINDICATION: PalpitationsMEDICATIONS: Atenolol.PROCEDURE: The patient was monitored on a three-channel Holter monitor for a period of 24 hours.FINDINGS: Rhythm is sinus rhythm.The average heart rate is 73 b.p.m.The minimum heart rate is 65 b.p.m.The maximum heart rate is 123 b.p.m., which was sinus tachycardia at 1449 hours. No diary entry.Occasional PACs, rare PVCs. No pauses.Diary entry at 2202 hours of waking up with palpitations. Rhythm at that time was sinus rhythm at 66 b.p.m. No ectopy.Of note: Diary entry at 1244 hours of palpitations, but monitor had stopped after 24 hours.CONCLUSION:1. Sinus rhythm with heart rates from 65 to 123 b.p.m., with Premature Ventricular Depolarization and no pauses.Robert JonesElectronically Signed by ROBERT JONES 1/1/20XX

CaseID: OPD7325 Primary Diagnosis: R09.81, B07.9 Secondary Diagnosis: CPT: 17110 E/M Level: 99214-25

MEDICAL RECORD MEDICAL RECORD SEX: MALE AGE: 10 DATE OF SERVICE: 1/1/20XXSUBJECTIVE: 10-year-old male patient presents for repeat wart treatment and to follow up for allergic rhinitis. Patient states nasal congestion has improved since starting fluticasone nasal spray treatment. He does still have some minor amount of nasal congestion, but states he has no difficulty breathing through his nose. Patient feels wart has resolved.OBJECTIVE: EXTREMITIES: Several rete pegs noted on one portion of previous wart. HEENT: Nasal mucosa continues to be swollen and blue. Patient demonstrates that he can breathe through both nostrils, but the left seems more congested than the right.ASSESSMENT AND PLAN:1. Wart. One drop Cantharone Plus applied to region of tissue with rete pegs noted. RTO in 2 weeks for repeat treatment. 2. Nasal congestion, likely due to allergic rhinitis. Will add loratadine 10 mg daily. This will be in addition to fluticasone, 1 spray each nostril daily. Follow up when patient returns in 2 weeks for wart treatment.Electronically signed by John Thompson, MD.

CaseID: OPD7357 Primary Diagnosis: M65.341 CPT: 76942, 20552-F8, J0702 x3 E/M Level: 99213-25

MEDICAL RECORD MEDICAL RECORD OFFICE - ESTABLISHED SEX: FEMALE AGE: 48 DOS: 1/1/20XX MD: Dr. Brandon AndrewsThe patient returns for reevaluation of her right ring finger triggering. The cortisone injection at her first visit gave her some improvement but not a lot. She still reports pain and triggering in the digit.PHYSICAL EXAMINATION: On examination, she has tenderness to the A1 pulley with active triggering today.DIAGNOSIS: Stenosis tenosynovitis, right ring finger.TREATMENT: The patient is requesting a second injection (she had her first one during her first visit). After verbal informed consent, the right ring finger A1 pulley and flexor sheath was injected under ultrasound guidance with 8 mg of Celestone (betamethasone and 1 mL of lidocaine). The patient tolerated the injection well. She will return as needed.Brandon Andrews, MD Electronically signed by BRANDON ANDREWS, MD 4/26/20XXUltrasound Guided Needle Placement: ULTRASOUND GUIDED: Right hand ring finger. REASON FOR EXAMINATION: Dx: Trigger finger TREATMENT PLAN: Celestone, injection given today under sterile conditions.Follow up in 1 week. Patient was instructed to contact our office for any adverse reaction.The skin overlying the right hand ring finger was prepped with Betadine and alcohol in the routine fashion. 1% Xylocaine was instilled into the soft tissues. Under ultrasound guidance using the BK Medical flex focus 400MSK ultrasound machine, a 22-gauge needle was advanced into right ringer finger and a combination of Xylocaine anesthetic and Celestone was injected.IMPRESSION: Successful right hand ring finger injection under ultrasound guidance.Brandon Andrews, MDElectronically signed by BRANDON ANDREWS, MD 1/1/20XX​

CaseID: OPD7305 Primary Diagnosis: I25.10, I11.9, E78.00 Secondary Diagnosis: Z95.5, Z79.02, Z79.82 E/M Level: 99214

MEDICAL RECORD MEDICAL RECORDOFFICE - ESTABLISHEDSEX: Male AGE: 68Date: 01/01/20XX PROBLEM LIST:1.Hospitalized (12/15/20XX) for chest pain with left heart catheter showing Atherosclerotic heart disease, treated with LAD stent and anticipating CABG in approximately three months.2.Hypercholesterolemia.3.Hypertension.4.History of depression.5.History of gout. ALLERGIES: Lisinopril causes ACE cough. MEDICATIONS:Nitroglycerin sublingual p.r.n.Metoprolol ER 50 mg q. am.Aspirin 325 mg q. am.Allopurinol 500 mg b.i.d.Plavix 75 mg q.d.Atorvastatin 80 mg q. hsMirtazapine 45 mg q. hs INTERVAL HISTORY:Patient is a male who presented to the hospital with chest pain approximately two weeks ago. Left heart catheter revealed atherosclerotic heart disease including an LAD that was amicable to a stent, which was felt to be the most likely culprit. This was stented and he was placed on Plavix. After further discussion, with his physicians and myself, it was deemed he would be a candidate for CABG bypass in approximately three months, taking into consideration hibernating myocardium and need for post-stent Plavix. He presents today feeling significantly fatigued and has a cough. He has no fever and no sputum.He does have seasonal allergies. He has had no groin or back pain. He had one episode of mid-chest pain that lasted one to two seconds only. He did take a nitroglycerin to evaluate its response and had no further pain following this; association is unclear. Home blood pressures range from 91/75 to 110/73. He is doing activities of daily living and short walks around the yard only. No lightheadedness or dizziness.PHYSICAL EXAMINATION: VITAL SIGNS: Weight 186 lbs. BP 112/63 in the right arm, pulse 88 and regular, oxygen saturation 95% on room air. CONSTITUTIONAL: In no acute distress. HEENT: Eyes: Fundi unremarkable. No A-V nicking. No h

CaseID: OPD7463 Primary Diagnosis: R14.0, R14.3 E/M Level: 99213

MEDICAL RECORD OFFICE - ESTABLISHEDCARDIOLOGYSEX: FEMALE AGE: 77 Date: 01/01/20XX CHIEF COMPLAINT: She is here for F/U medication check. PROBLEM LIST:1. 77-year-old with history of atypical chest pain and palpitations well-controlled on Toprol.2. 20+ year history of hypertension with relatively good control on treatment.3. Intermittent complete right bundle branch block.4. Mild hyperlipidemia.5. Positive family history for premature coronary artery disease.6. Sleep apnea, on CPAP as Rx.7. Hypothyroidism on natural thyroid replacement.8. Moderate left ICA and mild right ICA stenosis. ALLERGIES: Lunesta (GI pain), ACE (cough), Cipro (severe GI upset), HCTZ (incontinence), Losartan at high dose (weakness). MEDICATIONS:Coreg 37.5 mg b.i.d.Amitriptyline 25 mg one-half tab q.d.Vitamins A, B, C, D and E q.d.Lipoic acid q.d.Cholinergic complex q.d.Mineral complex q.d.Omega-3 fatty acids q.d.Fish oil 1200 mg q.d.Calcium 500 mg q.d.CoQ-l0 200 mg q.d.Klonopin 01 mg 1/4 to 1/2 tab p.r.n. insomniaTramadol p.r.n., usually 1 tab q.d.Nature thyroid 95 mg q.d.Losartan 100 mg q.h.s. Triamterene 37.5 mg q.d. INTERVAL HISTORY: The patient has noted after medication she will occasionally have abdominal bloating and gas. She requested this appointment to evaluate for possible Coreg or Losartan association; however, since that time she has had two episodes of clear association with flour and feels she may have a gluten allergy. Labs (12/15/20XX) show:1. Cholesterol 211, triglycerides 120, HDL 59, LDL 128. The patient has declined statins.2. C-reactive protein normal at 1.45.3. Stool for occult blood negative.4. H-pylori negative. CT of the abdomen (12/15/20XX) shows:1. No acute findings.2. Diverticulosis was noted. Pelvic ultrasound (12/1520XX) shows:1. No acute findings. PHYSICAL EXAMINATION:VITAL SIGNS: Weight 143 lbs, BP 118/64 in the le

CaseID: OPD7451 Primary Diagnosis: I34.0, I65.23, I45.89 Secondary Diagnosis: Z86.73, Z98.890 CPT: 93350, 93325 E/M Level: 99214-25

MEDICAL RECORD OFFICE - ESTABLISHEDCARDIOLOGYSEX: FEMALEAGE: 65Date: 01/01/20XXPROBLEM LIST:1. Female patient with paroxysmal atrial fibrillation, six months S/P atrial fibrillation ablation.2. Hypertension.3. She is seven years S/P gastric bypass surgery.4. Hepatitis C.5. Questionable TIA (01/20XX) manifest as a syncopal spell. No localizing neurologic symptoms.ALLERGIES: No known drug allergies.MEDICATIONS:Albuterol inhaler q.d.Omeprazole 20 mg t.i.d.KCl 10 mEq b.i.d. Gabapentin 800 mg t.i.d.Tramadol 50 mg t.i.d.Sotalol 160 mg b.i.d.Diovan HCTZ 320/12.5 mg 1/2 tab q.h.s. Trazodone 100 mg q.d. q.h.s. Multivitamins q.d.Calcium with vitamin D q.d.Fiber q.d.Valerian root q.d.Lasix 20 mg q.d.KCl 10 mEq q.d.INTERVAL HISTORY:Carotid Doppler (01/01/20XX) shows:1. 80-99% right ICA stenosis.2. 60-79% left ICA stenosis.Labs (01/01/20XX) show:1. Fasting lipids: Total cholesterol 115, triglycerides 54, HDL 65, LDL 44.2. TSH 1.6.Chemistry panel (01/01/20XX) shows:1. BUN 14, creatinine 0.56.2. GFR of 100.Labs (01/01/20XX) show:1. CBC: Hemoglobin 11.6 grams percent, platelet count 257, white cell count 6.3.PHYSICAL EXAMINATION:VITAL SIGNS: BP 128/62, pulse 54 and regular, oxygen saturation 91% on room air.CONSTITUTIONAL: She appears somewhat pale, in no acute distress.HEENT: Thyroidectomy scar is well-healed, otherwise negative. Eyes: Fundi unremarkable. No A-V nicking. No hemorrhages. No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis. No cervical lymphadenopathy. Thyroid unremarkable.RESPIRATORY: Respirations even and unlabored. Slightly reduced air entrybilaterally with bilateral expiratory rhonchi. Chest has normal contour.CARDIOVASCULAR: PMI unremarkable. Neck veins borderline elevated with a positive Kussmaul sign. No carotid bruits. S1 is normal. S2 is single and not acc

CaseID: OPD7449 Primary Diagnosis: Z01.810, I25.10, I72.3 Secondary Diagnosis: Z82.49, Z87.891, Z79.82, Z95.828 CPT: 93351, 93325, J1250 E/M Level: 99214-25

MEDICAL RECORD OFFICE - ESTABLISHEDCARDIOLOGYSEX: FEMALEAGE: 72Date of Service: 01/01/20XXPROBLEM LIST:1. Patient is a female is followed in this office for a history of moderate left anterior descending coronary disease, angiographically confirmed (20XX) and resolved with minor LAD atherosclerosis on repeat angiogram 1+ years ago.2. Positive family history for premature coronary artery disease.3. 70 pack-per-year history of smoking (none since 19XX).4. AAA stent (20XX) monitored by her physician.ALLERGIES: No known drug allergies.MEDICATIONS:Zocor 80 mg q.d.Zoloft 50 mg q.d.Saw palmetto 160 mg b.i.d.Multivitamin q.d.Aspirin 81 mg q.d.Aleve 1 tab q.d. INTERVAL HISTORY: The patient returns for preoperative evaluation prior to lumbosacral back surgery( by Dr. Smith). She has had no chest pain. No palpitations. No shortness of breath.She had a CT scan of her abdominal aorta 2 months ago showing:1. No evidence of endoleak.2. Bifurcated endoluminal stent graft is present3. There is aneurysm of the right iliac artery.4. Vessels are otherwise stable.Labs (01/01/20XX) show: 1. Lipid panel: LDL cholesterol 45, HDL 54, triglycerides 135, total cholesterol 126. PHYSICAL EXAMINATION:VITAL SIGNS: BP 104/68, pulse 82 and regular, oxygen saturation 93% on room air.CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid bruits. S1 and S2 normal. S4 gallop. No murmurs or clicks. Abdominal aorta not palpable.CONSTITUTIONAL: In no acute distress.HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.RESPIRATORY: Respirations even and unlabored. Good air entry bilaterally. Noadventitious sounds. Chest has normal contour.CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid bruits. S1, S2 and normal. No murmur, clicks or gallops. Abdominal aorta not palpable, no bruit. Femo

CaseID: OPD7281 Primary Diagnosis: I34.0, I34.1, G47.33, I44.1, I51.7 Secondary Diagnosis: Z95.1, Z79.82, Z99.89 CPT: 93000 E/M Level: 99214-25

MEDICAL RECORD OFFICE - ESTABLISHEDCARDIOLOGYSex: MAGE: 87Attending Physician:Referring Physician:Date: 01/01/20XXPROBLEM LIST1. Male with S/P coronary bypass single vessel LIMA/LAD for unstable angina (01/20XX).2. Severe ischemic cardiomyopathy, estimated ejection fraction initially 35%, now >50%.3. Paroxysmal atrial fibrillation after surgery.4. Type 2 diabetes; diet-controlled.5. He had a critical illness polyneuropathy and myopathy; improved.6. Familial tremor.7. Obstructive sleep apnea, managed satisfactorily with CPAPALLERGIES: CodeineMEDICATIONSAspirin 81 mg q.d.Simvastatin 40 mg q.d.Fosamax 70 mg 1 q wk.Fexofenadine p.r.n.Toprol XL 12.5 mg b.i.d.Vitamin C 500 mg q.d.Multivitamin q.d.Calcium q.d.Vitamin D3 500 IU b.i.d.INTERVAL HISTORY: The patient continues his regular activities with volunteer work three days a week. This requires being on his feet throughout the day. He feels unrestricted. He is not aware of any difficulty with breathing. No palpitations or lightheadedness.Labs (01/20XX) show:1. Lipids: LDL of 74, HDL 37, triglycerides 72, and total cholesterol 125.2. Liver function tests normal.3. TSH 2.9.4. GFR of 7O.PHYSICAL EXAMINATIONVITAL SIGNS: Weight 171-1/2 lbs, BP 126/78 in the left arm, pulse 65 and regular, oxygen saturation 89% on room air.CONSTITUTIONAL: In no acute distress.HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.RESPIRATORY: Respirations even and unlabored. Lungs are clear but diminished. No adventitious sounds.CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid or subclavian bruits.There is a pronounced mid-systolic click at the apex with associated grade I apical systolic murmur. S2 is single. There is an intermittent S3 gallop at the apex. There is an S4 gallop at the apex. No leg swelling.GASTROINTESTINAL:

CaseID: OPD7475 Primary Diagnosis: Z47.1 Secondary Diagnosis: Z96.641 E/M Level: 99024

