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Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke.

Psychiatry / Psychology

Neuropsychological Evaluation

REASON FOR REFERRAL: , Ms. A is a 60-year-old African-American female with 12 years of education who was referred for neuropsychological evaluation by Dr. X after she demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment with him for stroke in July. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION:, Historical information was obtained from a review of available medical records and clinical interview with Ms. A. A summary of pertinent information is presented below. Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:, Ms. A presented to the ABC Hospital emergency department on 07/26/2009 reporting that after she had woken up that morning she noticed numbness and weakness in her left hand, slurred speech, and left facial droop. Neurological evaluation with Dr. X confirmed left hemiparesis. Brain CT showed no evidence of intracranial hemorrhage or mass effect and that she received TPA and had moderate improvement in left-sided weakness. These symptoms were thought to be due to a right middle cerebral artery stroke. She was transferred to the ICU for monitoring. Ultrasound of the carotids showed 20% to 30% stenosis of the right ICA and 0% to 19% stenosis of the left ICA. On 07/29/2009, she was admitted for acute inpatient rehabilitation for the treatment of residual functional deficits of her acute ischemic right MCA/CVA. At discharge on 08/06/2009, she was mainly on supervision for all ADLs and walking with a rolling walker, but tolerating increased ambulation with a cane. She was discharged home with recommendations for outpatient physical therapy. She returned to the Sinai ER on 08/2009/2009 due to reported left arm pain, numbness, and weakness, which lasted 10 to 15 minutes and she reported that it felt "just like the stroke." Brain CT on 08/2009/2009 was read as showing "mild chronic microvascular ischemic change of deep white matter," but no acute or significant interval change compared to her previous scan. Neurological examination with Dr. Y was within normal limits, but she was admitted for a more extensive workup. Due to left arm pain an ultrasound was completed on her left upper extremity, but it did not show deep vein thrombosis.,Followup CT on 08/10/2009 showed no significant interval change. MRI could not be completed due to the patient's weight. She was discharged on 08/11/2009 in stable condition after it was determined that this event was not neurological in origin; however, note that Ms. A referred to this as a second stroke.,Ms. A presented for a followup outpatient neurological evaluation with Dr. X on 09/22/2009, at which time a brief neuropsychological screening was also conducted. She demonstrated significant impairments in confrontation naming, abstract verbal reasoning, and visual and verbal memory and thus a more comprehensive evaluation was suggested due to her intent to return to her full-time work duty. During the current interview, Ms. A reported that she noticed mild memory problems including some difficultly remembering conversations, events, and at times forgetting to take her medications. She also reported mild difficulty finding words in conversation, solving novel problems and tasks (e.g. difficulty learning to use her camcorder), but overall denied significant cognitive deficits in attention, concentration, language or other areas of cognitive functioning. When asked about her return to work, she said that she was still on light duty due to limited physical activity because of residual left leg weakness. She reported that no one had indicated to her that she appeared less capable of performing her job duties, but said that she was also receiving fewer files to process and enter data into the computer at the Social Security Agency that she works at. Note also that she had some difficulty explaining exactly what her job involved. She also reported having problems falling asleep at work and that she is working full-time although on light duty.,OTHER MEDICAL HISTORY: ,As mentioned, Ms. A continues to have some residual left leg weakness and continues to use a rolling walker for ambulation, but she reported that her motor functioning had improved significantly. She was diagnosed with sleep apnea approximately two years ago and was recently counseled by Dr. X on the need to use her CPAP because she indicated she never used it at night. She reported that since her appointment with Dr. X, she has been using it "every other night." When asked about daytime fatigue, Ms. A initially denied that she was having any difficulties, but repeatedly indicated that she was falling asleep at work and thought that it was due to looking at a computer screen. She reported at times "snoring" and forgetting where she is at and said that a supervisor offered to give her coffee at one point. She receives approximately two to five hours of sleep per night. Other current untreated risk factors include obesity and hypercholesterolemia. Her medical history is also significant for hypertension, asthma, abdominal adenocarcinoma status post hysterectomy with bilateral salpingo-oophorectomy, colonic benign polyps status post resection, benign lesions of the breast status post lumpectomy, and deep vein thrombosis in the left lower extremity status post six months of anticoagulation (which she had discontinued just prior to her stroke).,CURRENT MEDICATIONS: , Aspirin 81 mg daily, Colace 100 mg b.i.d., Lipitor 80 mg daily, and albuterol MDI p.r.n.,SUBSTANCE USE:, Ms. A denied drinking alcohol or using illicit drugs. She used to smoke a pack of cigarettes per day, but quit five to six years ago.,FAMILY MEDICAL HISTORY: , Ms. A had difficulty providing information on familial medical history. She reported that her mother died three to four years ago from lung cancer. Her father has gout and blood clots. Siblings have reportedly been treated for asthma and GI tumors. She was unsure of familial history of other conditions such as hypertension, high cholesterol, stroke, etc.,SOCIAL HISTORY: , Ms. A completed high school degree. She reported that she primarily obtained B's and C's in school. She received some tutoring for algebra in middle school, but denied ever having been held back a grade failing any classes or having any problems with attention or hyperactivity.,She currently works for the Social Security Administration in data processing. As mentioned, she has returned to full-time work, but continues to perform only light duties due to her physical condition. She is now living on her own. She has never driven. She reported that she continues to perform ADLs independently such as cooking and cleaning. She lost her husband in 2005 and has three adult daughters. She previously reported some concerns that her children wanted her to move into assisted living, but she did not discuss that during this current evaluation. She also reported number of other family members who had recently passed away. She has returned to activities she enjoys such as quire, knitting, and cooking and plans to go on a cruise to the Bahamas at the end of October.,PSYCHIATRIC HISTORY: , Ms. A did not report a history of psychological or psychiatric treatment. She reported that her current mood was good, but did describe some anxiety and nervousness about various issues such as her return to work, her upcoming trip, and other events. She reported that this only "comes and goes.",TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test

This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.

Psychiatry / Psychology

Huntington's Disease - Consult

CHIEF COMPLAINT: , "A lot has been thrown at me.",The patient is interviewed with husband in room.,HISTORY OF PRESENT ILLNESS: , This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 325 mg each, 40 tablets. She has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today. The patient states she had been thinking about suicide for a couple of weeks. Felt that her Huntington disease had worsened and she wanted to spare her family and husband from trouble. Reports she has been not socializing with her family because of her worsening depression. Husband notes that on Monday after speaking to Dr. X, they had been advised to alternate the patient's Pamelor (nortriptyline) to every other day because the patient was reporting dry mouth. They did as they have instructed and husband feels this may have had some factor on her worsening depression. The patient decided to ingest the pills when her husband went to work on Friday. She thought Friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened. Her husband left around 7 in the morning and returned around 11 and found her sleeping. About 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital.,She says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the Huntington gene. She does not clearly explain how this has made her suicidality subside.,This is the third suicide attempt in the last two months for this patient. About two months ago, the patient took an overdose of Tylenol and some other medication, which the husband and the patient are not able to recall. She was taken to Southwest Memorial Hermann Hospital. A few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor. Husband locked the gun after that and she was taken to Bellaire Hospital. The patient has had three psychiatric admissions in the past two months, two to Southwest Memorial and one to Bellaire Hospital for 10 days. She sees Dr. X once or twice weekly. He started seeing her after her first suicide attempt.,The patient's husband and the patient state that until March 2009, the patient was independent, was driving herself around and was socially active. Since then she has had worsening of her Huntington symptoms including short-term memory loss. At present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath. The patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her Huntington disease.,The patient's mother passed away 25 years ago from Huntington's. Her grandmother passed away 50 years ago and two brothers also passed away of Huntington's. The patient has told her husband that she does not want to go that way. The patient denies auditory or visual hallucinations, denies paranoid ideation. The husband and the patient deny any history of manic or hypomanic symptoms in the past.,PAST PSYCHIATRIC HISTORY: , As per the HPI, this is her third suicide attempt in the last two months and started seeing Dr. X. She has a remote history of being on Lexapro for depression.,MEDICATIONS: , Her medications on admission, alprazolam 0.5 mg p.o. b.i.d., Artane 2 mg p.o. b.i.d., Haldol 2.5 mg p.o. t.i.d., Norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily. Husband has stated that the patient's chorea becomes better when she takes Haldol. Alprazolam helps her with anxiety symptoms.,PAST MEDICAL HISTORY: , Huntington disease, symptoms of dementia and hypertension. She has an upcoming appointment with the Neurologist. Currently, does have a primary care physician and _______ having an outpatient psychiatrist, Dr. X, and her current Neurologist, Dr. Y.,ALLERGIES: , CODEINE AND KEFLEX.,FAMILY MEDICAL HISTORY: ,Strong family history for Huntington disease as per the HPI. Mother and grandmother died of Huntington disease. Two young brothers also had Huntington disease.,FAMILY PSYCHIATRIC HISTORY: , The patient denies history of depression, bipolar, schizophrenia, or suicide attempts.,SOCIAL HISTORY: ,The patient lives with her husband of 48 years. She used to be employed as a registered nurse. Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions. She rarely drinks socially. She denies any illicit substance usage. Her husband reportedly gives her medication daily. Has been proactive in terms of seeking mental health care and medical care. The patient and husband report that from March 2009, she has been relatively independent, more socially active.,MENTAL STATUS EXAM: ,This is an elderly woman appearing stated age. Alert and oriented x4 with poor eye contact. Appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips. She is cooperative. Her speech is of low volume and slow rate and rhythm. Her mood is sad. Her affect is constricted. Her thought process is logical and goal-directed. Her thought content is negative for current suicidal ideation. No homicidal ideation. No auditory or visual hallucinations. No command auditory hallucinations. No paranoia. Insight and judgment are fair and intact.,LABORATORY DATA:, A CT of the brain without contrast, without any definite evidence of acute intracranial abnormality. U-tox positive for amphetamines and tricyclic antidepressants. Acetaminophen level 206.7, alcohol level 0. The patient had a leukocytosis with white blood cell of 15.51, initially TSH 1.67, T4 10.4.,ASSESSMENT: , This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months. She took 30 tablets of Haldol and 40 tablets of Tylenol. At present, the patient is without suicidal ideation. She reports that her worsening depression has coincided with her worsening Huntington disease. She is more hopeful today, feels that she may be able to get help with her depression.,The patient was admitted four days ago to the medical floor and has subsequently been stabilized. Her liver function tests are within normal limits.,AXIS I: Major depressive disorder due to Huntington disease, severe. Cognitive disorder, NOS.,AXIS II: Deferred.,AXIS III: Hypertension, Huntington disease, status post overdose.,AXIS IV: Chronic medical illness.,AXIS V: 30.,PLAN,1. Safety. The patient would be admitted on a voluntary basis to Main-7 North. She will be placed on every 15-minute checks with suicidal precautions.,2. Primary psychiatric issues/medical issues. The patient will be restarted as per written by the consult service for Prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, Haldol 2 mg p.o. q.8h., Artane 2 mg p.o. daily, Xanax 0.5 mg p.o. q.12h., fexofenadine 180 mg p.o. daily, Flonase 50 mcg two sprays b.i.d., amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation.,3. Substance abuse. No acute concern for alcohol or benzo withdrawal.,4. Psychosocial. Team will update and involve family as necessary.,DISPOSITION: , The patient will be admitted for evaluation, observation, treatment. She will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy. We will place occupational therapy consult and social work consults.

Bender-Gestalt Neurological Battery and Beck testing.

Psychiatry / Psychology

Neurobehavioral Assessment

BENDER-GESTALT TEST: , Not organic.,BECK TESTING:,Depression: 37,Anxiety: 41,Hopelessness: 10,Suicide Ideation: 18,SUMMARY:, The patient was cooperative and appeared to follow the test instructions. There is no evidence of organicity on the Bender. He endorsed symptoms of depression and anxiety. He has moderately negative expectancies regarding his future and is expressing suicidal ideation. Great care should be taken to confirm the accuracy of the results as the patients seems over-medicated and/or drunk.

psychiatry / psychology, bender-gestalt neurological battery, beck anxiety inventory, beck depression inventory, beck hopelessness scale, beck scale, suicide ideation, bender-gestalt test, beck testing, bender gestalt, beck,

Sample for Neuropsychological Evaluation

Psychiatry / Psychology

Neuropsychological Evaluation - 1

REASON FOR EVALUATION: , The patient is a 37-year-old white single male admitted to the hospital through the emergency room. I had seen him the day before in my office and recommended him to go into the hospital. He had just come from a trip to Taho in Nevada and he became homicidal while there. He started having thoughts about killing his mother. He became quite frightened by that thought and called me during the weekend we were able to see him on that Tuesday after talking to him.,HISTORY OF PRESENT ILLNESS: , This is a patient that has been suffering from a chronic psychotic condition now for a number of years. He began to have symptoms when he was approximately 18 or 19 with auditory and visual hallucinations and paranoid delusions. He was using drugs and smoking marijuana at that time has experimenting with LXV and another drugs too. The patient has not used any drugs since age 25. However, he has continued having intense and frequent psychotic bouts. I have seen him now for approximately one year. He has been quite refractory to treatment. We tried different types of combination of medications, which have included Clozaril, Risperdal, lithium, and Depakote with partial response and usually temporary. The patient has had starting with probably has had some temporary relief of the symptoms and they usually do not last more than a few days. The dosages that we have used have been very high. He has been on Clozaril 1200 mg combined with Risperdal up to 9 mg and lithium at a therapeutic level. However, he has not responded.,He has delusions of antichrist. He strongly believes that the dogs have a home in the neighborhood are communicating with him and criticizing him and he believes that all the people can communicate to him with telepathy including the animals. He has paranoid delusions. He also gets homicidal like prior to this admission.,PAST PSYCHIATRIC HISTORY:, As mentioned before, this patient has been psychotic off and on for about 20 years now. He has had years in which he did better on Clozaril and also his other medications.,With typical anti-psychotics, he has done well at times, but he eventually gets another psychotic bout.,PAST MEDICAL HISTORY: , He has a history of obesity and also of diabetes mellitus. However, most recently, he has not been treated for diabetes since his last regular weight since he stopped taking Zyprexa. The patient has chronic bronchitis. He smokes cigarettes constantly up to 60 a day.,DRUG HISTORY:, He stopped using drugs when he was 25. He has got a lapse, but he was more than 10 years and he has been clean ever since then. As mentioned before, he smokes cigarettes quite heavily and which has been a problem for his health since he also has chronic bronchitis.,PSYCHOSOCIAL STATUS: , The patient lives with his mother and has been staying with her for a few years now. We have talked to her. She is very supportive. His only sister is also very supportive of him. He has lived in the ABCD houses in the past. He has done poorly in some of them.,MENTAL STATUS EXAMINATION:, The patient appeared alert, oriented to time, place, and person. His affect is flat. He talked about auditory hallucinations, which are equivocal in nature. He is not homicidal in the hospital as he was when he was at home. His voice and speech are normal. He believes in telepathy. His memory appears intact and his intelligence is calculated as average.,INITIAL DIAGNOSES:,AXIS I: Schizophrenia.,AXIS II: Deferred.,AXIS III: History of diabetes mellitus, obesity, and chronic bronchitis.,AXIS IV: Moderate.,AXIS V: GAF of 35 on admission.,INITIAL TREATMENT AND PLAN:, Since, the patient has been on high dosages of medications, we will give him a holiday and a structured environment. We will put him on benzodiazepines and make a decision anti-psychotic later. We will make sure that he is safe and that he addresses his medical needs well.