MEDICAL RECORD OFFICE - ESTABLISHEDDavid SmithAGE: 59DOS: 1/1/20XXMD: Dr. Brandon AndrewsThe patient returns postoperatively from right total hip arthroplasty. He is two and a half months from surgery. He is doing well. His groin arthritic pain is gone. He gets a little soreness in the inner thigh with start up in the morning. He thinks this may be from his back.EXAMINATION: On exam, his range of motion is full without pain. Neurovascular exam is intact.DIAGNOSIS: Stable right total hip arthroplasty.PLAN: The patient is doing well. He will return in three months for reevaluation and an x-ray of the hip.Brandon Andrews, MDElectronically signed by BRANDON ANDREWS, MD 1/1/20XX

CaseID: OPD7271 Primary Diagnosis: N39.46, R31.1 E/M Level: 99213

MEDICAL RECORD OFFICE - ESTABLISHEDSEX: FemaleAGE: 56DOS: 1/1/20XXHISTORY OF PRESENT ILLNESS: She comes in today in follow up for her mixed incontinence and her microscopic hematuria. She reports significant improvement with the Vesicare at 10 mg and would like to stay there and defer any decision about an operation for stress incontinence until later on. She says she does leak when she coughs, but it is minor at this point and would like to wait. The urgency incontinence which worried her the most is under good control right now. She states that she had a lifelong history with kidney problems and so she is not worried at this point. The urine did show a continued presence of blood in the urine at a level of moderate dissolved blood. Workup including a cysto, cytology, and a CT scan was negative except for possible lung lesion. In any case, we want to follow up on that.PAST MEDICAL HISTORY: Reviewed and all pertinent positives explored.PHYSICAL EXAM: Vital signs are within normal limits. She is a well-developed and well-nourished female in no acute distress. Neck is supple without thyroid enlargement or lymphadenopathy. Respiratory effort is good. Peripheral pulses are intact. There is no evidence of cyanosis. Abdomen is soft with normoactive bowel sounds. There is no organ enlargement. There is no evidence of hernia. GU exam was reported as normal by the nurses.TREATMENT PLAN: Keep her on Vesicare and I wrote her a 90 day supply with 3 refills to last her a year. We will also get a CT scan 2 weeks before she is to come in next time in 3 months. She will also get a urine cytology when she comes in. She will return to clinic in 3 months.DIAGNOSIS: 1.Urge and stress incontinence. 2.Benign Microscopic hematuria.John Kramer, MD - Electronically signed by JOHN KRAMER, MD 1/1/20XX

CaseID: OPD7308 Primary Diagnosis: I11.9, E78.5, G47.30, J44.9, E66.9 Secondary Diagnosis: Z79.82, Z99.89 E/M Level: 99214

MEDICAL RECORD OFFICE - ESTABLISHEDSEX: FemaleAGE: 71Date: 01/01/20XXCHIEF CONCERN: She is here for echocardiogram results.PROBLEM LIST:1. Female patient with hypertension.2. Mild aortic insufficiency, secondary to hypertension. Mitral valve prolapse.3. Hyperlipidemia.4. Obesity.5. Sleep apnea on CPAP as prescribed.6. COPD, with exercise-induced asthma.7. Complex fracture of her right femur (01/20XX) requiring surgery and several months of rehabilitation.ALLERGIES: Betadine, penicillin (rash/hives)MEDICATIONS:Aspirin 81 mg q.d.Lasix 20 mg q.d.Simvastatin 20 mg q.d.Lisinopril 5 mg q.d.Trazodone 50 mg q.d.Atenolol 25 mg q.d.Advair 250/50 b.i.d.Calcium +D q.d.Multivitamin q.d.Ventolin inhaler p.r.n.Flonase 50 mcg q.d. p.r.n.Oxycodone 7.5 mg p.r.n.INTERVAL HISTORY:Echocardiogram (12/19/20XX) shows:1. Ejection fraction of 65% with normal left ventricular function.2. Mild left ventricular hypertrophy.3. Mild mitral insufficiency.4. Trace aortic insufficiency.5. No significant change from previous echocardiogram.The patient is using CPAP as prescribed for her sleep apnea. She has regained five pounds due to dietary indiscretion. She continues to ambulate with a cane secondary to a fracture of her right femur. Her COPD is stable.Labs (01/01/20XX) show:1. Cholesterol 187, triglycerides 171, HDL 58, LDL 95.2. Creatinine 1.07.3. GFR 53 which is slightly decreased from previous labs. She admits to daily NSAID secondary to leg pain.PHYSICAL EXAMINATION:VITAL SIGNS: Weight 286 lbs, BP 126/70 in the left arm, pulse 92 and regular, oxygen saturation 95% on room air.CONSTITUTIONAL: Obese Caucasian female in no distress. She ambulates with crutches.HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.RESPIRATORY: Respirations even and unlabored. Good air entry bilaterall

CaseID: OPD7448 Primary Diagnosis: R09.02, G47.33, I10 Secondary Diagnosis: Z95.1 CPT: 93350, 93325 E/M Level: 99213-25

MEDICAL RECORD OFFICE - ESTABLISHEDSEX: MALEAGE: 73Date: 01/01/20XXCHIEF COMPLAINT: He is here for stress echocardiogram and 3-month check.PROBLEM LIST:1. Patient is a male who is 4 years S/P three-vessel CABG.2. Hyperlipidemia.3. Obstructive Sleep apnea4.. Right knee replacement (01/20XX).ALLERGIES: Penicillin (swelling)MEDICATIONS:Aspirin 81 mg q.d.Lisinopril 2.5 mg q.d.Simvastatin 40 mg q.d.INTERVAL HISTORY:He has had a good response to right knee replacement. He is contemplating left knee replacement now. His echocardiogram today done in office shows preserved left ventricular systolic function. No left ventricular hypertrophy. No other abnormalities. No evidence of pulmonary hypertension. It appears left ventricular hypertrophy, which was evident 01/20XX has declined.Stress echocardiogram done today is notable for:1. Developing mild hypoxemia with oxygen saturation falling to 87%.2. He is limited by shortness of breath.3. There is no evidence of ischemia at a low cardiac workload.Lipids as per his physician.PHYSICAL EXAMINATION:Patient weighs 165 pounds, 5'10, VITAL SIGNS: BP 142/90 (lg. cuff) in the left arm, pulse 74 and regular, oxygen saturation 94% on room air.CONSTITUTIONAL: In no acute distress.HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.RESPIRATORY: Respirations even and unlabored. Good air entry bilaterally. Noadventitious sounds. Chest has normal contour.CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid bruits. S1, S2 and normal. Grade 1/6 short systolic murmur along the left sternal edge. No clicks or gallops. Abdominal aorta not palpable, no bruit. Femoral, tibial, dorsalis pedis pulses intact. No leg swelling.GASTROINTESTINAL: Positive BS x4 quads. No masses or tenderness. No hepatosplenomegaly.SKIN: Pink, warm and dry.

CaseID: OPD7268 Primary Diagnosis: J35.8, H93.291, H69.91 E/M Level: 99212

MEDICAL RECORD OFFICE - ESTABLISHEDSEX: Male AGE: 10DOS: 1/1/20XXCC: Sore ThroatHPI:Location: throatQuality: 2 monthsSeverity: mildDuration: constantTiming: dailyContext: all dayModifying: noneAssoc symptoms: ?? hearingROS:Assoc symptoms: ?? hearinggen: negative sweats, chills, fatigue, wt gain or lossneuro: negative numbness, tingling, memory changes, headacheshead/neck: negative nosebleeds, hoarseness, hearing changes, tinnitus, + sore throatcv: negative chest pain, arrythmia, leg pain/swellinggi: negative n/v, dysphagia, reflux, diarrhea, constipationpsych: negative depression, anxietyresp: negative wheezing sob, hemoptysis, + coughskin: negative sores, change in moles, rashesgu: negative burning, frequency, blood in urine, dribbling, incontinencems: negative joint swelling, joint pain, stiffness, fallsheme: negative bleeding disorders, prior transfusion, bruising, fh of bleeding disordersPAST PROBLEMS: noneTOBACCO: noneALCOHOL: noneSURGERIES: noneMEDICATIONS: noneFMHX:mother: nonefather: nonesiblings: low irongrandparents: HTN SOCIAL HISTORY: Lives in Coalgate, OKOBJECTIVE:VS: BMI: 23.2 H: 54.5 in. T: 97.2 F. W: 97lbs 0oz.CON: normal appearance, strong voice, face without lesions, no sinus tenderness to palpationEYES: Pupils equal, round, and reactive to light and accommodation. conjunctiva normal.EARS: Weber and Rinne not performed due to age. Finger rub normal bilaterally right ear with normal external ear, normal external auditory canal, tm normal with decreased mobility left ear with normal external ear, normal external auditory canal, tm normal with good mobility.OC/OP: mucosa, hard and soft palate, lips/teeth/gums and normal. Tonsil fossa normalNOSE: Normal external nose, septum midline, mucosa normal, turbinate's normalHYPO/GLOTTIC: not done due to ageNECK: normal symmetry, trachea midline, lymph nodes norma

CaseID: OPD7274 Primary Diagnosis: L70.0, B07.8 Secondary Diagnosis: CPT: 17110 E/M Level: 99203-25

MEDICAL RECORD OFFICE - NEWSEX: MaleAGE: 21DOS: 1/1/20XXCC: complaint of acne and wartsHPIDuration: 1 yearModifying Factors: has tried compound W and OTC freezingLocation: R and L handsAlso mentions acne on the face. He does not really get big acne lesions.ROSSystemic: Not feeling tired or poorly. No fever, no chills, no night sweats, no recent involuntary weight loss, and no involuntary recent weight gain.Head: No Headache.Neck: No swollen glands in the neck.Eyes: No vision problems.Otolaryngeal: No earache, no nasal discharge, no nasal passage blockage, no sneezing, no hoarseness, no sore throat, and no bleeding gums.Cardiovascular: No chest pain or discomfort and no palpitations.Pulmonary: No dyspnea, no cough, not coughing up sputum, and no wheezing.Gastrointestinal: No dysphagia, no heartburn, no vomiting, and no abdominal pain.Genitourinary: No increase in urinary frequency. No dysuria.Endocrine: No feeling weak.Hematologic: No Hematologic symptoms.Musculoskeletal: No localized joint pain and no localized joint swelling.Neurological: No dizziness, no motor disturbances, and no sensory disturbances.Psychological: No anxiety and no depression.Skin: Skin lesion: No change in a mole.Allergic and Immunologic: No allergic/immunologic symptoms.Allergies - No Known Allergies.Family Hx: -Skin cancerPhysical ExamCONSTITUTIONAL: Healthy appearing, no acute distressNEUROLOGIC/PSYCHIATRIC: Alert and oriented. Appropriate mood and affectSKIN: Examination included the followingFace: inflammatory papulesR Fingers/Fingernails: rt 5th digit wart x1L fingers/Fingernails: lt 3-4 digit wart x2L Toes/Toenails: It distal sole wart.Assessment:Acne VulgarisCommon wartsDISCUSSEDWarts, Common (Verruca Vulgaris)Discussed tx options including do nothing or treat with LN2Choose application of a compound with cantharidin which does not hurt wh

CaseID: OPD7511 Primary Diagnosis: Z01.810 Secondary Diagnosis: C50.911 CPT: 93308-26, 93321-26, 93325-26

MEDICAL RECORD OFFICE PROCEDURESEX: FEMALE AGE: 55For Preprocedural cardiovascular exam for breast cancer surgeryTransthoracic Echocardiography ReportLimited 2D Study with M-Mode, Limited Spectral Doppler, and Color Doppler 01/01/20XXMR#Account: Status: OutpatientLocation: Tape: Ht 64 in (162.6 cm) Wt 219 lb (99.5 kg) BSA 2.03 m squaredDiagnoses: RIGHT FEMALE BREAST CA NOSEcho Attending: Echo Technologist: Attending Ordering: SummaryLeft ventricle: Systolic function was normal. Ejection fraction was estimated in the range of 55% to 65%. There were no regional wall motion abnormalities. COMPARISONS: No previous study is available for comparison.PROCEDURE: The procedure was performed in the outpatient area. This was a routine study. The transthoracic approach was used. Limited or follow-up 2D echocardiography study was performed with limited spectral Doppler and color Doppler. The heart rate was 78 b.p.m. at start. Systolic blood pressure was 126 mmHg at start. Diastolic blood pressure was 77 mmHg at start. Images were obtained from the low parasternal, apical, and subcostal acoustic windows. This was a technically difficult study. LEFT VENTRICLE: Size was normal. Systolic function was normal. Ejection fraction was estimated in the range of 55% to 65%. There were no regional wall motion abnormalities. Wall thickness was normal. DOPPLER: The ratio of early ventricular filling to atrial contraction velocities was within the normal range. AORTIC VALVE: The valve was not well visualized. AORTA: Not well visualized. MITRAL VALVE: Valve structure was normal. There was normal leaflet separation. DOPPLER: The transmitral velocity was within the normal range. There was no evidence for stenosis. There was no mitral regurgitation. LEFT ATRIUM: Size was normal. RIGHT VENTRICLE: The size was normal. Systolic function was normal. Wall

CaseID: OPD7486 Primary Diagnosis: E11.65, M25.572, F17.210, I10 Secondary Diagnosis: Z79.4, Z79.84 E/M Level: 99214

MEDICAL RECORD OFFICE-ESTABLISHEDSEX: FEMALEAGE: 51DOS: 1/1/20XXCHIEF COMPLAINT: 3 month follow up, left foot pain/problem.Had muscle tear and fx 1 month ago - went to local ER. Wants to quit smoking and patches breaking her out - Chantix?HPI: Diabetes follow up. Reported by patient. Review finger sticks: ave 190 per patient report; ranging from 86-300; mostly around 180-200. Context: seeing eye doctor regularly (has apt next week); taking aspirin daily; last A1C 8.6 6 mo. ago; she didn't keep her follow up visits. Associated Symptoms: no confusion; no increased thirst; no increased appetite; no increased urination. Notes: Ex-husband dropped a bed on her toe accidentally in April. Her L great toenail still black and painful. She has not seen podiatrist. She also states she had a small fracture to her foot - had x-ray at ER and small fracture and muscles tear and still having pain -that was 6 weeks ago. She is also trying to quit smoking but having an allergic reaction to the adhesive in the patches; doesn't like the gum or lozenges. She has tried Chantix before and she would like to try again. Hyperlipidemia. Reported by patient. Control: usually well controlled (on medication); improving; at goal. Compliance: compliant; compliant with diet; exercises. Complications: no coronary artery disease; no peripheral artery disease; no cardiovascular disease; diabetes; hypertension; smoking; obesity. Notes: Hx of hypothyroidism; time for lab; taking her meds.PROBLEMS: • Smoking cessation• Hypertension controlled• Pain in joint; ankle and foot.ALLERGIES: Reviewed Allergies: NKDA.MEDICATIONS: Reviewed Medications:BD INSULIN PEN NEEDLECHANTIX 1 MG TABESTRADIOL 1 MG TABGABAPENTIN 300 MG CAPGLYBURIDE 5 MG TABHYDROCODONE 10 MG TABLANTUS SOLOSTAR 100 UNIT/MLLEVOTHYROXINE 200 MCG TABLISINOPRIL 20 MG TABLOVASTATIN 40 MG TABMETFORMIN 1,0