psychiatry / psychology, neuropsychological, gaf, schizophrenia, anti-psychotic, chronic psychotic condition, delusions, hallucination, homicidal, marijuana, psychological, psychotic, smokes cigarettes, smoking, neuropsychological evaluation, clozaril, bronchitis, axis,

Falls at home. Anxiety and depression. The patient had been increasingly anxious and freely admitted that she was depressed at home.

Psychiatry / Psychology

Falls - Discharge Summary

CHIEF COMPLAINT:, Falls at home.,HISTORY OF PRESENT ILLNESS:, The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety. Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home. They noted that she frequently came to the emergency room for "attention." The patient denied any chest pain or pressure and no change to exercise tolerance. The patient denied any loss of consciousness or incontinence. She denies any seizure activity. She states that she "tripped" at home. Family states she frequently takes Darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating. They stated that she has numerous medications at home, but they were not sure if she was taking them. The patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression. The patient denied SI or HI.,PHYSICAL EXAMINATION:,GENERAL: The patient is pleasant 82-year-old female in no acute distress.,VITAL SIGNS: Stable.,HEENT: Negative.,NECK: Supple. Carotid upstrokes are 2+.,LUNGS: Clear.,HEART: Normal S1 and S2. No gallops. Rate is regular.,ABDOMEN: Soft. Positive bowel sounds. Nontender.,EXTREMITIES: No edema. There is some ecchymosis noted to the left great toe. The area is tender; however, metatarsal is nontender.,NEUROLOGICAL: Grossly nonfocal.,HOSPITAL COURSE: , A psychiatric evaluation was obtained due to the patient's increased depression and anxiety. Continue Paxil and Xanax use was recommended. The patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls.,DISCHARGE DIAGNOSES:,1. Falls ,2. Anxiety and depression.,3. Hypertension.,4. Hypercholesterolemia.,5. Coronary artery disease.,6. Osteoarthritis.,7. Chronic obstructive pulmonary disease.,8. Hypothyroidism.,CONDITION UPON DISCHARGE: , Stable.,DISCHARGE MEDICATIONS: , Tylenol 650 mg q.6h. p.r.n., Xanax 0.5 q.4h. p.r.n., Lasix 80 mg daily, Isordil 10 mg t.i.d., KCl 20 mEq b.i.d., lactulose 10 g daily, Cozaar 50 mg daily, Synthroid 75 mcg daily, Singulair 10 mg daily, Lumigan one drop both eyes at bed time, NitroQuick p.r.n., Pravachol 20 mg daily, Feldene 20 mg daily, Paxil 20 mg daily, Minipress 2 mg daily, Provera p.r.n., Advair 250/50 one puff b.i.d., Senokot one tablet b.i.d., Timoptic one drop OU daily, and verapamil 80 mg b.i.d.,ALLERGIES: , None.,ACTIVITY: , Per PT.,FOLLOW-UP: , The patient discharged to a skilled nursing facility for further rehabilitation.

The patient was referred after he was hospitalized for what eventually was diagnosed as a conversion disorder.

Psychiatry / Psychology

Conversion Disorder

REASON FOR REFERRAL: ,The patient was referred to me by Dr. X of Children's Hospital after he was hospitalized for what eventually was diagnosed as a conversion disorder. I had met the patient and his mother in the hospital and had begun getting information regarding his symptoms and background at that time. After his discharge, the patient was scheduled to see me for followup services. This was a 90-minute intake that was completed on 10/10/2007 with the patient's mother. I reviewed with her the treatment consent form as well as the boundaries of confidentiality, and she stated that she understood these concepts.,PRESENTING PROBLEMS:, Please see the inpatient hospital progress note contained in his chart for additional background information. The patient's mother reported that he continues with his conversion episodes. She noted that they are occurring approximately 6 times a day. They consist primarily of tremors, arching his back, and, by her report, doing some gang signs during the episode. She reported that the conversion reactions had decreased after his hospitalization, and he had none for 3 days, but then, they began picking up again. From information gathered from mother, it would suggest that she frequently does "status checks," where she asks him how he is doing, and that after she began checking on him more that he began having more conversion reactions. In terms of what she does when he has a conversion reaction, she reported that primarily that she tries to keep him safe. She puts a sheath under him because the carpeting is dirty. She removes any furniture, she wraps his legs together so they do not knock together, she sits with him and she gives him attention and says "calm down, breathe" and after it is over, she continues to tell him to be calm and to breathe. She denied that she gives them any more attention. I strongly encouraged her to stop doing status checks, as this likely is reinforcing the behavior. I also noted that while he certainly needs to be kept safe, that she does not want to give a lot of attention to this behavior, and that over time we will teach him ways of coping with this independently. In regards to his mood, she reported that his mood is quite good. She denied any sadness or irritability. She denied anhedonia. She reports that he is a little bit hard to get up in the morning. He is going to bed at about 11, getting up at 8 or 9. No changes in weight or eating were noted. No changes in concentration, suicidal ideation, and any suicidal history was denied. She denied symptoms of anxiety, although she did note that she thought he worried a little about going to school and some financial stress. Other symptoms of psychopathology were denied.,DEVELOPMENTAL HISTORY: , The patient was reportedly a 7 pounds 12 ounces product of an unplanned and uncomplicated pregnancy and planned cesarean delivery. Mother reported that she did receive prenatal care. The use of alcohol, drugs, or tobacco during the pregnancy were denied. She denied that he had any feeding or sleeping problems in the perinatal period. She described him as a fussy and active baby, but he was described as a cuddly baby. She noted that the pediatricians never expressed any concerns regarding his developmental milestones. SHE REPORTED THAT HE IS ALLERGIC TO PENICILLIN. Serious injures or toileting problems were denied as were a history of seizures.,FAMILY BACKGROUND: , The patient currently lives with his mother who is age 57 and with her partner who is age 40. They have been together since 1994, and he is the only father figure that the patient has even known. The father was previously in a relationship that resulted in an 11-year-old daughter who visits the patient's home every other weekend. The patient's father's whereabouts are unknown. There is no information on his family. Mother stated that he discontinued his involvement in her life when she was about 3 months pregnant with the patient, and the patient has never met him. As noted, there is no information on the paternal side of the family. In terms of the mother's side of family, the maternal grandfather died in his 60s due to what mother described as "hardening of the arteries," and the maternal grandmother died in 2003 due to stroke. There were 4 maternal aunts, one of them died at age 9 months from pneumonia, one of them died at 19 years old from what was described as a brain tumor, and there are 3 maternal uncles. In terms of family relationships, it was reported that overall the patient tends to get along fairly well with his parents, who reported that the patient and her partner tend to compete for mother's attention, and she noted this is difficult at times. She reported that the patient and her partner do not really do anything together. Mother reported that there is no domestic violence in the home, but there is some marital conflict, and this is may be difficult for The patient, as it is carried on in Spanish, and he does not speak Spanish. There also is some stress in the home due to the stepdaughter, as there are some concerns that her mother may be involved in drugs. The mother reported that she attended high school, did not attend any college. She denied learning problems. She denied psychological problems or any drug/alcohol history. In terms of the biological father, she reported he did not graduate from high school. She did not know of learning problems, psychological problems. She denied that he had a drug/alcohol history. There is a family history of alcoholism in one of the maternal uncles as well as in the maternal grandfather. It should be noted that the patient and his family live in a small 4-bedroom apartment, where privacy is very difficult.,SOCIAL BACKGROUND:, She reported that the patient is able to make and keep friends, but he enjoys lifting weights, skateboarding, and that he recently had an opportunity to do rock climbing, he really enjoyed that. I encouraged her to have him involved in physical activity, as this is good for discharge the stress, to encourage the weightlifting, as well as the skateboarding. Mother is going to check further information regarding the rock climbing that the patient had been involved in, which was at it sounds like by her description as some sort of boys' and girls' type of club. Abuse of drugs or alcohol were denied. The patient was not described as being sexually active.,ACADEMIC BACKGROUND: , The patient is currently in the 10th grade. At present, he is on independent studies, which began after his hospitalization. The mother reported that the teacher, who had come to school saw one of his episodes, and stated that, they would not want him to be attending school. I spoke with her very clearly and directly regarding the fact that it was probably not best for the patient to be on independent studies, that he needed to be returned to his normal school environment. He has never had an episode at school, and he needs to be back with his peers, back in a regular environment, where he is under normal expectations. I spoke with her regarding my concerns, regarding the fact that he is unsupervised during the day, and we do not want this turning into one big long vacation, where he is not getting his work done, and he gets himself in trouble. Normally, he would be attending at High School. The mother stated that she would contact them as well as check into possibly a 504-Plan. She reported that he really does not to go back to High School. He says, the "kids are bad;" however, she denied that he has any history of fighting. She noted that he is stressed by the school, there have been some peer problems, possibly some bullying. I noted these need to be addressed with the school, as she had not done so. She stated that she would speak with a counselor. She noted, however, that he has a history of not liking school and avoiding going to school. She noted that he is somewhat behind in his work due to the hospitalization. His grades traditionally are C's. She denied any Special Education Services.,PREVIOUS COUNSELING: , Denied.,DIAGNOSTIC SUMMARY AND IMPRESSION: , Similar to my impression at the hospital, it would appear that the patient clearly qualifies for a diagnosis of conversion disorder. It appears that there are multiple stressors in the family, and that the mother is reinforcing his conversion reaction. I am also very concerned regarding the fact that he is not attending school and want him back in the normal school environment as quickly as possible. My plan is to meet the patient at the next session to update the information regarding his functioning and to begin to teach him skills for reducing his stress and relaxing.,DSM-IV DIAGNOSES: ,AXIS I: Conversion disorder (300.11).,AXIS II: No diagnosis (V71.09).,AXIS III: No diagnosis.,AXIS IV: Problems with primary support group, educational problems, and peer problems.,AXIS V: Global Assessment of Functioning equals 60.

psychiatry / psychology, developmental history, academic background, global assessment of functioning, normal school environment, conversion reactions, conversion disorder, conversion, background, environment, peers, disorder, axis,

Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability

Psychiatry / Psychology

Mental Status Evaluation

COMPREHENSIVE MENTAL STATUS EVALUATION,REASON FOR REFERRAL/GENERAL OBSERVATIONS:, The patient was referred for a Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability. He is a 43-year-old married, white male who came unaccompanied to the evaluation. He drove himself suggesting that he drives regularly. He reportedly has been on Disability since around 2002. He was a good historian, freely offering information. He was dressed and groomed casually, yet neat and appropriate in appearance. He was cooperative with all questions presented and the information collected is felt to be a reliable indication of current functioning. No censorship of data was indicated. ,PRESENT PROBLEMS:, The claimant described his recent problems as, "serious depression. Very hard to concentrate. Very short tempered. Usually distracted." ,The claimant reportedly has had significant problems with depression since around 1997.,The claimant last worked about six weeks ago. He was drafting at a company in Stanfield, North Carolina, for almost six months and was laid off because "I had a breakdown and ended up in the hospital. They said that I wasn't reliable enough and laid me off." Prior to that he worked for two and a half months doing drafting at another company and was laid off because he was no longer needed. ,The claimant has had significant emotional problems since around 1997. He was first hospitalized in that year and has been hospitalized five more times since then. The last hospitalization was last month in Atlanta, Georgia. He has tried to overdose in the past as well as cut his wrist. He even had to undergo electroconvulsive therapy in 2001, because of depression. He also, supposedly, has a history of sexual assault towards a minor and his on probation for that incident. Details regarding this episode of child sexual assault were not forthcoming.,The claimant now takes Effexor 75 mg b.i.d. He is not involved in outpatient therapy. ,PERSONAL, FAMILY AND SOCIAL HISTORY:, The claimant indicated that he graduated from high school in regular classes. He did have to repeat the kindergarten because he was too young. He worked for about 10 years at a company in Massachusetts. He was not advancing on that job and therefore quit. He has had three subsequent jobs and a number of emotional problems since. He indicated usually getting along with others but stated, "I had trouble taking direction from someone younger than me. I resent getting nagged at. I'd get angry or just seethe." He has been let go from his last two jobs because of emotional issues. ,The claimant was married the first time for five years. He has no children. He now lives at home with his wife., ,The claimant denied any legal problems. He suggested that his mother had bipolar disorder. He has never served in the military.,The claimant denied the use or abuse of tobacco, alcohol or illicit drugs. He stopped drinking in 1997. Prior to that he drank about a six pack of beer per day for about 15 years.,The claimant takes the no other prescribed medications., ,DAILY ACTIVITIES AND FUNCTIONING:, The claimant described his typical day as follows, "I usually get up about 7:00 to 7:30. Have breakfast. Take a shower about 8:30. Do errands. Me and my wife are out of the house by 9:00. Check e-mail at the library. I like the computer. We have lunch 11:30 or 12:00. Do errands or watch talk shows or I'll read. I love to read. Around 5:00 to 5:30, have supper. Watch the news, game shows. In bed by 10:00." He will help with vacuuming, doing the dishes or yard work. His wife does most of the house cleaning. He does no cooking. He and his wife get out every day usually for three or four hours. He has a neighbor next door that he will see twice a week. He used to go to the gym but has not been in a few weeks. No other family contact was described and he does not go to church. When asked what he enjoys he stated, "read, use my computer or go ride my bike.", ,MENTAL STATUS EVALUATION:, On interview, the claimant looked his stated age of 43 years. He was tall in stature and thin in weight. He was neat and clean in appearance. Posture was somewhat tense but psychomotor activity was not remarkable. Eye contact was fleeting with fair social skills evident. Facial expression was tense and affect was restricted with little animation noted. General mood appeared dysphoric. Speech was clear, coherent, logical, goal-directed and relevant. He was cooperative in attitude toward the examiner. He described his recent mood as, "cloudy, gray because we've got a lot of personal problems right now. I'm frustrated because I don't know where things are going." He described some problems with falling asleep and staying asleep at night as well as decreased energy level. He denied appetite disturbance. He has lost interest in some activities suggesting mild anhedonia. He has trouble with attention and concentration stating, "I have trouble recalling how to do things on the computer. I've always been technically minded, but now it's harder." He has thoughts of suicide about once or twice a week and has often fled situations in the past. He stated, "I try to keep myself from running away." He denied any plan or intent for suicide. He suggested significant anxiety problems as well. He stated, "I'm dealing with pedophilia. I try to time it so that I don't go to a store with lots of people around. If there is people I get real edgy, heart pounds, shortness of breath. A lot of chest discomfort." He has these panic symptoms quite regularly and they have occurred ever since 1997. That was the time that he engaged in some type of sexual assault with a minor and spent about a week in jail. No phobic processes were suggested. No psychotic symptoms were revealed. He denied hallucinations and no delusional material was elicited. Thought content was appropriate to mood and circumstances.,The claimant was oriented in all spheres. He evidenced adequate memory for both recent and remote events. He was able to recall 3 of 3 words after a 1 minute and 10 minute delay. Fair sustained attention and concentration skills were shown. He was able to spell a word backward and performed a serial 7 subtraction task affectively. Basic calculation skills were intact and no language-based dysfunction was noted. Social judgment was also intact as he gave a good response to finding a wallet in the street, "find who the owner was, bring it to the police station or contact the person," and to seeing smoke in a theater, "Get a hold of staff so they could evacuate." Adequate conceptual abilities was shown with similarity comparisons. Somewhat limited abstraction was shown with proverb interpretation, glass houses, "don't do anything you're not supposed to do." Premorbid intellect is estimated to be at least in the average range. Insight regarding his situation was fair.,DIAGNOSTIC IMPRESSION:,Axis I: Major Depression, recurrent, moderate. Panic disorder without agoraphobia.,SUMMARY AND CONCLUSIONS:, Based on this evaluation, I believe the claimant's current condition would continue to result in difficulty with work-related activities. He continues to show significant problems with depression and anxiety. He is quite withdrawn and socially isolated and has panic attacks whenever he is confronted with public situations. He relies on his wife to take care of most all household task. He engages in very few simple, routine and repetitive activities. Cognitive capacity was relatively intact suggesting no significant problems in maintaining focus and pace with task.,RECOMMENDATIONS/CAPABILITY:, The claimant was strongly encouraged to get some additional help for his emotional problems. He would benefit from having someone to speak with on a regular basis and some referrals were offered. ,It is the opinion of this examiner that the claimant is capable of handling his own funds if so assigned.