CaseID: OPD7131 Primary Diagnosis: M16.11 CPT: 20610-RT, 77002-26

MEDICAL RECORD OPERATIVE NOTEAge: 83Date of Service: 7/21/20XX Location: Mountain Hospital Service Department: Orthopedic Group GeneralProvider: Dr. Brandon AndrewsDIAGNOSIS: Right hip joint primary osteoarthritis.PROCEDURE: Right hip cortisone injection.SURGEON: Brandon Andrews, MDDESCRIPTION OF PROCEDURE: The patient was placed on fluoroscopy table in a supine position. The right hip was identified under fluoroscopy. The skin was prepped with Betadine, skin anesthetized with 1% lidocaine. Under fluoroscopy guidance, a 22-gauge needle was guided into the right hip capsule using anterolateral approach. Confirmation made by injection of a small amount of contrast. Once this was confirmed, injection of bupivacaine and Kenalog was placed in the hip capsule. The patient tolerated the procedure well without complications, leaving the department in improved, stable condition. We will see her back to follow up in the office for recheck and reevaluation. Reinjections as needed.Brandon Andrews, MDElectronically signed by BRANDON ANDREWS, MD 7/21/20XX

CaseID: OPD7015 Primary Diagnosis: N82.3 Secondary Diagnosis: K57.32 CPT: 44145, 57305

MEDICAL RECORD OPERATION REPORTAGE: 71 SEX: FEMALEDATE OF OPERATION: 1/01/20XXPREOPERATIVE DIAGNOSIS: COLOVAGINAL FISTULA.PROCEDURES:1. EXAMINATION UNDER ANESTHESIA, PROCTOSIGMOIDOSCOPY.2. EXPLORATORY LAPAROTOMY, TAKEDOWN OF COLOVAGINAL FISTULA, SIGMOID RESECTION AND PRIMARY COLORECTAL ANASTOMOSIS.POSTOPERATIVE DIAGNOSIS: RECTOVAGINAL FISTULA.SURGEON:ANESTHESIA: GENERAL ENDOTRACHEAL.ESTIMATE BLOOD LOSS: 60 ML.SPECIMENS: SIGMOID COLON.COMPLICATIONS: NONE.INDICATIONS: This is a female who presented with six-month history of passing feces per vagina.INTRAOPERATIVE FINDINGS: Rectovaginal fistula between posterior vaginal cuff and mid sigmoid colon.PROCEDURE: The patient was brought to the operating room and placed in the supine position. Bilateral Venodyne boots were placed. General endotracheal anesthesia was administered by the anesthesiologist. An orogastric tube was placed. The patient received 2 gm of cefoxitin prior to induction. The patient was then placed in the lithotomy position and rectal and vaginal exam was performed along with proctosigmoidoscopy. The examination confirmed fistulous tract in the posterior vaginal wall. Cystoscopy and bilateral ureteral stent placement was done by urology. The patient was then prepped and draped in the sterile fashion.A vertical midline incision was made from the pubis to the supraumbilical region. The incision was deepened through the subcutaneous tissue and the linea alba was identified and divided in the midline.Peritoneal cavity was entered. The abdomen was explored. There is evidence of diverticulitis in the sigmoid colon and the sigmoid colon was found adherent to the vaginal cuff. Balfour retractor was placed and small bowel was retracted using moist towel. Adhesions between the rectosigmoid, vaginal cuff and bladder were lysed and a fistulous tract was identified commu

CaseID: OPD6955 Primary Diagnosis: T84.82XA Secondary Diagnosis: Z96.653 CPT: 27570-50

MEDICAL RECORD OPERATIVE NOTEAGE: 63 Sex: FEMALEDOS: 1/1/20XXPREOPERATIVE DIAGNOSIS: Arthrofibrosis, both knees.POSTOPERATIVE DIAGNOSIS: Arthrofibrosis, both knees.OPERATIVE PROCEDURE: Manipulation under anesthesia, bilateral knees.SURGEON: Dr. MDANESTHESIA: General with muscle relaxation.COMPLICATIONS: None.CONDITION: Stable to recovery room.INDICATIONS: Patient is a female status post bilateral total knee arthroplasty approximately 4 months previous. She has considerable stiffness with her artificial knee joints and wishes to proceed with manipulations. The surgeries were done by Dr. Kim Jones Possible and he asked me, because of timing, to perform these and patient agrees. The risks and benefits were thoroughly discussed with the patient and elected to proceed.FINDINGS: Preoperative range of motion on the right was 17 to 80; left was 15 to 83. Postoperative range of motion was 0 to 135 bilaterally.PROCEDURE: Patient was brought to the operating room. Preoperative range of motion was documented. She was then placed under general anesthesia. Muscle relaxation was used and then gentle manipulation was then done on both knees, starting with the right. Audible breaking of scar tissue was done. It took a normal amount of force for both extension and flexion and I was not concerned that there were any fractures. The post-manipulation range of motion was 0 to 135 bilaterally. Patient was awakened from anesthesia. Large ice packs were placed on the knees. Patient was to attend physical therapy later this day.Electronically signed by: MD 1/1/20XX

CaseID: OPD6952 Primary Diagnosis: S62.617A Secondary Diagnosis: S62.615A, S62.613A CPT: 26727-F4, 26727-F3, 26727-F2

MEDICAL RECORD OPERATIVE NOTEAge: 56Sex: FEMALEDOS: 1/1/20XXPHYSICIAN:PREOPERATIVE: Left Fourth, Third, and Second finger displaced proximal phalanx fractures.POSTOPERATIVE: Left Fourth, Third, and Second finger displaced proximal phalanx fractures.OPERATIVE PROCEDURE: (Code in order of procedures listed)1. Closed reduction and percutaneous pin fixation left Fourth finger (fifth digit) proximal phalanx base fracture.2. Closed reduction and percutaneous pin fixation left Third finger (fourth digit) proximal phalanx fracture.3. Closed reduction and percutaneous pin fixation left Second finger (third digit) proximal phalanx fracture.SURGEON:ANESTHESIA: General.COMPLICATIONS: None.INDICATIONS: Ms. Smith is a female who presented to the clinic with comminuted proximal phalanx fractures near the metacarpal phalangeal joint. The patient had significant angulation at the left small finger proximal phalanx. She did have fairly good range of motion, but obvious gross deformity to the long, small and ring finger. I recommended either treatment closed in a cast, that she would likely lose some flexion potentially at the metacarpal phalangeal joint. After considering options, the patient wishes to proceed with closed reduction and percutaneous pin fixation with possible open reduction if necessary. She agreed to surgery understanding the alternatives, risks, and the benefits of the surgery.DESCRIPTION OF PROCEDURE: The patient was brought back to the operating room where she was placed in supine position. The left upper extremity was sterilely prepped and draped in the usual fashion. Esmarch bandage was used to exsanguinate the left upper extremity. The axial traction was placed on the left small finger. The metacarpal phalangeal joint was flexed and pressure was placed along the volar aspect of the proximal phalanx. The fracture r

CaseID: OPD7008 Primary Diagnosis: K63.5, K62.1, K57.30, K64.8 Secondary Diagnosis: Z86.0100 CPT: 45385, 99152-59, 99153

MEDICAL RECORD OPERATIVE NOTESEX: Male AGE: 84DOS: 1/1/20XXPHYSICIAN:PREOPERATIVE DIAGNOSIS: History of colon polyps.POSTOPERATIVE DIAGNOSIS: Colon polyps, rectal polyps, diverticulosis of the colon, hemorrhoids.OPERATIVE PROCEDURE: Colonoscopy, snare polypectomy, Conscious Sedation Time 31 min.SURGEON:FINDINGS: The patient is a gentleman who has had multiple colon polyps previously and also diverticulosis. He has had no bleeding. No trouble with his bowels. His examination shows his prostate is increased in firmness. He has internal hemorrhoids. He has moderate diverticular disease and he has three small adenomatous-appearing polyps in the rectum, less than 1 cm in diameter. He has a 1-cm polyp at 30 cm, one at 65, and one in the cecum. All of these were removed with a snare polypectomy technique. Because of the multiplicity of the recurrent polyps, I would recommend that he maintain adequate fiber in his diet and repeat colonoscopy in three years.TECHNIQUE: After explaining the operative procedure, the risks and potential complications of bleeding and perforation, the patient as given 165 mg of propofol intravenously for conscious sedation. His pulse was 59, saturations 98, blood pressure 104/62. A rectal examination was done and then the colonoscope was inserted through the anorectum, rectosigmoid; descending, transverse, and ascending colon to the ileocecal valve. The areas were examined carefully and then the cecal polyp was encircled with a snare and removed with a mixture of cutting coagulating current. Scopes were withdrawn at 65 cm, where the second polyp was removed in this manner, and then 30 cm similarly and in the rectum. These three polyps were removed with a snare polypectomy technique as well. The instruments were then withdrawn and removed. The patient tolerated the procedure well. Electronically signe

CaseID: OPD7006 Primary Diagnosis: K40.30 CPT: 49507-LT

MEDICAL RECORD OPERATIVE NOTESEX: MaleAGE: 29DOS: 1/1/20XXPHYSICIAN:PREOPERATIVE DIAGNOSIS: Left inguinal hernia.POSTOPERATIVE DIAGNOSIS: Incarcerated left inguinal hernia (indirect).OPERATIVE PROCEDURE: Repair of incarcerated left inguinal hernia with mesh (PHSL).SURGEON:ASSISTANT: NoANESTHESIA: General, local.COMPLICATIONS: None.FINDINGS: He had a very large, indirect inguinal hernia. There was some omental fat, which was up into this hernia sac.INDICATIONS: The patient is a male who has had problems with a left inguinal bulge. He now presents for repair of an obvious left inguinal hernia.DESCRIPTION OF PROCEDURE: After informed consent was obtained and after marking the area, the patient was brought back to the operating room placed on the operating table in supine fashion. After adequate monitors were placed, the patient was placed under general anesthesia. The left groin was prepped with Hibiclens soap and sterilely draped. A time out was performed, and the patient received IV antibiotics. Local anesthetic was then infiltrated, and a skin incision made. I then slowly took my dissection down to the external oblique fascia. I could tell at the external ring that this was going to be a very large, bulky hernia. Initially I incised into the external oblique fascia and then divided the external ring. I then swept my finger creating superior and inferior flaps. I swept my finger around the spermatic cord, but it was just very bulky and so I did not put any Penrose drain around this at this point. I then opened up the cremasteric fibers, which were attenuated. I then identified hernia sac and then pulled it up out of the distal aspect, and then was able to place a Penrose drain around the spermatic cord. I then continued my dissection, began to free up the hernia sac. I eventually had to transect the hernia sac to allow

CaseID: OPD7135 Primary Diagnosis: S76.112A Secondary Diagnosis: W01.198A, Y92.310, Y93.67 CPT: 27380-LT

MEDICAL RECORD OPERATIVE REPORT AGE: 32 DOS: 1/1/2013 PHYSICIAN: Jack Thomas, MD PREOPERATIVE DIAGNOSIS: Ruptured patella tendon, left knee. POSTOPERATIVE DIAGNOSIS: Ruptured patella tendon, left knee. OPERATIVE PROCEDURE: Open repair left patella tendon rupture. SURGEON: Jack Thomas, MD ANESTHESIA: General endotracheal anesthetic ESTIMATED BLOOD LOSS: Minimal. COMPLICATIONS: None. INDICATIONS: Patient is a male who ruptured his left patella tendon while playing basketball yesterday at the High School Gym. Fell due to stumbling and striking the court floor. Felt appropriate to go ahead with surgical repair. Risks, benefits, as well as nature of the procedure were thoroughly explained. He understands, desires to proceed. DESCRIPTION OF PROCEDURE: Patient was taken to the operating room, placed in a supine position on the operative table, where general endotracheal anesthetic was administered. Excellent anesthetic was obtained. He experienced no anesthetic complications. He was then positioned supine. Bony prominences well padded. Prepped and draped in usual sterile manner to his left lower extremity, pneumatic tourniquet being applied and inflated. A longitudinal anterior incision was created. Dissection was carried down through the skin and subcutaneous tissue sharply. Upon entering the deep fascial layer, the rupture was immediately identified. Hematoma was evacuated. We did irrigate with normal saline. There were no intraarticular abnormalities encountered. I then freshened up the distal pole of the patella, all soft tissue attachments that remained were debrided and removed. I then decorticated the distal pole of the patella with a rongeur. Then the proximal portion of the patella tendon was prepared. I freshened up the proximal end sharply. I then passed two #2 FiberWire sutures in a Krackow-type stitch through the

CaseID: OPD7344 Primary Diagnosis: M87.051 CPT: 27130-RT, 0054T-RT

MEDICAL RECORD OPERATIVE REPORT Orthopedic Group General SEX: M AGE: 67 Date of Service: 1/1/20XX PREOPERATIVE DIAGNOSIS: Avascular necrosis, right hip POSTOPERATIVE DIAGNOSIS: Avascular necrosis, right hip NAME OF PROCEDURE: Right total hip arthroplasty Computer-assisted navigation Fluoroscopy SURGEON: Brandon Andrews, ASSISTANT: Anne Jones, CNRA ANESTHESIA: General and spinal ANESTHESIOLOGIST: Bob Thompson, MD ESTIMATED BLOOD LOSS: 500 mL COMPLICATIONS: None. DRAINS: ConstaVac reinfusion drain IMPLANTS: Stryker Accolade 2, #6 stem, 62 mm Tritanium cup with 36 + 0 Biolox head. INDICATIONS FOR PROCEDURE: The patient is a male with severe right hip pain due to stage 3 avascular necrosis. He is presenting for total hip arthroplasty. The risks, benefits, alternatives, and potential complications were discussed in detail. Informed consent was obtained. DESCRIPTION OF PROCEDURE: After spinal and general anesthetic, the patient was positioned on the hana table. All bony prominences were well-padded. Intravenous antibiotics were given. A time out was given. The left iliac crest, right hip, and right thigh were prepped and draped in the usual sterile fashion. A direct anterior minimally invasive skin incision was carried, creating full-thickness skin flaps. The fascia was incised, and the interval between the tensor fascia lata and rectus and inferiorly along the femoral neck. The anterior hip capsule was excised. The femoral neck was osteotomized to the proper height. The femoral head was removed with a corkscrew. This revealed subchondral collapse of the femoral head. This was a fairly thickened hip capsule and there was marked joint synovitus. The acetabular labrum and soft tissue was excised from the acetabulum. A retractor was placed anteriorly and posterior inferiorly. The acetabulum was then reamed using navigation assi

CaseID: OPD7369 Primary Diagnosis: D12.0, D25.2 CPT: 44204

MEDICAL RECORD OPERATIVE REPORT SEX: FEMALE AGE: 55 DATE OF OPERATION: 1/1/20XX SURGEON: Dr. Cohen Andrews ASSISTANT: Anne Jones, PA-C PREOPERATIVE DIAGNOSIS: Tubulovillous adenoma, right colon. Left adnexal mass. POSTOPERATIVE DIAGNOSIS: Tubulovillous adenoma, right colon cecum. Left adnexal mass (uterine fibroid). PROCEDURE PERFORMED: Laparoscopic hand-assisted right colon resection with anastomosis. Intraoperative gynecological consultation (Dr. Jones). ANESTHESIA: General. SKIN PREP: ChloraPrep. DRAINS: None. INDICATIONS: This patient was noted to have a villous tumor in the right colon on colonoscopy. Biopsy showed Tubulovillous adenoma and it was not resectable by colonoscopy. CT scan showed a left adnexal mass. Pelvic ultrasound could not differentiate between ovarian tumor versus uterine fibroid. Preoperative CA 125 was normal. FINDINGS: The pelvic mass turned out to be a uterine fibroid in the broad ligament on the left. The tumor in the cecum was soft with no obvious malignancy. Other abdominal organs were normal. DESCRIPTION OF PROCEDURE: The abdomen was prepped and draped. A 6.5 cm vertical midline umbilical area incision was made. A hand-assist port was placed. A 12-mm port was placed in the epigastrium and then a 5-mm lower abdominal midline port was placed. The abdomen was insufflated and contents inspected and palpated. Dr. Jones was asked to come in and evaluate the pelvic mass, which I examined. The right and left ovaries appeared to be normal. The uterus was small and the mass was adjacent to or contiguous with the left side of the uterus within the broad ligament. Meanwhile, the right colon was mobilized by incising along the lateral attachments, taking care to avoid injury to the ureter and duodenum. Dr. Jones then arrived and evaluated the pelvic mass and agreed that it was most likely a uterine f

CaseID: OPD7366 Primary Diagnosis: K94.29 Secondary Diagnosis: L76.82, L92.8, G80.9 CPT: 43763

MEDICAL RECORD OPERATIVE REPORT SEX: FEMALE AGE: 8 DATE OF OPERATION: 1/1/20XX PREOPERATIVE DIAGNOSIS: GRANULATION TISSUE AT GASTROSTOMY TUBE AT ENTRY SITE PROCEDURES: REVISION OF GASTROSTOMY TUBE. POSTOPERATIVE DIAGNOSIS: GRANULATION TISSUE AT GASTROSTOMY TUBE ENTRY SITE SURGEON: ARTHUR KRAMER, M.D. INDICATION: This is an 8-year-old female with history of cerebral palsy who was unable to tolerate PO intake. The patient required G-tube. The patient's G-tube had excess granulation tissue around entry site into the abdomen. The patient's parents requested revision of G-tube. PROCEDURE: The patient was brought into the operating suite. Time Out was called to ensure proper patient identification as well as procedure to be performed. The patient was placed in the supine position. The patient was given adequate sedation by the anesthesia staff. Preoperative antibiotics were given. The abdomen around the site of the gastrostomy tube was prepped and draped in sterile fashion. The cuff of the G-tube was deflated. The G-tube was then removed. Upon inspection there was excess granulation tissue around the G-tube entry site. Using applicator, the direction of the tract into the stomach was identified. Using Bovie electrocautery, the excess granulation tissue was removed, obtaining proper hemostasis. A short flap which extended laterally about 0.5 cm was created using Metzenbaum scissors. Electrocautery was once again used to ensure adequate hemostasis. Using nylon sutures, the edges of the flap were sutured to the edges of the gastrostomy tract. The gastrostomy tract was identified once again using applicator tip. The gastrostomy tube was placed back into the tract into the stomach. The cuff was re-inflated. The patient tolerated this procedure well and was taken to the postanesthesia care unit in stable condition. Arthur Kramer,

CaseID: OPD7168 Primary Diagnosis: K80.10 CPT: 47563, 74300-26

MEDICAL RECORD OPERATIVE REPORT SEX: Female AGE: 33 DATE OF OPERATION: 01/1/20XX SURGEON: Dr. Cohen Andrews PREOPERATIVE DIAGNOSIS:1. Cholelithiasis.2. Chronic cholecystitis. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: Laparoscopic cholecystectomy with operative cholangiography.ANESTHESIA: General. SKIN PREP: ChloraPrep. DRAINS: None. INDICATIONS: This patient has documented cholelithiasis with intermittent right upper quadrant and epigastric abdominal pain. FINDINGS: The gallbladder contained multiple small stones. The cystic duct was fairly long. Operative cholangiography showed good flow of dye into the duodenum with no evidence of stones or obstruction. DESCRIPTION OF PROCEDURE: The abdomen was prepped and draped. A small right subcostal incision was made through which a nonbladed 5-mm Optiview port was placed under direct vision. The abdomen was insufflated and contents briefly inspected. The patient then had a 5-mm umbilical port placed under direct vision. The patient was positioned in reverse Trendelenburg position, and additional ports were placed in the epigastrium and right upper quadrant. The gallbladder was grasped and elevated. Peritoneal resections were taken down exposing the cyst duct and cystic artery. The cystic artery was hemoclipped and divided. The cystic duct was dissected down toward the common hepatic duct and up onto the gallbladder. The cystic duct was hemoclipped near the gallbladder and was opened and cannulated. Operative cholangiography was obtained, which was normal. The cannula was removed, and the cystic duct remnant was doubly hemoclipped and divided. The gallbladder was dissected free from the gallbladder bed using the Harmonic scalpel and was brought up and extracted through the 10-mm epigastric port site. The port was replaced, and the right upper quadrant was again irrigat

CaseID: OPD7362 Primary Diagnosis: I83.812 Secondary Diagnosis: E66.9 CPT: 37766-LT, 36475-LT, 37700-LT

MEDICAL RECORD OPERATIVE REPORT SEX: M AGE: 54 DATE OF OPERATION: 1/1/20XX SURGEON: Dr. Cohen Andrews PREOPERATIVE DIAGNOSIS: Symptomatic left lower extremity varicose veins with anterior saphenous vein reflux as a primary source of varicose veins. POSTOPERATIVE DIAGNOSIS: Symptomatic left lower extremity varicose veins with anterior saphenous vein reflux as a primary source of varicose veins. PROCEDURE PERFORMED: Radiofrequency ablation, left anterior saphenous vein. Left femoral open exposure, saphenous vein, with ligation of branches and greater saphenous vein ligation proximally with preservation of superficial epigastric branch. Excision of multiple gigantic varicose veins, left thigh, medial and anterior and lateral leg and ankle regions through 40 incisions. ANESTHESIA: General. FINDINGS: It was difficult to isolate the source of varicose veins to the mappable anterior saphenous vein. I could only find 1 saphenous vein branch that extended into the anterior medial thigh and it could be accessed in the distal one-third of the thigh. There was some early branching. The extensive varicose vein source was hard to identify with this intraoperative ultrasound. It was reported to be from the anterior saphenous vein. When I did the ablation, the probe I noted passed through this anterior saphenous leaving a large-diameter vein adjacent to the anterior saphenous untreated. I concluded that it was best to ligate this because he has extremely symptomatic varicose veins with an extensive network and the untreated large branch that I could visualize could be a contributor. Therefore, I did ligate the greater saphenous vein proximally through an open incision. I also disrupted the branches that communicate with a perforator just above the ankle medially. He has a great number of varicose veins around the ankle. DESCRIPTION OF

CaseID: OPD7167 Primary Diagnosis: K40.90 CPT: 49505-LT

MEDICAL RECORD OPERATIVE REPORT SEX: Male AGE: 27 DATE OF OPERATION: 1/1/20XX SURGEON: Dr. Cohen Andrews PREOPERATIVE DIAGNOSIS: Left inguinal hernia. POSTOPERATIVE DIAGNOSIS: Indirect left inguinal hernia. PROCEDURE PERFORMED: Left inguinal hernia repair with mesh (PerFix plug and patch). ANESTHESIA: General. SKIN PREP: Betadine. DRAINS: None. INDICATIONS: Left inguinal hernia. FINDINGS: Indirect left inguinal hernia. DESCRIPTION OF PROCEDURE: The abdomen and groin were prepped and draped. Marcaine 0.25% with epinephrine was injected for postop pain relief. A left suprainguinal incision was made and carried down to the external oblique which was injected and opened in the direction of its fibers. Cord structures were encircled with a Penrose drain and the hernia sac was dissected away up into the internal ring where it was suture ligated with a pursestring of 2-0 Prolene. Redundant sac was excised. A large PerFix plug was inserted into the inguinal ring and sutured into place with 2-0 Prolene suture. The onlay patch was ten placed over the inguinal floor passing it around the cord and suturing it to itself lateral to the cord with 2-0 Prolene. The cord was returned to the inguinal canal and the external oblique was closed with running 3-0 Vicryl suture. Subcutaneous sutures of 3-0 Vicryl were placed and the skin was closed with a running subcuticular 4-0 Vicryl. A sterile OpSite dressing was applied. The patient was taken to the recovery room in satisfactory condition having tolerated the procedure well. Sponge, instrument and needle counts were reported as correct. Cohen Andrews, MDElectronically signed by COHEN ANDREWS, MD 1/1/20XX

CaseID: OPD7166 Primary Diagnosis: K81.0 Secondary Diagnosis: K85.90 CPT: 47562

MEDICAL RECORD OPERATIVE REPORT SEX: Male AGE: 82 DATE OF OPERATION: 01/1/20XX SURGEON: Dr. Cohen Andrews PREOPERATIVE DIAGNOSIS: Acute cholecystitis and mild pancreatitis. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: Laparoscopic cholecystectomy. ANESTHESIA: General endotracheal. INDICATION: A male who has been admitted for several days with evidence of thickened gallbladder and mildly elevated pancreatic enzymes. These were returned to normal, and the patient is felt to be ready for surgery. FINDINGS: Edematous gallbladder distended but without any evidence of gangrenous changes. The cystic duct was not dilated. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, placed in the supine position, given general endotracheal anesthesia. Once properly anesthetized, he was prepped and draped in the usual sterile fashion. Marcaine 9.5% with epinephrine was used to anesthetize the skin supraumbilically. Incision was carried down through the skin and subcutaneous tissue. A Veress needle was inserted without resistance. Aspiration and flushing revealed no abnormality. Pneumoperitoneum was obtained. An 11-mm trocar was placed infraumbilically. Pneumoperitoneum was obtained. Under direct vision, the epigastric 11-mm port and 2 lateral 5-mm ports were placed after the skin had been anesthetized with 0.5% Marcaine with epinephrine. The gallbladder was grasped at its fundus and tented up over the liver. The infundibulum was grasped. The left lobe of the liver was quite large and heavy and would not retract away from the gallbladder to provide exposure. Therefore, another 11-mm port was placed down between the lateral 5-mm ports in the umbilical port site. The umbilical port site and an Endo fan was placed to retract the left lobe of the liver out of the way so the porta hepatis and triangle of Calot could b

CaseID: OPD7321 Primary Diagnosis: L02.433 CPT: 11042, 99152

MEDICAL RECORD OPERATIVE REPORTAGE: 29 Sex: FDATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Carbuncle, right ulnar forearm. POSTOPERATIVE DIAGNOSIS: Carbuncle, right ulnar forearm. 0.4cm PROCEDURE PERFORMED: Excisional debridement. Conscious sedation. Intraservice time 20 mins. Administered by Cohen Andrews, MD DESCRIPTION OF PROCEDURE: The patient was brought into the operating room and placed in the supine position.Conscious sedation was administered by me. Right arm was prepped and draped in the usual sterile manner. A combination of 0.5% Marcaine and 1% Xylocaine was utilized. The area was anesthetized. An elliptical incision was made along the ulnar in an axial direction to completely excise the carbuncle. The underlying infected subcutaneous tissue was debrided. Hemostasis was secure with electrocautery. A dry gauze dressing was applied. The patient tolerated the procedure well and was transported back to her room in good condition. Anticipation is for discharge later this afternoon and follow-up in my office.Cohen Andrews, MDElectronically signed by COHEN ANDREWS, MD 1/1/20XX

CaseID: OPD7043 Primary Diagnosis: R10.9 CPT: 76700

MEDICAL RECORD PROCEDURE: ABDOMINAL ULTRASOUNDLocation: OB/Gyn Office (Global) Sex: FemaleAge: 62DOS:1/1/20XXCOMPARISON: None.INDICATIONS: Abdominal pain.TECHNIQUE: High-resolution sonographic examination was performed of the abdomen.FINDINGS:LIVER: Normal.GALLBLADDER: Normal. There is no evidence of cholelithiasis or cholecystitis.BILIARY: Normal. The extrahepatic bile duct measures 3 mm.PANCREAS: The visualized portions of the pancreas are normal.SPLEEN: Normal.KIDNEYS: Normal.AORTA/IVC: Normal.OTHER: Negative.CONCLUSION: Negative abdominal ultrasound. No evidence of cholelithiasis, cholecystitis, or bile duct dilation.Electronically signed by 1/1/20XX

CaseID: OPD7342 Primary Diagnosis: I73.9 CPT: 27880-RT

MEDICAL RECORD OPERATIVE REPORTAGE: 40 Sex: FSURGEON: Dr. Cohen AndrewsASSISTANT: Anne Jones, PA-CPREOPERATIVE DIAGNOSIS: Gangrene, right foot due to Peripheral Vascular Disease. POSTOPERATIVE DIAGNOSIS: Gangrene, right foot due to Peripheral Vascular Disease. PROCEDURE PERFORMED: Right below-knee amputation. ANESTHESIA: General. SKIN PREP: ChloraPrep. DRAINS: None. INDICATIONS: This patient has progressive gangrenous change, right foot. She has peripheral vascular disease and underwent intervention with angioplasty. Transcutaneous oxygen saturation study shows unlikely healing at the ankle but good healing at the below-knee area. DESCRIPTION OF PROCEDURE: The right lower extremity was prepped and draped. Flaps were outlined with a marking pen and incisions were made. A posterior flap was developed, dividing the gastrocnemius muscle at the level of the flap. The lesser saphenous vein was ligated and divided. The anterior compartment muscles were divided with cautery and the anterior compartment vessels and nerves were clamped, divided and ligated with 2-0 Vicryl. The soleus muscle was then divided. The posterior tibial nerve was clamped as high as possible. It was divided and ligated. Remaining muscle was divided. Small vessels were ligated and divided and cautery was used for hemostasis otherwise. The periosteum of the fibula was elevated and it was divided with the Horsley bone cutter. The tibia periosteum was elevated and the tibia was divided with the Gigli saw. The specimen was removed. Bone edges were rasped smooth and the wound was irrigated. Hemostasis was achieved and the flap was rotated anteriorly. The fascia was approximated with interrupted 2-0 Vicryl and subcutaneous tissue was approximated with 2-0 Vicryl. The skin was closed with interrupted 3-0 nylon. A sterile dressing was applied.Estimated blood loss

CaseID: OPD7386 Primary Diagnosis: C54.1 CPT: 38572

MEDICAL RECORD OPERATIVE REPORTDATE OF OPERATION: 01/01/20XXPATIENT NAME: Fannie JonesAGE:52SURGEON: Andy Andrews.,MDPREOPERATIVE DIAGNOSES:1. Endometrial cancer.POSTOPERATIVE DIAGNOSES:1. Endometrial cancer.PROCEDURES PERFORMED:1. Robotic assisted pelvic lymph node dissection.ANESTHESIA: General.COMPLICATIONS: NoneINDICATION FOR SURGERY: The patient is a patient of Dr. Smith, who completed the robotic assisted vaginal hysterectomy with bilateral salpingo-oophorectomy, along with anterior and posterior colporrhaphy for pelvic relaxation. Despite well-differentiated tumor, frozen section determine on gross evaluation that the myometrium was greater than 50% invaded and therefore the pelvic lymph node dissection was indicated.FINDINGS: At time of surgery, there were four 9-mm ports in the abdomen as follows; in umbilicus, in the left upper quadrant, and left lower quadrant, and the right lower quadrant pain. With pneumoperitoneum reestablished, an additional port was placed in the right upper quadrant, and the assistant port and an 8-mm diameter was swabbed out to a 12-mm port. The robot was docked in steep Trendelenburg position. After satisfactory docking, I broke scrub and became the consult surgeon. Instrumentation was PK desiccator divider in the left lower quadrant, a Pro-grasp in the right lower quadrant and a hot scissor in the left upper quadrant. The PK was set at 26 watts and the hot scissor was at 25 watts. Irrigation at this confirmed hemostasis and the sigmoid colon was reflected medially to further expose the external iliac region. The peritoneum was incised, and the sub peritoneal adipose tissue, and external iliac node chain was reflected medially off the external iliac artery. The dissection went from the infundibulum pelvic ligament to the circumflex artery beneath the round ligament. In block dissecti