The patient has a manic disorder, is presently psychotic with flight of ideas, tangential speech, rapid pressured speech and behavior, impulsive behavior. Bipolar affective disorder, manic state. Rule out depression.

Psychiatry / Psychology

Bipolar Affective Disorder - Consult

IDENTIFYING DATA: ,The patient is a 35-year-old Caucasian female who speaks English.,CHIEF COMPLAINT: ,The patient has a manic disorder, is presently psychotic with flight of ideas, believes, "I can fly," tangential speech, rapid pressured speech and behavior, impulsive behavior. Last night, she tried to turn on the garbage disposal and put her hand in it, in the apartment shared by her husband. She then turned on the oven and put her head in the oven and then tried to climb over the second storied balcony. All of these behaviors were interrupted by her husband who called 911. He reports that she has not slept in 3 to 5 days and has not taken her meds in at least that time period.,HISTORY OF PRESENT ILLNESS: ,The patient was treated most recently at ABCD Hospital and decompensated during that admission resulting in her 90-day LR being revoked. After leaving ABCD approximately 01/25/2010, she stopped taking her Abilify and lithium. Her husband states that he restrained her from jumping, "so she would not kill herself," and this was taken as a statement in his affidavit. The patient was taken to X Hospital, medically cleared, given Ativan 2 mg p.o. and transferred on an involuntary status to XYZ Hospital. She arrives here and is today pacing on the unit and in and out of the large TV room area. She is friendly towards the patients although sometimes raises her voice and comes too close to other patients in a rapid manner. She is highly tangential, delusional, and disorganized. She refused to sign all admit papers and a considerable part of her immediate history is unknown.,PAST PSYCHIATRIC HISTORY: ,The patient was last admitted to XYZ Hospital on January 14, 2009, and discharged on January 23, 2009. Please see the excellent discharge summary of Dr. X regarding this admission for information, which the patient is unable to give at the present. She is currently treated by Dr. Y. She has been involuntarily detained at least 7 times and revoked at least 6 times. She was on XYZ Inpatient in 2001 and in 01/2009. She states that she "feels invincible" when she becomes manic and this is also the description given by her husband.,MEDICAL HISTORY: ,The patient has a history of a herniated disc in 1999.,MEDICATIONS: , Current meds, which are her outpatient meds, which she is not taking at the moment are lithium 300 mg p.o. AM and 600 mg p.o. q.p.m., Abilify 15 mg p.o. per day, Lyrica 100 mg p.o. per day, it is not clear if she is taking Geodon as the record is conflicting in this regard. She is being given Vicodin, is not sure who the prescriber for that medication is and it is presumably due to her history of herniated disc. Of note, she also has a history of abusing Vicodin.,ALLERGIES: ,Said to be PENICILLIN, LAMICTAL, and ZYPREXA.,SOCIAL AND DEVELOPMENTAL HISTORY: , The patient lives with her husband. There are no children. She reportedly has a college education and has 2 brothers.,SUBSTANCE AND ALCOHOL HISTORY: , Per ABCD information, the patient has a history of abusing opiates, benzodiazepines, and Vicodin. The X Hospital tox screen of last night was positive for opiates. Her lithium level per last night at X Hospital was 0.42 mEq/L. She smokes nicotine, the amount is not known although she has asked and received Nicorette gum.,LEGAL HISTORY: , She had a 90-day LR, which was revoked at ABCD Hospital, 12/ 25/2009, when she quickly deteriorated.,MENTAL STATUS EXAM:,ATTITUDE: ,The patient's attitude is agitated when asked questions, loud and evasive.,APPEARANCE:, Disheveled and moderately well nourished.,PSYCHOMOTOR: , Restless with erratic sudden movements.,EPS:, None.,AFFECT: , Hyperactive, hostile, and labile.,MOOD: , Her mood is agitated, suspicious, and angry.,SPEECH: ,Circumstantial and sometimes intelligible when asked simple direct questions and at other points becomes completely tangential describing issues which are not real.,THOUGHT CONTENT: , Delusional, disorganized, psychotic, and paranoid. Suicidal ideation, the patient refuses to answer the questions, but the record shows a past history of suicide attempt.,COGNITIVE ASSESSMENT: ,The patient was said on her nursing admit to be oriented to place and person, but could not answer that question for me, and appeared to think that she may still be at ABCD Hospital. Her recent, intermediate, and remote memory are impaired although there is a lack of cooperation in this testing.,JUDGMENT AND INSIGHT:, Nil. When asked, are there situations when you lose control, she refuses to answer. When asked, are meds helpful, she refuses to answer. She refuses to give her family information nor release of information to contact them.,ASSETS:, The patient has an outpatient psychiatrist and she does better or is more stable when taking her medications.,LIMITATIONS:, The patient goes off her medications routinely, behaves unsafely and in a potentially suicidal manner.,FORMULATION,: The patient has bipolar affective disorder in a manic state at present. She also may be depressed and is struggling with marital issues.,DIAGNOSES:

The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother.