CaseID: OPD7353 Primary Diagnosis: M79.81 CPT: 27603-LT

MEDICAL RECORD OPERATIVE REPORTOrthopedic Group GeneralSEX: FAGE: 75Date of Service: 1/1/20XXDr. Brandon AndrewsPREOPERATIVE DIAGNOSIS: Left distal calf organized painful hematoma.POSTOPERATIVE DIAGNOSIS: Same.NAME OF PROCEDURE: Excision of organized hematoma with drainage and local fasciotomy.SURGEON: Brandon Andrews, MDASSISTANT: Anne Jones, PA-CANESTHESIA: GENERALDESCRIPTION OF PROCEDURE: The patient was taken to the operating room. After satisfactory general anesthesia, she was placed supine on the operating table and her left leg was sterilely scrubbed, prepped, and draped in usual manner form the knee to the foot. The painful area of the organized hematoma was identified and the point where she indicated maximally tender was particularly identified. The incision was centered over this area and taken for a distance of approximately 3.5 cm total length. The underlying subcutaneous tissue consistent with organized hematoma, which was excised with a combination of digital dissection and sharp dissection. The underlying muscle was then identified. A small opening was made in the fascia and a fasciotomy performed. The wound was then irrigated, closed with subcutaneous sutures of 2-0 Vicryl followed by wire and staples on the skin. Sterile dressing was applied. Patient was transferred to the recovery room in satisfactory condition.Brandon Andrews, MDElectronically signed by BRANDON ANDREWS, MD 1/1/20XX​

CaseID: OPD7377 Primary Diagnosis: C56.2, C78.6 CPT: 58952-52

MEDICAL RECORD OPERATIVE REPORTSEX: FAGE: 73DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: 71-YEAR-OLD GRAVIDA IV, PARA 4-0-0-4 WITH HIGHLY SUSPECTED METASTATIC OVARIAN CANCER.PROCEDURES: EXPLORATORY LAPAROTOMY, SUBOPTIMAL DEBULKING OF OVARIAN CANCER, OMENTECTOMY, LEFT SALPINGO-OOPHORECTOMY WITH TUMOR.POSTOPERATIVE DIAGNOSIS: 73-YEAR-OLD GRAVIDA IV, PARA 4-0-0-4 WITH PRIMARY METASTATIC OVARIAN CANCER.SURGEONS: Hector Kramer, MDANESTHESIA: GENERAL, ENDOTRACHEAL.ESTIMATED BLOOD LOSS: 500 CC.IV FLUIDS: 4 LITERS OF LACTATED RINGER'S. AND 750 CC OF HESPAN.URINE OUTPUT: 100 CC CLEAR.SPECIMENS: OMENTAL CAKE, LEFT OVARY AND TUBES.COMPLICATIONS: NONE.CONDITION: STABLE.FINDINGS: There was 7 liters of clear ascites and large omental cake about 15 x 12 cm extending to diaphragm and right lobe of liver and numerous tumors adhered to bowel, bladder and peritoneum. The left ovary and tube infiltrated with tumor which was removed. A small uterus, the right ovary and tube appeared normal. Appendix had tumor invasion all the way to cecum. There was a tumor nodule felt on liver as well. Spleen felt free of tumor.PROCEDURE: The patient was taken to operating room where general anesthesia was found to be adequate and the patient was prepped and draped in normal sterile fashion, placed in dorsal supine position with the Foley insertion.A skin incision was made with a scalpel vertically from two finger above the pubic symphysis to the umbilicus and around umbilicus and extended up to above umbilicus. The incision was carried through to the underlying layer of the fascia and the fascia was incised in the midline. The incision was extended superiorly and inferiorly with Mayo scissors. The fascia was then grasped with Kocher clamps and the rectus muscle was then dissected off from the fascia in the midline and the rectus muscles were then s

CaseID: OPD7380 Primary Diagnosis: O90.2 CPT: 57022-78

MEDICAL RECORD OPERATIVE REPORTSEX: FEMALEAGE: 36DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: HEMATOMA OBSTETRIC WOUNDSTATUS POST NSVD WITH RIGHT MEDIOLATERAL EPISIOTOMY AND THIRD DEGREE EXTENSION.PROCEDURES: EVACUATION OF HEMATOMA, EXPLORATION OF HEMATOMA BED; LIGATION OF BLEEDERS AND REPAIR OF EPISIOTOMY.POSTOPERATIVE DIAGNOSIS: HEMATOMA OBSTETRIC WOUNDSURGEON: Monte Kramer, M.D.FIRST ASSISTANT: ANESTHESIA: CONSCIOUS SEDATION.ESTIMATED BLOOD LOSS: 500 CC.ANTIBIOTICS: PROPHYLAXIS.IV FLUIDS: 250 CC HESPAN ALONG WITH OTHER IV FLUIDS.URINE OUTPUT: 500 CC OF CLEAR URINE.DRAINS: FOLEY.COMPLICATIONS: NONE.DISPOSITION: THE PATIENT TOLERATED THE PROCEDURE WELL.PATIENT CONDITION: STABLE.FINDINGS: Large amount of blood clots and right-sided hematoma extending down into right buttock. Hematoma evacuated. Several figure-of-eight sutures of 0-Vicryl were used to ligate arterial bleeders. Episiotomy reapproximated with 2-0 chromic. Skin reapproximated with interrupted sutures of 3-0 chromic.PROCEDURE: The patient was taken to the operating room where conscious sedation was used to obtain appropriate anesthesia for patient. The patient was prepped and draped and placed in the dorsal lithotomy position.Attention was turned to the patient's perineal area. The episiotomy, which was previously sutured was reopened and arterial bleeder was identified and ligated. Other bleeders were also ligated using 0-Vicryl. Hematoma was evacuated. Large amount of clots evacuated from right-sided hematoma. Episiotomy was then reapproximated with 2-0 chromic. The skin was reapproximated with interrupted sutures of 3-0 chromic. Vaginal packing was soaked in normal saline/water and was used to pack the vagina. Ice packs were applied to the perineum.The patient tolerated the procedure well and the patient was taken to the recovery room in stable con

CaseID: OPD7388 Primary Diagnosis: N93.9 CPT: 58563

MEDICAL RECORD OPERATIVE REPORTSEX: FEMALEAGE: 36DATE OF OPERATION: 11/15/20xxHOSPITAL/MR NUMBER: 1234567SURGEON: Dr. O.B. Andrews.PREOPERATIVE DIAGNOSES: 1. Abnormal uterine bleeding POSTOPERATIVE DIAGNOSES: 1. Abnormal uterine bleeding PROCEDURES PERFORMED: 1. Hysteroscopy2. Dilation and curettage3. Ablation of the endometrium using NovaSure.ESTIMATED BLOOD LOSS: MinimalANESTHESIA: GeneralSPECIMENS: Endometrial curettings.COMPLICATIONS: None.INDICATIONS FOR PROCEDURE: The patient is a 36 year old who presents complaining of abnormal uterine bleeding. She has failed conservative medical management. She now presents requesting conservative surgical management.FINDINGS: Lush appearing endometrium.DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where general anesthesia was obtained without difficulty. She was then positioned in dorsal lithotomy position using Allen stirrups and prepped and draped in the usual sterile fashion. A Graves speculum was placed in the introitus for visualization of the cervix. A single toothed tenaculum was attached to the posterior lip of the cervix. The cervix was progressively dilated to #17 Hanks dilator. The hysteroscope was then advanced under saline distention with findings as noted above. The uterus was gently sharp curetted in a 360 degree fashion and specimens were submitted to pathology for further evaluation.. The uterus was sounded to 10.5 cm. The cervix measured out at 6 cm giving a cavity length of 4.5 cm. The cervical width measured out at 4.2cm giving an overall pore of 104. The lining was then ablated X 2 minutes and 2 seconds. All of the instruments were allowed to cool and then removed. The hysteroscope was then replaced with adequate destruction noted. All instruments were removed. Complete hemostasis was visualized. The patient was then awakened and t

CaseID: OPD7392 Primary Diagnosis: I62.03 CPT: 61312-78

MEDICAL RECORD OPERATIVE REPORTSEX: FEMALEAGE: 80DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: LEFT-SIDED CHRONIC SUBDURAL HEMATOMA WITH MIDLINE SHIFT.PROCEDURES: LEFT-SIDED CRANIOTOMY WITH EVACUATION OF SUBDURAL HEMATOMA.POSTOPERATIVE DIAGNOSIS: LEFT-SIDED CHRONIC SUBDURAL HEMATOMA WITH MIDLINE SHIFT.SURGEON: Thanh Kramer, M.D.FIRST ASSISTANT:ANESTHESIA: GENERAL.ESTIMATED BLOOD LOSS: MINIMALCOMPLICATIONS: NONEINDICATIONS: Ms. Smith is a patient we operated on previously for multiple subdural hematomas after a cranioplasty one month ago and she now presented with left-sided chronic subdural hematoma with mass effect therefore the decision was made to offer surgical decompression.PROCEDURE: The patient was brought to the operating room and was intubated and anesthetized by anesthesia. She was positioned on the operating room table in supine position. The left side of the head was prepped and draped in the regular sterile fashion.A linear skin incision was made which was previously infiltrated with lidocaine with epinephrine. A skin incision was made and a retractor was placed. A burr hole was then made and a long craniotomy was fashioned using the drill. The bone was removed and the underlying dura was found to be intact. A cruciate incision of the dura was made and the subdural yellowish fluid was evacuated and re-irrigated very carefully.All membranes were moved and coagulated with bipolar coagulation. A red rubber catheter was then placed anteriorly and tunneled posteriorly. The dura was then closed using watertight fashion using Nurolon sutures. The cavity was filled with saline to avoid a pneumocephalus. The bone was reinserted and attached to the skull using bone screws and the galea was closed using 2-0 Vicryl sutures and staples for the skin.Thanh Kramer, MD Electronically signed by THANH KRAMER, MD 1/1/20X

CaseID: OPD7033 Primary Diagnosis: G93.40 CPT: 70551-26

MEDICAL RECORD RADIOLOGY REPORTLocation: Valley HospitalPATIENT: Hedy SmithSEX: FAGE: 73DATE OF EXAM: 1/1/20XXREFERRING PHYSICIAN(S): Robert Thompson M.D.PROCEDURE: MRI BRAIN WITHOUT CONTRASTCOMPARISON: CT study dated 08/30/20XX.INDICATIONS: Encephalopathy. Question of a pineal cyst.TECHNIQUE: Sagittal FLAIR; axial T1, FLAIR, fast spin echo T2, and diffuse weighted images were obtained.FINDINGS: The ventricles are normal size for age. There is no shift. No abnormal extra-axial fluid collections. On the T2 weighted images, there are some scattered areas of bright signal in the white matter tracts superiorly. These are probably old gliosis changes. No signs of any extra-axial fluid collections. No new masses are seen. There are no signs of any expanding mass lesions in the pineal region. There is no abnormal signal change to suggest any new ischemia or new hemorrhage.CONCLUSION:1. Encephalopathy.Electronically signed by S. Smith MD1/1/20XX

CaseID: OPD7341 Primary Diagnosis: E11.52 Secondary Diagnosis: I10, Z89.422 CPT: 28810-TA, 11043

MEDICAL RECORD OPERATIVE REPORTSEX: Female AGE: 69DATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Wet gangrene of the left medial foot along the first toe with cellulitis. POSTOPERATIVE DIAGNOSIS: Wet gangrene of the left medial foot PROCEDURE PERFORMED:1. Left first toe ray amputation.2. Excisional debridement of the left foot wound with removal of necrotic skin, subcutaneous tissue, muscle and tendon. INDICATIONS: This is a pleasant elderly female with history of diabetes and hypertension who presented to the office with gangrene and foul odor involving the left foot. She was noted to have severe gangrene along the medial aspect of the metatarsophalangeal joint as well as pus draining from the wound. There was erythema overlying the dorsal aspect of the foot. The patient subsequently was admitted through the emergency room. She now presents for a left foot wound debridement with possible amputation of the first toe. The risks, benefits and alternatives of the procedure were discussed with the patient who understands and is in agreement to proceed. DESCRIPTION OF PROCEDURE: This patient was brought to the operating room table and laid supine on the table. After the laryngeal mask anesthesia was established the left foot was then prepped and draped in a standard surgical fashion. The patient is already on IV antibiotic therapy.The area of necrotic tissue along the medial aspect was sharply debrided with a #15 blade, incising all the skin and necrotic subcutaneous tissue as well as tendons and muscles. This was extended down into the metatarsophalangeal joint where there is pus noted coming from the joint space itself it is a wound between the previously amputated second toe and the first toe also had some pus drainage with a large ulcer noted on the plantar aspect. A decision was made to j

CaseID: OPD7395 Primary Diagnosis: S02.0XXA, S06.4X0A CPT: 62005, 62140

MEDICAL RECORD OPERATIVE REPORTSEX: MALEAGE: 34DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: DEPRESSED SKULL FRACTURE.PROCEDURES: RIGHT PARIETAL CRANIOTOMY WITH EVACUATION OF DEPRESSED SKULL FRACTURE AND TITANIUM MESH CRANIOPLASTY.POSTOPERATIVE DIAGNOSIS: DEPRESSED SKULL FRACTURE WITH SMALL EPIDURAL HEMATOMA.SURGEON: Antione Kramer, M.D.ESTIMATE BLOOD LOSS: APPROXIMATELY 150 CC.ANESTHESIA: GENERAL, ENDOTRACHEAL.HISTORY & INDICATIONS: This patient was brought into the emergency room with the history of having fallen. On examination in the ER, he is alert and oriented. CAT scan showed a depressed skull fracture in the right parietal region. He was neurologically intact. The patient was monitored in the ICU and the rationale for surgery was explained to him and informed consent was obtained.PROCEDURE: The patient was taken to the operating room where general endotracheal anesthesia was induced. His head was shaved. Intraoperative x-rays were taken to confirm the correct location of the fracture. We saw an aberration over the scalp over the fracture site itself. All pressure points were padded. The eye was protected. A Foley catheter was inserted and 1 gm of vancomycin was given through IV Soluset.A curvilinear incision was marked out with the skin being infiltrated with Xylocaine, epinephrine solution. The skin incision was made with a #10 blade. It was deepened down through the level of the periosteum. We placed scalp clips for hemostasis. Self-retaining retractors were positioned. We then used the periosteal elevator to take out the periosteum from around the fracture site itself. The fracture site itself was found to be about 3 cm in diameter with the outer table being depressed.A small bur-hole was made posteriorly. The Dura was reached, we used a craniotome blade and went around the fracture to elevate it in one

CaseID: OPD7391 Primary Diagnosis: G56.01 CPT: 64721-RT

MEDICAL RECORD OPERATIVE REPORTSEX: MALEAGE: 39DATE: 01/1/20XXPREOPERATIVE DIAGNOSIS: Right carpal tunnel syndrome.POSTOPERATIVE DIAGNOSIS: Right carpal tunnel syndrome.OPERATION: Right carpal tunnel release,Surgeon: Christopher R. Kramer, M.D.1st Assistant:Anesthesia:Indications: This is a male with numbness and tingling in his right hand. He has positive electrodiagnostic studies of carpal tunnel syndrome. He has not responded to nonsurgical measures. He is being taken to the operating room for right carpal tunnel release. The risks and benefits were explained to him prior to proceeding.Procedure: The patient was given a regional anesthetic, and his right arm was prepped and draped sterilely below a tourniquet.A 2-cm longitudinal incision was made in the thenar crease and dissected through palmar fascia to the transverse carpal ligament. The distal end of the ligament was identified and incised from distal to proximal with a 6400-Beaver blade. At the proximal junction, Metzenbaum scissors were used to complete the release into the distal forearm fascia. We then dissected the median nerve from beneath the radial leaf of the ligament. The nerve itself had a moderate amount of hyperemia. The ligament was clearly thickened. We irrigated the wound thoroughly. A final pass was made proximally and distally confirming complete decompression. We then closed the skin in a single layer with 5-0 nylon. A light dressing was placed. The patient tolerated the procedure well and was taken to recovery without apparent complications. Christopher Kramer, MDElectronically signed by CHRISTOPHER KRAMER, MD 1/1/20XX

CaseID: OPD7359 Primary Diagnosis: J93.81 CPT: 32666-RT, 32650-RT

MEDICAL RECORD OPERATIVE REPORTSEX: MALEAGE: 41DATE OF OPERATION: 01/03/20XXPREOPERATIVE DIAGNOSIS: RT CHRONIC PNEUMOTHORAX.PROCEDURES: RIGHT VATS WEDGE RESECTION OF LUNG AND PLEURODESIS.POSTOPERATIVE DIAGNOSIS: RT CHRONIC PNEUMOTHORAX.SURGEON: ENRIQUE A. KRAMER, M.D.ANESTHESIA: GENERAL ENDOTRACHEAL.ANESTHESIOLOGIST: DAVID ANDREWS, M.D.INDICATIONS: The patient was admitted to the hospital with right lung chronic pneumothorax. A trial with chest tube insertion failed and this particular operation was planned.PROCEDURE: After satisfactory general endotracheal anesthesia through a double-lumen tube, the patient was placed on the lateral position right side up and the chest and abdomen were prepped and draped following the usual sterile manner. A port was introduced through the opening of the recently inserted chest tube. The right lung collapsed well. There were adhesions between the lateral aspect of the lung and the parietal pleura, which were bluntly and easily divided.Attention was directed towards the apex of the lung and there was a tear on the apex of the lung covered with fibrin was interpreted at the area that had produced the pneumothorax. This area was rigid using an Endostapler. In order to perform this, another incision was made immediately beneath the axilla with a small incision to insert a clamp to hold the lung while the procedure was being done. Also a port was introduced through a small incision on the anterior axillary line above the 4th intracostal space. Following the wedge resection, the lung was examined no other areas of damage were seen. Pleurodesis was performed by using small segments of the cautery passed shelved by EndoClamps to rub the parietal pleura until the entire parietal pleura was gently debrided. This was not done on the diaphragm or the pericardium. Two chest tubes were introduced u

CaseID: OPD7201 Primary Diagnosis: M51.16 CPT: 0275T

MEDICAL RECORD OPERATIVE REPORTSEX: MALEAGE: 63DOS: 1/1/20XXPREOPERATIVE DIAGNOSIS: HERNIATED DISC ON THE LEFT AT L2-3 WITH RADICULOPATHY.POSTOPERATIVE DIAGNOSIS: HERNIATED DISC ON THE LEFT AT L2-3 WITH RADICULOPATHY.PROCEDURES: LEFT-SIDED L2-3 MINIMALLY INVASIVE INTERLAMINAR LAMINOTOMY AND MICRODISCECTOMY.SURGEON: Rich Thompson, M.D.ANESTHESIA: GENERALESTIMATE BLOOD LOSS: LESS THAN 20 CC.INDICATIONS: The patient is a middle-aged man referred to the neurosurgery clinic for management of intractable left leg pain. The patient's symptoms radiated along the L3 dermatoma distribution and he complained of weakness in the quadriceps muscle on the left side. An MRI performed showed the presence of degenerative disc disease at multiple levels but there was a large disc herniation at the level of L2-3 that correlated with his symptoms. The patient had no back pain. Because of his constellation of symptoms, our recommendation was to proceed with a surgical decompression of the L3 nerve root via a laminectomy and discectomy.The procedure along with its risks, possible benefits and possible complications were explained to the patient to his understanding. Surgical and nonsurgical alternatives were discussed and his questions were answered to his satisfaction. He consented to the operation as described.PROCEDURE: The patient was brought into the operating room and while on the stretcher, general anesthesia was induced and he was endotracheally intubated. He was transferred to the Jackson table in the prone position where the surgical site was shaved, prepped and draped in the usual fashion.Using AP and lateral fluoroscopy, the site of the incision immediately overlying the L2-3 disc on the right was identified and marked. A small transverse incision was made with a scalpel on the right side. Subcutaneous tissues were divided with u

CaseID: OPD7141 Primary Diagnosis: S81.041A Secondary Diagnosis: Z18.10 CPT: 27372-RT

MEDICAL RECORD OPERATIVE REPORTSEX: Male AGE: 29DATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Foreign body, right knee.POSTOPERATIVE DIAGNOSIS: Foreign body, right knee.PROCEDURE PERFORMED: Excision, foreign body, right knee (parapatellar).ANESTHESIA: General.SKIN PREP: ChloraPrep.DRAINS: None.INDICATIONS: This patient was chopping wood and a piece of metal from a wedge broke off and entered his right knee just medial to the patella. He pulled one piece of metal out, but subsequently developed erythema and pain and came to the emergency room. I was asked to evaluate him by the emergency room physician for extraction of foreign body which is identified on PA and lateral x-ray of the knee. I reviewed the x-ray of the knee which shows the foreign body, metallic, about 6-mm in size just medial to the patella. The patient consents to removal of the foreign body. There is a small, punctuate, healed-over wound present.DESCRIPTION OF PROCEDURE: The area was prepped and draped. A transverse incision was made in that area and dissection was carried down and spreading with hemostats, I was able to identify the foreign body just medial to the patella and extract it. The wound was irrigated and closed with interrupted 4-0 nylon suture. A sterile dressing including an Ace wrap was applied. The patient is discharged home on Keflex and pain medication to follow up in the office.Cohen Andrews, MDElectronically signed by COHEN ANDREWS, MD 1/1/20XX

CaseID: OPD7172 Primary Diagnosis: I12.0 Secondary Diagnosis: N18.6 CPT: 49421

MEDICAL RECORD OPERATIVE REPORTSEX: Male AGE: 65DATE OF OPERATION: 01/1/20XXSURGEON: Dr. Cohen Andrews PREOPERATIVE DIAGNOSIS: End-stage renal disease. POSTOPERATIVE DIAGNOSIS: Hypertension End-Stage Renal Disease. PROCEDURE PERFORMED: Placement of tunneled Peritoneal Dialysis catheter for future dialysis. ANESTHESIA: Local MAC. SKIN PREP: ChloraPrep DRAINS: None. DESCRIPTION OF PROCEDURE: The abdomen was prepped and draped. Once percent Xylocaine was administered and a vertical midline infraumbilical incision was made and carried down to the fascia which was anesthetized and opened vertically as well. The peritoneum was dissected up and a small opening made in it. A pursestring suture of 2-0 Prolene was placed. A double-cuffed pigtail catheter was inserted into the peritoneal cavity and directed into the pelvis using a catheter guide. The catheter guide was removed. The pursestring suture on the peritoneum was tied, placing the inner cuff between peritoneum and fascia. The fascia was closed with running 0 PDS suture. The catheter was then tunneled to a separate exit site in the right lower quadrant. The wound was irrigated. Subcutaneous layer was closed with 3-0 Vicryl suture and the skin was closed with a running subcuticular 4-0 Vicryl skin closure. Meanwhile during closure, two liters of dialysate were infused over 10 minutes. The catheter was clamped and separated. The dressing was applied and the patient was taken to the recovery area in satisfactory condition having tolerated the procedure well. Sponge, instrument and needle counts were reported as correct.Cohen Andrews, MDElectronically signed COHEN ANDREWS, MD 1/1/20XX

CaseID: OPD7178 Primary Diagnosis: K60.0, K64.0 CPT: 46200, 46221

MEDICAL RECORD OPERATIVE REPORTSEX: MaleAGE: 55DATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Severe proctalgia with hemorrhoids and probable anal fissure. POSTOPERATIVE DIAGNOSES:1. Posterior acute anal fissure.2. First Degree Internal hemorrhoids. PROCEDURES PERFORMED:1. Proctoscopy.2. Posterior anal fissurectomy and repair.3. Right lateral internal sphincterotomy.4. Internal hemorrhoid banding x 1. ANESTHESIA: Spinal. SKIN PREP: Betadine. DRAINS: None. INDICATIONS: This patient is suffering from severe proctalgia for two months with severe anal sphincter spasms, some possible hemorrhoid prolapse by his own description and clinically consistent with an anal fissure. FINDINGS: A deep posterior anal fissure was present in the midline. Internal hemorrhoids were prominent at the 9 o'clock position and 2 o'clock position (in lithotomy). Proctoscopy to 20cm was otherwise negative. DESCRIPTION OF PROCEDURE: The patient was anesthetized, placed in lithotomy position, prepped and draped. Proctoscopy was carried out to 20 cm with negative findings with the exception of hemorrhoids and a posterior anal fissure. Perianal skin was injected with Marcaine with epinephrine which was also injected more deeply as well. The anus was dilated to three fingers. The anal canal was inspected. The internal sphincter and external sphincter could easily be identified by palpation separately. A prominent posterior anal fissure was present. I made the decision to do a lateral internal sphincterotomy. There was a hemorrhoid internal at the 9 o'clock position and so I chose that site for the internal sphincterotomy as well. A figure-of-eight suture of 2-0 Monocryl was placed above the internal hemorrhoid. A triangular incision was made out onto the perianal skin at the 9 o'clock position and this was undermined and di

CaseID: OPD7318 Primary Diagnosis: I83.013 Secondary Diagnosis: I83.023, B87.1 CPT: 11043

MEDICAL RECORD OPERATIVE REPORTSEX: MaleAGE: 78DATE OF OPERATION: 01/01/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Bilateral lower extremity medial and lateral ankle venous stasis ulceration with maggot infestation. POSTOPERATIVE DIAGNOSIS: Bilateral lower extremity medial and lateral ankle venous stasis ulceration with maggot infestation. PROCEDURE PERFORMED: Excisional debridement of bilateral medial and lateral ankle ulcers with removal of necrotic skin and subcutaneous tissue. Total debridement area 19.5 cm. ANESTHESIA: General endotracheal. INDICATIONS: This is an elderly gentleman with long-standing history of venous insufficiency with venous stasis ulceration along bilateral medial and ankles. The patient was being followed in the wound care clinic at the local hospital. However, he stopped going to the wound care. He recently presented to the hospital with worsening of his wounds. The patient is known to have maggot infestation of the right medial ankle ulcer with degeneration of the surrounding tissue. There is extensive necrotic tissue as well as callus around this wound. There is also evidence of possible cellulitis. The patient was admitted for IV antibiotic therapy. The patient now presents for excisional debridement of his bilateral medial and lateral ankles. The risks, benefits, and alternatives of the procedure were discussed with the patient, who understands and is in agreement to proceed. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and laid supine on the table. After general endotracheal anesthesia was established, the bilateral lower extremities were then prepped and draped in a standard surgical fashion. Using a #15 blade, a sharp dissection was carried along both medial and lateral ankle ulcers with removal of all necrotic skin and subcutaneous tissues and mus

CaseID: OPD6977 Primary Diagnosis: Z45.010 Secondary Diagnosis: I49.5, I25.2 CPT: 33228, 99152, 99153

MEDICAL RECORD PATIENT INFORMATIONPatient ID: 527XXXXStudy Date: 1/1/20XXPerforming:Referring:Age: 79SEX: MaleHeight: 193 cm; BSA: 2.10 m2; Weight: 88.9 kgPerforming:ANESTHESIA: Conscious Sedation - Time: 30 minutesClinical Summary:History: PMH: Myocardial infarction.Procedure: Dual Chamber Pacemaker replacement due to end of life of batteryIndication: End of life battery status & years S/P dual chamber pacemaker implant for high grade sinus pauses.Risk factors: Dyslipidemia.Allergies: Penicillin.Labs, prior tests, procedures, and surgery:Serum creatinine (current admission) of 1.2 mg/dl. Hematocrit 46.4%. White blood cell count (WBC) 5.7 th/ul. Platelet count of 166 th/ul. Serum sodium (Na) of 140 mEq/L. Serum potassium (K) of 3.9 mEq/L. Glucose of 90 mg/dl.Blood urea nitrogen of 20 mg/dl. Hemoglobin (pre-procedure) of 15.4 g/dl.Study data: Study status: Cardiac cath: Elective. Consent: The risks, benefits, and alternatives to the procedure were explained and informed consent was obtained.Description of Procedure:Procedure:1. Initial setup. The patient was brought to the laboratory. Surface ECG, leads, blood pressure measurements, and pulse oximetric signals were monitored.2. Patient to the Cath lab fasting. Left infraclavicular site prepped, draped, and infiltrated with 2% Lidocaine. With a #15 scalpel blade a 4 cm horizontal incision was made and S/C dissection to the fibrous pocket surrounding the device. The latter incised & the pacer explanted. The new device was then connected to the appropriate leads. The pocket flushed with an antibiotic solution. The device placed into the pocket & the wound closed with S/C 29 Vicryl and subcuticular 30 Vicryl. Noninvasive testing showed stable lead impedances. Pace was programmed to the original settings. The patient tolerated the procedure uneventfully.3. Skin preparation.