Psychiatry / Psychology

Attempted Suicide - Consult

IDENTIFYING DATA: , The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approximately 72 hours before arriving at ABCD Hospital. He says he had a "panic attack leading to the car wreck" and denies that any of his behavior was suicidal in nature responding, "I was just trying to scare my mother.",CHIEF COMPLAINT: , The patient does say, "I screwed up my whole life and wrecked my car." The patient claims he is med compliant, although his mother, and stepfather saying he is off his meds. He had a two-day stay at XYZ Hospital for medical clearance after his car accident, and no injuries were found other than a sore back, which was negative by x-ray and CT scan.,PRESENT ILLNESS: ,The patient is on a 72-your involuntary hold for danger to self and grave disability. He has a history of bipolar disorder with mania and depression with anxiety and panic attacks. Today, he went to involuntary court hearing and was released by the court. He is now being discharged from second floor ABCD Psychiatric Hospital.,PAST PSYCHIATRIC HISTORY:, Listed extensively in his admission note and will not be repeated.,MEDICAL HISTORY: , Includes migraine headaches and a history of concussion. He describes "allergy" to Haldol medication.,OUTPATIENT CARE: , The patient sees a private psychiatrist, Dr. X. Followup with Dr. X is arranged in four days' time and the patient is discharged with four days of medication. This information is known to Dr. X.,DISCHARGE MEDICATIONS:,The patient is discharged with:,1. Klonopin 1 mg t.i.d. p.r.n.,2. Extended-release lithium 450 mg b.i.d.,3. Depakote 1000 mg b.i.d.,4. Seroquel 1000 mg per day.,SOCIAL HISTORY: ,The patient lives with his girlfriend on an on-and-off basis and is unclear if they will be immediately moving back in together.,SUBSTANCE ABUSE: , The patient was actively tox screen positive for benzodiazepines, cocaine, and marijuana. The patient had an inpatient stay in 2008 at ABC Lodge for drug abuse treatment.,MENTAL STATUS EXAM:, Notable for lack of primary psychotic symptoms, some agitation, and psychomotor hyperactivity, uncooperative behavior regarding his need for ongoing acute psychiatric treatment and stabilization. There is an underlying hostile oppositional message in his communications.,FORMULATION: , The patient is a 21-year-old male with a history of bipolar disorder, anxiety, polysubstance abuse, and in addition ADHD. His recent behavior is may be at least in part associated with active polysubstance abuse and also appears to be a result of noncompliance with meds.,DIAGNOSES:,AXIS I:,1. Bipolar disorder.,2. Major depression with anxiety and panic attacks.,3. Polysubstance abuse, benzodiazepines, and others street meds.,4. ADHD.,AXIS II: , Deferred at present, but consider personality disorder traits.,AXIS III:, History of migraine headaches and past history of concussion.,AXIS IV: , Stressors are moderate.,AXIS V: , GAF is 40.,PLAN: , The patient is released from the hospital secondary to court evaluation, which did not extend his involuntary stay. He has an appointment in four days with his outpatient psychiatrist, Dr. X. He has four days' worth of medications and agrees to no self-harm or harm of others. Additionally, he agrees to let staff know or authorities know if he becomes acutely unsafe. His mother and stepfather have been informed of the patient's discharge and the followup plan.

Painful enlarged navicula, right foot. Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.

Podiatry

Tarsectomy

PREOPERATIVE DIAGNOSES:,1. Painful enlarged navicula, right foot.,2. Osteochondroma of right fifth metatarsal.,POSTOPERATIVE DIAGNOSES:,1. Painful enlarged navicula, right foot.,2. Osteochondroma of right fifth metatarsal.,PROCEDURE PERFORMED:,1. Partial tarsectomy navicula, right foot.,2. Partial metatarsectomy, right foot.,HISTORY: ,This 41-year-old Caucasian female who presents to ABCD General Hospital with the above chief complaint. The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin. She states that she has been diagnosed with hereditary osteochondromas. She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back. The patient desires surgical treatment at this time.,PROCEDURE: ,An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap. Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 5 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal. Foot was then prepped and draped in the usual sterile orthopedic fashion.,Foot was elevated from the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was then inflated to 250 mmHg. The foot was lowered as well as the operating table. The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge. Attention was then directed to the navicular region on the right foot. The area was palpated until the bony prominence was noted. A curvilinear incision was made over the area of bony prominence. At that time, a total of 10 cc with addition of 1% additional lidocaine plain was injected into the surgical site. The incision was then deepened with #15 blade. All vessels encountered were ligated for hemostasis. The dissection was carried down to the level of the capsule and periosteum. A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone. The periosteum and the capsule were then reflected from the navicular bone at this time. A bony prominence was noted both medially and plantarly to the navicular bone. An osteotome and mallet were then used to resect the enlarged portion of the navicular bone. After resection with an osteotome there was noted to be a large plantar shelf. The surrounding soft tissues were then freed from this plantar area. Care was taken to protect the attachments of the posterior tibial tendon as much as possible. Only minimal resection of its attachment to the fiber was performed in order to expose the bone. Sagittal saw was then used to resect the remaining plantar medial prominent bone. The area was then smoothed with reciprocating rasp until no sharp edges were noted. The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted. The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with #3-0 Vicryl. The subcutaneous tissues were then reapproximated with #4-0 Vicryl to reduce tension from the incision and running #5-0 Vicryl subcuticular stitch was performed.,Attention was then directed to the fifth metatarsal. There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal. Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal. The incision was then deepened with #15 blade. Care was taken to preserve the extensor tendon. The incision was then created over the capsule and periosteum of the fifth metatarsal head. Capsule and periosteum were reflected both dorsally, laterally, and plantarly. At that time, there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal. A sagittal saw was used to resect both of these osteal prominences.,All remaining sharp edges were then smoothed with reciprocating rasp. The area was inspected for the remaining bony prominences and none was noted. The area was flushed with copious amounts of sterile saline. The capsule and periosteum were then reapproximated with #3-0 Vicryl. Subcutaneous closure was then performed with #4-0 Vicryl in order to reduce tension around the incision line. Running #5-0 subcutaneous stitch was then performed. Steri-Strips were applied to both surgical sites. Dressings consisted of Adaptic, soaked in Betadine, 4x4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot.,The patient tolerated the above procedure and anesthesia well without complications. The patient was transferred to the PACU with vital signs stable and vascular status intact. The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated. The patient is to follow-up with Dr. X in his office as directed or sooner if any problems or questions arise.

podiatry, navicula, metatarsal, osteochondroma, tarsectomy, metatarsectomy, painful enlarged navicula, navicular bone, foot, bony, capsule, periosteum, navicular, incision, bone

Itchy red rash on feet - Tinea Pedis

Podiatry

Tinea Pedis - H&P

CHIEF COMPLAINT (1/1): ,This 24 year-old female presents today complaining of itchy, red rash on feet. Associated signs and symptoms: Associated signs and symptoms include tingling, right. Context: Patient denies any previous history, related trauma or previous treatments for this condition. Duration: Condition has existed for 4 weeks. Location: She indicates the problem location is right great toe, right 2nd toe, right 3rd toe and right 4th toe. Modifying factors: Patient indicates ice improves condition. Quality: Quality of the itch is described by the patient as constant. Severity: Severity of condition is unbearable. Timing (onset/frequency): Onset was after leaving on sweaty socks.,ALLERGIES: , Patient admits allergies to adhesive tape resulting in severe rash.,MEDICATION HISTORY:, None.,PAST MEDICAL HISTORY: , Childhood Illnesses: (+) chickenpox, (+) frequent ear infections.,PAST SURGICAL HISTORY: ,Patient admits past surgical history of ear tubes.,SOCIAL HISTORY: , Patient admits alcohol use Drinking is described as social, Patient denies tobacco use, Patient denies illegal drug use, Patient denies STD history.,FAMILY HISTORY:, Patient admits a family history of cataract associated with maternal grandmother,,headaches/migraines associated with maternal aunt.,REVIEW OF SYSTEMS:, Unremarkable with exception of chief complaint.,PHYSICAL EXAM: , BP Sitting: 110/64 Resp: 18 HR: 66 Temp: 98.6,Patient is a 24 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus. Cardiovascular: Skin temperature of the lower extremities is warm to cool, proximal to distal.,DP pulses palpable bilateral.,PT pulses palpable bilateral.,CFT immediate.,No edema observed.,Varicosities are not observed. Skin: Right great toe, right 2nd toe, right 3rd toe and right 4th toenail shows erythema and scaling.,Neurological: Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal.,Musculoskeletal: Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Inspection and palpation of bones, joints and muscles is unremarkable.,TEST RESULTS:, No tests to report at this time,IMPRESSION: , Tinea pedis.,PLAN: ,Obtained fungal culture of skin from right toes. KOH prep performed revealed no visible microbes.,PRESCRIPTIONS:, Lotrimin AF Dosage: 1% cream Sig: apply qid Dispense: 4oz tube Refills: 0 Allow Generic: Yes

Right foot trauma. Three views of the right foot. Three views of the right foot were obtained.

Podiatry

Three Views - Foot

EXAM: ,Three views of the right foot.,REASON FOR EXAM: , Right foot trauma.,FINDINGS: , Three views of the right foot were obtained. There are no comparison studies. There is no evidence of fractures or dislocations. No significant degenerative changes or obstructive osseous lesions were identified. There are no radiopaque foreign bodies.,IMPRESSION: , Negative right foot.

podiatry, three views, radiopaque, fractures, foot trauma

School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom. Asperger disorder. Obsessive compulsive disorder.

Psychiatry / Psychology

Asperger Disorder

SUBJECTIVE: ,School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom. He appears confused and depressed at times. Mother also indicates that preservative questioning had come down, but he started collecting old little toys that he did in the past. He will attend social skills program in the summer. ABCD indicated to me that they have identified two psychologists to refer him to for functional behavioral analysis. There is lessening of tremoring in both hands since discontinuation of Zoloft. He is now currently taking Abilify at 7.5 mg.,OBJECTIVE: , He came in less perseverative questioning, asked appropriate question about whether I talked to ABCD or not, greeted me with Japanese word to say hello, seemed less.,I also note that his tremors were less from the last time.,ASSESSMENT: , 299.8 Asperger disorder, 300.03 obsessive compulsive disorder.,PLAN:, Decrease Abilify from 7.5 mg to 5 mg tablet one a day, no refills needed. I am introducing slow Luvox 25 mg tablet one-half a.m. for OCD symptoms, if no side effects in one week we will to tablet one up to therapeutic level.,I also will call ABCD regarding the referral to psychologists for functional behavioral analysis. Parents will call me in two weeks. I will see him for medication review in four weeks. Mother signed informed consent. I reviewed side effects to observe including behavioral activation.,Abilify has been helpful in decreasing high emotional arousal. Combination of medication and behavioral intervention is recommended.

psychiatry / psychology, repetitive questioning, obsession with cleanness, inability to relate, obsessive compulsive disorder, functional behavioral analysis, asperger disorder, inability, asperger,

Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy. Mass, left second toe. Tumor. Left hallux bone invasion of the distal phalanx.

Podiatry

Symes Amputation - Hallux

PREOPERATIVE DIAGNOSES:,1. Mass, left second toe.,2. Tumor.,3. Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1. Mass, left second toe.,2. Tumor.,3. Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1. Excision of mass, left second toe.,2. Distal Syme's amputation, left hallux with excisional biopsy.,HISTORY: , This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot. The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size. The patient also has history of shave biopsy in the past. The patient does state that he desires surgical excision at this time.,PROCEDURE IN DETAIL:, An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap. Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated from the operating table and exsanguinated with an Esmarch bandage. Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses. The foot was lowered to the operating table. The stockinet was reflected and the foot was cleansed with wet and dry sponge. A distal Syme's incision was planned over the distal aspect of the left hallux. The incision was performed with a #10 blade and deepened with #15 down to the level of bone. The dorsal skin flap was removed and dissected in toto off of the distal phalanx. There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx. The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer. Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen. At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx. The area was inspected for any remaining suspicious tissues. Any suspicious tissue was removed. The area was then flushed with copious amounts of sterile saline. The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,Attention was then directed to the left second toe. There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe. A linear incision was made just medial to the tissue mass. The mass was then dissected from the overlying skin and off of the underlying capsule. This tissue mass was hard, round, and pearly-gray in appearance. It does not invade into any other surrounding tissues. The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon. Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to PACU with vital signs stable and vascular status intact. The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed. The patient will be contacted immediately pending the results of pathology. Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC.

podiatry, distal phalanx, mass, tumor., hallux bone, phalanx, symes amputation, excisional biopsy, distal, amputation, invasion, toe, symes, incision, flushed, excision, tissue, hallux

The patient was referred due to concerns regarding behavioral acting out as well as encopresis.