CaseID: OPD7107 Primary Diagnosis: I11.9, J44.9 Secondary Diagnosis: Z95.1, Z95.3, Z99.81 E/M Level: 99214

MEDICAL RECORD PROGRESS NOTEAGE: 75Sex: FReferring Physician:Date: 01/01/20XXCHIEF COMPLAINT: She is here for echo and medication check.PROBLEM LIST1. Patient is S/P bovine aortic valve replacement (01/20XX) and single right coronary artery vein bypass graft.2. Postoperative respiratory insufficiency associated with phrenic nerve palsy and persistent elevation of left hemidiaphragm.3. Hyperlipidemia.4. Hypertension.5. COPD Nonsmoker. Nocturnal oxygen desaturation on supplemental oxygen at 1.5-2L.ALLERGIES: Penicillin, aspirin (history GI bleed)MEDICATIONSLopressor 75 mg b.i.d.Lisinopril 10 mg q.d.Vytorin 10/20 one half tab h.s.Lasix 80 mg q.d.Vitamin C q.d. (not regularly)Multivitamins q.d.Albuterol inhaler MID, uses zero to two times/day (p.r.n. only)Magnesium 250 mg t.i.d.Oxygen 1 L p.r.n. daytime and then continuously at night onlyTemazepam 30 mg p.r.n.Fe 325 2 q.d.Omeprazole 40 mg q.d.KCl OTC mEq q.d.Vitamin D 3000 IU q.d.INTERVAL HISTORY: At last office visit, echocardiogram showed hyperkinetic left ventricle with ejection fraction 70%. Metoprolol was increased to 75 mg b.i.d. She has had no significant side effects. No chest pain, lightheadedness, dizziness, palpitations, or shortness of breath. Blood pressure remains suboptimally controlled.PHYSICAL EXAMVITAL SIGNS: Weight 126-1/2 lbs, BP 148/76 in the left arm, pulse 67 and regular, oxygen saturation 94% on room air.CONSTITUTIONAL: In no acute distress.HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.RESPIRATORY: Lungs are diminished. Respirations even and unlabored. No adventitious sounds. Chest has normal contour.CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid bruits. S1, S2 and normal. She has a grade 2/4 aortic systolic murmur heard best at right sternal border. No clicks or gall

CaseID: OPD7101 Primary Diagnosis: R60.0, I11.9 E/M Level: 99214

MEDICAL RECORD PROGRESS NOTEAGE: 82Attending Physician:Referring Physician:Date: 01/01/20XXCHIEF COMPLAINT: Today he is here for six-month check and echocardiogram results.PROBLEM LIST1. 82-year-old with history of early constrictive pericarditis, secondary to acute pericarditis, treated with prednisone.2. History of progressive increase in white cell count increasing from pericardial effusion and thickening secondary to recent pericarditis; so far refractory to steroid therapy with left heart catheterization showing normal coronary arteriogram and left ventriculogram. Findings consistent with constrictive pericarditis.3. Normal coronary arteriogram (0X/20XX).4. Pulmonary infiltrates settling on recent CT scan.5. S/P left anterior descending and diagonal branch stenting (20XX) with residual diffuse circumflex disease.6. Mild to moderate ischemic cardiomyopathy, ejection fraction initially 40%, now 65%.7. 13+ year history of hypertension.8. Hyperlipidemia.9. Glaucoma.ALLERGIES: No known drug allergies.MEDICATIONSToprol-XL 100 mg q.d.Furosemide 40 mg q.d.Aspirin 81 mg q.d.Azopt eye drops q.d.Lisinopril 40 mg q.d.Timolol eye dropsLipitor 10 mg q.d.Travatan eye dropsOmega-3 fatty acids q.d.Spironolactone 50 mg q.d.Multivitamins q.d.Norvasc 10 mg q.d. (holding)INTERVAL HISTORY: The patient is here for six-month check and echocardiogram results.EKG today shows:1. Normal sinus rhythm at 69 b.p.m.Echocardiogram shows:1. Ejection fraction of 55-60% with mild left ventricular hypertrophy that is borderline elevated from previous echo.2. Essentially normal echocardiogram.Norvasc was discontinued by his PCP due to increasing lower extremity edema. No true cellulitis. Spironolactone and furosemide were started. He has had improvement in lower extremity edema, but blood pressure at home averages 140/80. His weight is down 8 lbs due

CaseID: OPD7099 Primary Diagnosis: I27.20, I10 Secondary Diagnosis: Z95.0 E/M Level: 99213

MEDICAL RECORD PROGRESS NOTESEX: FAGE: 94Attending Physician:Primary Care Physician:Date: 01/01/2XXCHIEF COMPLAINT: She is here for echocardiogram results.PROBLEM LIST1. 94-year-old with pulmonary hypertension, most severe at 86 mmHg, now 45 mmHg on Letairis and Revatio. She remains oxygen dependent.2. Hospitalized (01/01/20XX) for anemia, transfused with 2 units of packed RBCs.3. Hospitalized (01/20XX) for pneumonia, pleural effusions requiring thoracentesis, and increased pulmonary hypertension.4. Dual chamber pacemaker upgrade from VVI to DDD (01/20XX).5. S/P community acquired pneumonia (01/20XX); resolved with treatment.6. Paroxysmal atrial flutter and atrial fibrillation with 2:1 A-V block.7. Sick sinus syndrome, S/P single chamber VVI pacemaker (01/01/XX).8. History of coronary artery disease, S/P right coronary stent (8+ years ago).9. Hypothyroidism, on replacement therapy.10. Hypertension; markedly labile and difficult to control secondary to left ventricular noncompliance and aortic inelasticity.11. History of gout.12. History of osteoporosis.ALLERGIES: Demerol, BenadrylMEDICATIONSSotalol 40 mg b.i.d.Lipitor 10 mg q.d.Levothyroxine 25 mcg q.d.Clonidine 0.1 mg p.r.n. increased BPRevatio 20 mg t.i.d.Oxygen 3-5 L/minute continuousCoumadin ADLasix 20 b.i.d.Allopurinol 300 mg 1/2 tablet q.d.KC1 20 mEq q.d.Ferrous sulfate 325 mg q. a.m.Letairis 10 mg q.d.Calcium with D3 1000 mg 4 tabs q.d.INTERVAL HISTORY: The patient presents today for echocardiogram results. Overall, she feels she is better. Her oxygen is at 3 liters per nasal cannula most of the time but increases to 6 liters a minute with walking upstairs or other heavier exercise. Her home blood pressure is 120/82. She has had no chest pain, no syncopal episodes, and no major illnesses or hospitalizations.Echocardiogram (01/01/20XX) shows:1. Ejection fraction

CaseID: OPD7403 Primary Diagnosis: R07.9, R06.02 CPT: 71046-26

MEDICAL RECORD Study performed at Mountain HospitalSEX: FEMALEAge: 36DATE OF EXAM: 1/1/20XXPHYSICIAN(S): Marc Kramer, M.D.PROCEDURE: X-RAY CHEST TWO VIEWS, PA AND LATERALCOMPARISON: 06/19/20XX.INDICATIONS: Chest pain, shortness of breath, worse when lying down.TECHNIQUE: PA and lateral radiographs of the chest were performed. FINDINGS: CARDIAC: Normal. LUNGS: Normal.MEDIASTINUM: Normal.PLEURA: Normal.BONES: Normal for age.OTHER: Negative.CONCLUSION: 1. NEGATIVE TWO VIEW CHEST.Adam M. Andrews M.D.

CaseID: OPD7109 Primary Diagnosis: Z45.018, I48.0, I42.9 Secondary Diagnosis: Z79.01 CPT: 93288

MEDICAL RECORD PROGRESS NOTESex: FAge: 89Attending Physician:Referring Physician:Date: 01/01/20XXCHIEF COMPLAINT: She is here for pacemaker check and six-month office visit.PROBLEM LIST1. 89-year-old S/P biventricular pacemaker for cardiomyopathy (201X). Ejection fraction initially 25% and improving to 35%.2. Moderate LAD stenosis per angiography (20XX).3. Echocardiogram (01/20XX) showing normal left ventricle.4. S/P hospitalization for palpitations and chest pain (20XX) diagnosed with pulmonary emboli, right lung; now maintained on Warfarin5. Hypothyroidism, on replacement therapy.6. Complete right bundle-branch block and a left anterior hemiblock.ALLERGIES: CodeineMEDICATIONSWarfarin (through her physician)Synthroid 50 mcg q.d.Toprol 25 mg a.m. and 12.5 mg p.m.Tylenol 1000 mg q h.s.Hydrocodone/APAP 5/325 q 4-6 hours p.m. (uses rarely)Flovent inh. b.i.d.Imodium p.r.n.Slow-Mag 64 mg b.i.d.Colace q.d.Multivitamin q.d.B12 1000 mcg IM monthlyINTERVAL HISTORY: The patient is here for a six-month check and pacemaker interrogation. Overall, she feels well. She has had no episodes of chest pain or shortness of breath. No palpitations or new diagnosis. No falls. Her weight is down nine pounds. She states her appetite is poor and she is sleepy quite a bit, requiring two daytime naps, but is fatigued most of the time.Pacemaker interrogation (01/01/20XX) shows:1. Boston Scientific BiV pacemaker that is LV pacing only.2. RV lead is essentially turned off with programmed outputs decreased to avoid capture, secondary to increased ejection fraction per echo with LV only.3. She has had significant mode switches but totaled only 4% of time.4. She is on Warfarin.5. Battery status is > 5 years.Electronically signed by ROBERT JONES 1/1/20XXPHYSICAL EXAMVITAL SIGNS: Weight 132 lbs, BP 98/62 in the left arm, pulse 88 and irregular, oxygen s

CaseID: OPD7030 Primary Diagnosis: I51.7, J18.1 CPT: 71046-26

MEDICAL RECORD RADIOLOGY REPORT Location: Mountain HospitalSex: FemaleAGE: 64DATE OF EXAM: 1/01/20XXPHYSICIAN(S):PROCEDURE: X-RAY CHEST TWO VIEWS, PA AND LATERALCOMPARISON: None.INDICATIONS: Fever, cough, and weakness.TECHNIQUE: PA and lateral radiographs of the chest were performed.FINDINGS:CARDIAC: Cardiomegaly. Pulmonary vascularity is within normal limits.LUNGS: Patchy air space disease in the right lower lobe pneumonia.MEDIASTINUM: Normal.PLEURA: No effusion or pneumothorax.BONES: Normal for age.CONCLUSION:1. CARDIOMEGALY.2. PATCHY AIR SPACE CONSOLIDATION IN THE RIGHT LOWER LOBE - LOBAR PNEUMONIA.Electronically signed by 1/1/20XX

CaseID: OPD7029 Primary Diagnosis: R10.9 Secondary Diagnosis: Z87.442 CPT: 74018

MEDICAL RECORD RADIOLOGY REPORTLocation: AAPC Family Practice Sex: MAGE: 31DATE OF EXAM: 1/01/20XXREFERRED BY PHYSICIAN(S): M.D.PROCEDURE: X-RAY ABDOMEN/KUB SUPINE, ONE VIEWCOMPARISON: None.INDICATIONS: Abdomen pain. History of stones.TECHNIQUE: A single AP supine view of the abdomen was performed.FINDINGS:BOWEL GAS PATTERN: Normal.CALCIFICATIONS: None significant.OTHER: Normal for age.CONCLUSION: 1. NORMAL EXAM. NO KIDNEY STONES IDENTIFIED.Electronically signed by 1/1/20XX

CaseID: OPD6979 Primary Diagnosis: N73.4 CPT: 49020

MEDICAL RECORD SEX: FEMALE Age: 24 DATE OF OPERATION: 1/1/20XX PREOPERATIVE DIAGNOSIS: CHRONIC PELVIC PERITONITIS ABSCESS. PROCEDURES: EXPLORATORY LAPAROTOMY WITH DRAINAGE OF PERITONEAL ABSCESS, ABDOMINAL WASHINGS. POSTOPERATIVE DIAGNOSIS: CHRONIC PELVIC PERITONITIS ABSCESS. SURGEON: M.D. ANESTHESIA: GENERAL, ENDOTRACHEAL. ESTIMATED BLOOD LOSS: 400 CC. WOUND CLASS: CLEAN AND CONTAMINATED. SPECIMEN: PERITONEAL CULTURE. PATIENT'S CONDITION: INTUBATED TO SICU STABLE. FINDINGS: 200 cc of foul smelling yellowish green pus upon entering peritoneal cavity an abscess was found, this has been an ongoing problem, made a low transverse uterine incision to the posterior aspect of the bladder with multiple loculations. Uterus was about 10 to 12-week size. Normal tubes and ovaries bilaterally. No signs of bladder or bowel nor posterior cul-de-sac involvement and no hemoperitoneum; with normal appendix visualized. Excellent hemostasis. Drain applied, from lower pelvic cavity, with minimal drainage noted post procedure, Smead-Jones closure, wound left open for closure by secondary intention. The patient was consented and before taking to the operating room told of risks, benefits and alternatives and the risks and benefits to the alternatives. PROCEDURE: Once this was signed and agreed to procedure, she was taken to the operating room where she was placed in dorsal lithotomy position. General anesthesia was then placed and found to be adequate. The patient was prepped and draped in usual sterile fashion.A Pfannenstiel skin incision was made over the previous scar as the patient had clearly asked that a vertical scar not be made. Once a Pfannenstiel incision was made with a scalpel, it was carried down all the way to the fascia and dissected bilaterally. The fascia was then incised using the scalpel and carefully dissected to both late

CaseID: OPD7003 Primary Diagnosis: Z12.11 Secondary Diagnosis: Z80.0, Z83.719 CPT: 45378, 45378-59

MEDICAL RECORD SEX: MALE AGE: 47DOS: 1/1/20XXPHYSICIAN:PREOPERATIVE DIAGNOSIS: Family history of colon cancer and multiple colon polyps.POSTOPERATIVE DIAGNOSIS: Normal colon.OPERATIVE PROCEDURE: Screening Colonoscopy with Conscious Sedation. Time 19 min.SURGEON:FINDINGS: The patient is a male with regular bowel movements and no history of bleeding, and whose family, multiple people, who has had multiple colon polyps and colon cancer. His examination shows essentially normal rectum. His prostate does not feel enlarged, but is difficult to palpate because of his body habitus. The remainder of his colon is well prepared and the mucosa appears normal, without evidence of pathology. I would recommend maintaining adequate fiber intake in his diet and repeat colonoscopy at age 50, or sooner if he develops bowel habit change or bleeding.TECHNIQUE: After explaining the operative procedure, the risks, and potential complications of bleeding and perforation, the patient was given 320 mg of propofol intravenously for conscious sedation by me. His pulse was 70, saturations 97, blood pressure 134/83. A rectal examination was done and then the colonoscope was inserted through the anorectum, rectosigmoid, descending, transverse, and ascending colon to the ileocecal valve. The areas were examined carefully. Then, the air and instrument were gradually withdrawn. The patient tolerated the procedure well.Analgesia/sedation given. Patient status during sedation was attended constantly and was cooperative. Vitals were stable monitored.Electronically signed by 1/1/20XX

CaseID: OPD6932 Primary Diagnosis: S72.352A CPT: 27506-LT

MEDICAL RECORD SEX: MALE Age: 55DATE OF OPERATION: 01/1/20XXPREOPERATIVE DIAGNOSIS: LEFT FEMUR FRACTURE.PROCEDURES: LEFT FEMUR INTERMEDULLARY NAILINGPOSTOPERATIVE DIAGNOSIS: DISPLACED COMMUNITED LEFT FEMORAL SHAFT FRACTURE.SURGEON:ANESTHESIA: GENERAL VIA ENDOTRACHEAL TUBE.ESTIMATE BLOOD LOSS: 300 CC.ANTIBIOTICS: 1 GM ANCEF PREOP AND 1 GM ANCEF POSTOP.COMPLICATIONS: NONE.INDICATIONS: The patient is a male who was found on train tracks and on physical examine and x-ray was found to have a displaced comminuted fracture of the left femur. Options, risks, and benefits were discussed with the brother, as the patient was unable to give consent. He agreed with intramedullary nailing.PROCEDURE: The patient was brought to the operating room and anesthesia was induced via endotracheal tube. The patient was then positioned on the fracture table and closed reduction was performed. The left hip and lower extremity were then prepped and draped in sterile fashion.A longitudinal incision was made superior to the greater trochanter and taken down through the subcutaneous tissue to the tip of the trochanter. A guide rod was placed and centered in the AP and lateral views. This was then over reamed, and a bead guide rod was placed down the shaft across into the distal fragment. This was then sequentially reamed up to 10 and then a 10 x 400 Stryker nail was inserted and then the proximal interlock was done with the guide in the static position. The distal interlocks were done in a perfect circle technique.Clinically, he had good rotation compared to the other side and x-ray showed anatomic reduction and good position of the hardware. The wounds were then irrigated out. The gluteus fascia was closed with interrupted 0-Vicryl. The subcutaneous tissue was closed with interrupted 2-0 Vicryl. Skin was closed with skin clips as were the interloc

CaseID: OPD6931 Primary Diagnosis: M17.11 CPT: 27447-RT

MEDICAL RECORD SEX: MALE Age: 63DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: PRIMARY DEGENERATIVE JOINT DISEASE-RIGHT KNEE.PROCEDURES: RIGHT TOTAL KNEE ARTHROPLASTY (ZIMMER).1. FEMORAL SIZE-SIZE E; RIGHT.2. TIBIAL SIZE 6.3. ARTICULAR SURFACE-SIZE E-RIGHT; 10-MM HEIGHT.4. TAPER STEM PLUG AND STEM EXTENSION SCREW.POSTOPERATIVE DIAGNOSIS: PRIMARY DEGENERATIVE JOINT DISEASE-RIGHT KNEE.SURGEON: Stephanie Andrews MDANESTHESIA: GENERAL.ANESTHESIOLOGIST:PROCEDURE: After adequate induction with general anesthesia and the patient in the supine position, a pneumatic tourniquet was applied to the high right thigh region and not inflated. The right lower extremity was scrubbed, prepped with Betadine and draped in the usual manner for knee surgery. An Esmarch tourniquet was applied to the right lower extremity, which was elevated for a period of two minutes. The pneumatic tourniquet was inflated to the appropriate level and the Esmarch removed.A linear incision was made along the anterior aspect of the right knee from the distal quadriceps to the tibial tubercle. The incision was brought to the subcutaneous tissue and undermined medially. A medial parapatellar incision was made extending from the quadriceps raphe to the medial tibial tubercle. The patella was mobilized laterally and the infrapatellar fat pad was excised. The anteromedial and the anterolateral capsule of the proximal tibia was released. The knee was flexed and the patella everted.Advanced degenerative changes of the interior of the right knee was observed, which was most advanced in the patellofemoral and medial joints with exposure of subchondral bone. The extramedullary alignment rod was applied to the tibia and fixed with pin. The proximal cut was made with an oscillating saw, having determined the height by 10-mm of the lateral tibial plateau. A drill hole

CaseID: OPD7020 Primary Diagnosis: M48.061 Secondary Diagnosis: Z98.1 CPT: 63047-LT

MEDICAL RECORD SEX: MaleAge: 68Date of Service: 1/1/20XXService Department: OrthopedicProvider:OPERATIVE NOTE:PREOPERATIVE DIAGNOSIS: Previous spinal fusion at the L5-S1 level with stenosis of a previous fusion at L4-L5.POSTOPERATIVE DIAGNOSIS: Previous spinal fusion at the L5-S1 level with stenosis of a previous fusion at L4-L5 with claudicationNAME OF PROCEDURE: Repeat spinal surgery. Lumbar laminotomy L4-5 with foraminotomy.SURGEON:ANESTHESIA: General.ESTIMATED BLOOD LOSS: Negligible.COMPLICATIONS: None.INDICATIONS: Severe lower back pain radiating down the left lower extremities towards the foot, paresthesias, dysesthesias and claudication difficulty with walking. Positive straight leg raising.IMAGING STUDIES: Previous fusion L5-S1. MRI study and myelogram showing that at L4-5 he has relatively good disk type remaining, not a lot of instability, posterior stenosis.RECOMMENDATIONS: I have encouraged the patient to live with his symptoms. He says this is not an option; it is unbearable for him. I think just a laminectomy and decompression and foraminotomy at the L4-5 level will probably take care of it for him. I really do not see a lot of indication for a fusion but I think I should be able to give him the results that he needs just with the laminectomy. If he does not get these results he may have to come back and have a fusion. He was a successful fusion at L5-S1. I do not see any stenosis at 5-1 or compression.DESCRIPTION OF PROCEDURE: General anesthesia, TEDs, SCDs, antibiotics, catheter. Two-plane fluoroscopy. The patient transferred onto the OR table, marking on L4-5. Wash and prep. Sterile draping. Pressure areas carefully padding observed.The old incision was opened over the L4-5 level, taken through the skin and subcutaneous tissue, coming down to the scar tissue at L4-5, 5-1, carefully dissecting through t

CaseID: OPD7044 Primary Diagnosis: H57.13 CPT: 70553-26, 70543-26

RADIOLOGY LOCATION: Mountain HospitalPROCEDURE: 1. MRI ORBIT WITHOUT AND WITH CONTRAST 2. MRI BRAIN WITHOUT AND WITH CONTRASTCOMPARISON: None.INDICATIONS: Pain in both eyes.TECHNIQUE: Sagittal T1; axial FLAIR; TSE T2, and DW; coronal and axial T1 pre and post gadolinium, and coronal TSE T2 weighted images through the orbits; sagittal, axial, and coronal post gadolinium T1 weighted whole brain images.MRI BRAIN:FINDINGS:CERVICAL CORD: Normal.BRAINSTEM: Normal.BASAL CISTERNS: Normal for age.CEREBELLUM: Normal for age.SELLA: Normal.VENTRICLES: Normal size and configuration for age.CEREBRUM: Normal; no signal abnormalities.SKULL: Normal.AIR SPACES: Normal.OTHER: Negative.CONCLUSION: Normal MRI of the brain.MRI ORBITS:FINDINGS:GLOBES: Normal.EXTRAOCULAR MUSCLES: Normal.OPTIC NERVES: Normal.LACRIMAL GLANDS: Normal.OTHER: Negative.CONCLUSION: Normal MRI of the orbits.Electronically signed by TECHNICIAN, 01/01/20XX

CaseID: OPD7275 Primary Diagnosis: L30.9, D23.72 Secondary Diagnosis: Z85.820 E/M Level: 99213

[INDEX] MEDICAL RECORD [INDEX] ESTABLISHED PATIENT - OFFICESEX: Female AGE: 45DOS:1/1/20XXCC: Skin CheckHPI: Patient returns for her skin check. Patient was previously diagnosed with Melanoma and was referred to Dr. Jones for treatment. Also, had lymph node removed and the melanoma was not found in the lymph node. Patient mentions some lesions on L Leg that do not hurt or itch. They have been there for a while.Allergies: No Known Drug Allergies. Current Meds:Vivelle 0.1 MG/24HR PTTW; RPTAlbuterol Sulfate HFA; RPTVentolin HFA 108 (90 Base) MCG/ACT Inhalation Aerosol Solution; INHALE 2 PUFFS EVERY 4 HOURS AS NEEDED FOR COUGH AND WHEEZE.; RxTrazodone HC1 100 MG Oral Tablet; TAKE 0.5 TABLET BEDTIME; RPTTramadol HC1 50 MG Oral Tablet; TAKE 1 TABLET EVERY 12 HOURS AS NEEDED.; RxHydroxyzine HC1 5 MG Oral Tablet; TAKE 1 TABLET 3-4 TIMES DAILY.; RxCyclobenzaprine HC1 5 MG Oral Tablet; Take 1 tablet 2-3 times a day as needed for muscle spasm. May cause drowsiness.; RxMiscellaneous; Benadryl/Maalox/visc lidocaine 1:1:1 liquid Sig 1 tsp swish/swallow QAC PRN pain 1 bottle, 120mL., no Refill; RxZolpidem Tartrate 10 MG Oral Tablet; 1HS- TAKE ONE TABLET BY MOUTH AT BEDTIME; RxIbuprofen 800 MG Oral Tablet; TAKE 1 TABLET 3 TIMES DAILY WITH FOOD AS NEEDED, RxDiazepam 5 MG Oral Tablet; TAKE 1 TABLET AS NEEDED.; RxLyrica 150 MG Oral Capsule; TAKE 1 CAPSULE 3 TIMES DAILY .; RxTramadol HC1 50 MG Oral Tablet; TAKE 2 TABLET 3 TIMES DAILY; RxSertraline HC1 100 MG Oral Tablet; TAKE ONE TABLET BY MOUTH EVERY DAY; Rx.Patient Medical History:Abdomen Tenderness Direct SuprapubicAnxiety Disorder NOSAsthmaBack Muscle SpasmChange in Skin TextureDepressionFatigue InsomniaJoint Pain, Localized in The HipNauseaPain During UrinationTaking Female Hormones for Postmenopausal HRTUrinary Frequency Increased.ROS: Skin conditions listed above. Menstrual Cycle;

CaseID: OPD7202 Primary Diagnosis: Z30.46 E/M Level: 99212

[INDEX] MEDICAL RECORD [INDEX] FOLLOW- UP VISITDATE: 11/21/20xxSex: F AGE: 20HPI: This patient presents today for 2 weeks recheck of Nexplanon. Her Nexplanon was placed on 12/19/12 without complications per Dr. Huebert. She reports doing well with it. She denies pain at insertion site, no signs or symptoms of infection. She has been afebrile. She has had no vaginal bleeding. She offers no complaints today. Vitals: Wt.: 162 BP: 108/76 Allergies: NKDAMeds: NoneLMP: 12/5/12ASSESSMENT: Gen: WDWN, presents in no acute distress. The inner side of upper left arm was palpated and the Nexplanon rod was noted to be located at its original insertion site. No ecchymosis, no edema, no erythema, no s & s of infection. Neg. TTP.PLAN: Nexplanon recheck, doing well. She is to RTC in 1 year, otherwise sooner if needed.Signed Dr. Kramer

CaseID: OPD7303 Primary Diagnosis: I10, R00.0 E/M Level: 99213

[INDEX] MEDICAL RECORD [INDEX] OFFICE - ESTABLISHEDSEX: Female AGE: 67Date: 01/01/20XXCHIEF CONCERN: She is here for four-month checkup.PROBLEM LIST:1. Hypertension, adequately controlled on present medications.2. Abnormal EKG.3. Hyperlipidemia.ALLERGIES: Sulfa (nausea and vomiting), simvastatin (agitation).MEDICATIONS:Cardizem CD 240 mg q.d.Lisinopril 40 mg a.m. and 20 mg p.m.Lorazepam 1 mg b.i.d.Fenofibrate 160 mg h.s.Omega 3 fish oil q.d.Calcium 1000 mg q.d.Vitamin D3 400Move FreeTylenol Arthritis h.s.Metoprolol ER 50 mg q.d.INTERVAL HISTORY: Following complaints of increasing lower extremity edema, diltiazem was decreased and beta blocker was added. Overall, she feels quite well. Home blood pressures are now 120/80 to 138/89, pulse 69 to 80. She is having no significant side effects. Last month, she was treated as an outpatient for bronchitis, which has now completely resolved, and she feels well.PHYSICAL EXAMINATION:VITAL SIGNS: Weight 184 lbs, BP 128/74 in the left arm. Pulse 75 and regular, oxygen saturation 97% on room air.CONSTITUTIONAL: In no acute distress.HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.RESPIRATORY: Respirations even and unlabored. Good air entry bilaterally. No adventitious sounds. Chest has normal contour.CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid bruits. S1 is normal and increased S2. Apical S4. No murmurs and clicks. Abdominal aorta not palpable, no bruit. Femoral, tibial, dorsalis pedis pulses intact. She has trace only lower extremity edema.GASTROINTESTINAL: Abdomen: Soft. Positive BS x4 quads. No masses or tenderness. No hepatosplenomegaly.SKIN: Pink, warm and dry. Skin intact. No rashes. No lesions. No clubbing or cyanosis.NEUROLOGIC/PSYCH: Cranial nerves II-XII grossly intact. Alert and oriented x3.

CaseID: OPD7296 Primary Diagnosis: E05.80 Secondary Diagnosis: I25.2, Z79.02, Z87.891 E/M Level: 99213

[INDEX] MEDICAL RECORD [INDEX] OFFICE - ESTABLISHEDSEX: Male AGE: 55Date: 01/01/20XXCHIEF CONCERN: He is here for a one-month follow-up.PROBLEM LIST:1. 55-yo five years S/P myocardial infarction.2. 30 pack-year history of smoking, reportedly off for five years.3. Hyperlipidemia.4. Hypothyroidism on replacement therapy.5. Bipolar disorder.ALLERGIES: Sulfa (rash).MEDICATIONS:Levothyroxine 150 mcg q.d.Plavix 75 mg q.d.Seroquel 150 mg q.h.s.Nitroglycerin sl p.r.n.Risperdal 1 mg b.i.d.Tamsulosin 0.4 mg q.h.s.Sertraline 100 mg q.d.Clonazepam 0.5 mg b.i.d.Citalopram 40 mg q.d.Hydroxyzine 50 mg b.i.d.Lamotrigine 100 mg q.d.INTERVAL IIISTORY: At last office visit, TSH was 22.97 and levothyroxine was increased in response. A repeat one month later is now 0.86. He has felt no significant change. No chest pain, shortness of breath, lightheadedness or dizziness.PHYSICAL EXAMINATION:VITAL SIGNS: Weight 166 lbs. BP 100/70 in the left arm, pulse 98 and regular, oxygen saturation 98% on room air.CONSTITUTIONAL: He is somewhat agitated but remains pleasant.RESPIRATORY: Respirations even and unlabored. No adventitial sounds. Lungs clear with good air entry to all lung fields. Normal chest contour.CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid bruits. S1, S2 are normal. There is a physiologic S4 gallop. No nonejection click. Grade 1/6 short systolic murmur along the left sternal border. Murmur decreases with Valsalva maneuver. No diastolic murmur. No S3 gallop or opening snap.ASSESSMENT: 1. History of hypothyroidism, now iatrogenic hyperthyroidism.PLAN:1. Decrease Synthroid to 125 mcg a day.2. Recheck labs in one month.3. Office visit in one month.Robert Jones, MDElectronically signed by ROBERT JONES, MD 1/1/20XX

CaseID: OPD7203 Primary Diagnosis: H66.001, E66.3 Secondary Diagnosis: Z77.22, Z68.54, Z23, Z71.85 CPT: 90460 x3, 90461 x2, 90660, 90619, 90715 E/M Level: 99213-25

[INDEX] MEDICAL RECORD [INDEX] Pediatric Clinic - Established Patient Sex: M AGE: 12DATE OF SERVICE: 1/1/20XXHISTORIAN: MotherVISIT TYPE: Office visitCHIEF COMPLAINT: Ear pain.HISTORY OF PRESENT ILLNESS: This 12-year-old male presents with ear pain that started 1 day ago. The pain is located in the right ear. The problem was severe. Symptoms are associated with exposure to secondhand smoke. Symptoms are not associated with recent URI/cold and repeated Q-Tip use. Denies aggravating factors. Awoke from sleep at 4:00 a.m. with right ear pain.PHYSICAL EXAMINATION:GENERAL: No acute distress, nourishment type is overweight, well developed.VITAL SIGNS: Weight 209 pounds with BMI 28.34, 6'2 temperature 97.2HEENT: Eyes: No injection. Ears: Right, unremarkable to inspection. Canal normal in caliber, no excessive cerumen, no drainage. Tympanic membrane bulging and effusion moderate. Left, unremarkable to inspection. Canal normal in caliber, no excessive cerumen, no drainage. Normal tympanic membrane. No mucosal abnormality. Normal teeth and gums with dental caries. Palate and uvula appear symmetric and normal. No tonsillar hypertrophy or exudates. No pharyngeal erythema or exudates or mucosal lesion.MEDICATIONS: Added Amoxicillin 400 mg/5 mL take 10 mL orally every 12 hours for 10 days.ALLERGIES: No known allergies. Reviewed, no changes.IMMUNIZATIONS: Administered this visit: Influenza virus vaccine, intranasal #1, 0.2 mL nasally. Tdap 0.5 mL IM, MCV4 0.5 mL IM.ASSESSMENT AND PLAN:1. Acute suppurative otitis media without spontaneous rupture of right ear drum. Use antibiotics and reassure.2. Overweight. Should stop gaining weight. Ideal weight would be 190 for height of 62ins. Exercise!3. Counseled parent on vaccination.Electronically signed by John Thompson, MD.