Psychiatry / Psychology

Adjustment Disorder & Encopresis

REASON FOR REFERRAL:, The patient was referred to me by Dr. X of the Clinic due to concerns regarding behavioral acting out as well as encopresis. This is a 90-minute initial intake completed on 10/03/2007. I met with the patient's mother individually for the entire session. I reviewed with her the treatment, consent form, as well as the boundaries of confidentiality, and she stated that she understood these concepts.,PRESENTING PROBLEMS: , Mother reported that her primary concern in regard to the patient had to do with his oppositionality. She was more ambivalent regarding addressing the encopresis. In regards to his oppositionality, she reported that the onset of his oppositionality was approximately at 4 years of age, that before that he had been a very compliant and happy child, and that he has slowly worsened over time. She noted that the oppositionality occurred approximately after his brother, who has multiple medical problems, was born. At that time, mother had spent 2 months back East with the brother due to his feeding issues and will have to go again next year. She reported that in terms of the behaviors that he loses his temper frequently, he argues with her that he defies her authority that she has to ask him many times to do things, that she has to repeat instructions, that he ignores her, that he whines, and this is when he is told to do something that he does not want to do. She reported that he deliberately annoys other people, that he can be angry and resentful. She reported that he does not display these behaviors with the father nor does he display them at home, but they are specific to her. She reported that her response to him typically is that she repeats what she wants him to do many, many times, that eventually she gets upset. She yells at him, talks with him, and tries to make him go and do what she wants him to do. Mother also noted that she probably ignores some his misbehaviors. She stated that the father tends to be more firm and more direct with him, and that, the father sometimes thinks that the mother is too easy on him. In regards to symptoms of depression, she denied symptoms of depression, noting that he tends to only become unhappy when he has to do something that he does not want to do, such as go to school or follow through on a command. She denied any suicidal ideation. She denied all symptoms of anxiety. PTSD was denied. ADHD symptoms were denied, as were all other symptoms of psychopathology.,In regards to the encopresis, she reported that he has always soiled, he does so 2 to 3 times a day. She reported that he is concerned about this issue. He currently wears underwear and had a pull-up. She reported that he was seen at the Gastroenterology Department here several years ago, and has more recently been seen at the Diseases Center, seen by Dr. Y, reported that the last visit was several months ago, that he is on MiraLax. He does sit on the toilet may be 2 times a day, although that is not consistent. Mother believes that he is probably constipated or impacted again. He refuses to eat any fiber. In regards to what happens when he soils, mother basically takes full responsibility. She cleans and changes his underwear, thinks of things that she has tried, she mostly gets frustrated, makes negative comments, even though she knows that he really cannot help it. She has never provided him with any sort of rewards, because she feels that this is something he just needs to learn to do. In regards to other issues, she noted that he becomes frustrated quite easily, especially around homework, that when mother has to correct him, or when he has had difficulty doing something that he becomes upset, that he will cry, and he will get angry. Mother's response to him is that either she gets agitated and raises her voice, tells him to stop etc. Mother reported it is not only with homework, but also with other tasks, such as if he is trying to build with his LEGOs and things do not go well.,DEVELOPMENTAL BACKGROUND: , The patient was reported to be the 8 pound 12 ounce product of a planned and noncomplicated pregnancy and emergency cesarean delivery. The patient presented in a breech position. Mother denied the use of drugs, alcohol, or tobacco during the pregnancy. No sleeping or eating issues were present in the perinatal period. Temperament was described as easy. He was described as a cuddly baby. No concerns expressed regarding his developmental milestones. No serious injuries reported. No hospitalizations or surgeries. No allergies. The patient has been encopretic for all of his life. He currently is taking MiraLax.,FAMILY BACKGROUND: , The patient lives with his mother who is age 37, and is primarily a homemaker, but does work approximately 48 hours a month as a beautician; with his father, age 35, who is a police officer; and also, with his younger brother who is age 3, and has significant medical problems as will be noted in a moment. Mother and father have been together since 1997, married in 1999. The maternal grandmother and grandfather are living and are together, and live in the Central California Coast Area. There is one maternal aunt, age 33, and then, two adopted maternal aunt and uncle, age 18 and age 13. In regards to the father's side of the family, the paternal grandparents are divorced. Grandfather was in Arkansas, grandmother lives in Dos Palos. The patient does not see his grandfather. Mother stated that her relationship with her child was as described, that he very much stresses her out, that she wishes that he was not so defiant, that she finds him to be a very stressful child to deal with. In regards to the relationship with the father, it was reported that the father tends to leave most of the parenting over to the mother, unless she specifically asks him to do something, and then, he will follow through and do it. He will step in and back mother up in terms of parenting, tell the child not to speak to his mother that way etc. Mother reported that he does spend some time with the children, but not as much as mother would like him to, but occasionally, he will go outside and do things with them. The mother reported that sometimes she has a problem in interfering with his parenting, that she steps in and defends The patient. It was reported that mother stated that she tries the parenting technique, primarily of yelling and tried time-out, although her description suggests that she is not doing time-out correctly, as he simply gets up from his time-out, and she does not follow through. Mother reported that she and the patient are very much alike in temperament, and this has made things more difficult. Mother tends to be stubborn and gets angry easily also. Mother reported becoming fatigued in her parenting, that she lets him get away with things sometimes because she does not want to punish him all day long, sometimes ignores problems that she probably should not ignore. There was reported to be jealousy between The patient and his brother, B. B evidently has some heart problems and feeding issues, and because of that, tends to get more attention in terms of his medical needs, and that the patient is very jealous of that attention and feels that B is favored and that he get things that The patient does not get, and that there is some tension between the brothers. They do play well together; however, The patient does tend to be somewhat intrusive, gets in his space, and then, B will hit him. Mother reported that she graduated from high school, went to Community College, and was an average student. No learning problems. Mother has a history of depression. She has currently been taking 100 mg of Zoloft administered by her primary medical doctor. She is not receiving counseling. She has been on the medications for the last 5 years. Her dosage has not been changed in a year. She feels that she is getting more irritable and more angry. I encouraged her to see a primary medical doctor. Mother has no drug or alcohol history. Father graduated from high school, went to the Police Academy, average student. No learning problems, no psychological problems, no drug or alcohol problems are reported. In terms of extended family, maternal grandmother as well as maternal great grandfather have a history of depression. Other psychiatric symptoms were denied in the family.,Mother reported that the marriage is generally okay, that there is some arguing. She reported that it was in the normal range.,ACADEMIC BACKGROUND: , The patient attends the Roosevelt Elementary School, where he is in a regular first grade classroom with Mrs. The patient. This is in the Kingsburg Unified School District. No behavior problems, academic problems were reported. He does not receive special education services.,SOCIAL HISTORY: , The patient was described as being able to make and keep friends, but at this point in time, there has been no teasing regarding smell from the encopresis. He does have kids over to play at the house.,PREVIOUS COUNSELING:, Denied.,DIAGNOSTIC SUMMARY AND IMPRESSION: , My impression is that the patient has a long history of constipation and impaction, which has been treated medically, but it would appear that the mother has not followed through consistently with the behavioral component of toilet sitting, increased fiber, regular medication, so that the problem has likely continued. She also has not used any sort of rewards as a way to encourage him, in the encopresis. The patient clearly qualifies for a diagnosis of disruptive behavior disorder, not otherwise specified, and possibly oppositional defiant disorder. It would appear that mother needs help in her parenting, and that she tends to mostly use yelling and anger as a way, and tends to repeat herself a lot, and does not have a strategy for how to follow through and to deal with defiant behavior. Also, mother and father, may not be on the same page in terms of parenting.,PLAN:, In terms of my plan, I will meet with the child in the next couple of weeks. I also asked the mother to bring the father in, so he could be involved in the treatment also, and I gave the mother a behavioral checklist to be completed by herself and the father as well as the teacher.,DSM IV DIAGNOSES: ,AXIS I: Adjustment disorder with disturbance of conduct (309.3). Encopresis, without constipation, overflow incontinence (307.7),AXIS II: No diagnoses (V71.09).,AXIS III: No diagnoses.,AXIS IV: Problems with primary support group.,AXIS V: Global assessment of functioning equals 65.

psychiatry / psychology, developmental background, axis, dsm iv, adjustment disorder, behavioral, adjustment, depression, oppositionality, encopresis,

Pain. Three views of the right ankle. Three views of the right ankle are obtained.

Podiatry

Three Views - Ankle

EXAM: , Three views of the right ankle.,INDICATIONS: ,Pain.,FINDINGS: , Three views of the right ankle are obtained. There is no evidence of fractures or dislocations. No significant degenerative changes or destructive osseous lesions of the ankle are noted. There is a small plantar calcaneal spur. There is no significant surrounding soft tissue swelling.,IMPRESSION: ,Negative right ankle.

podiatry, three views, calcaneal, plantar, spur, osseous, ankle

Right foot series after a foot injury.

Podiatry

Right Foot Series

EXAM: , Right foot series.,REASON FOR EXAM: ,Injury.,FINDINGS: , Three images of the right foot were obtained. On the AP image only, there is a subtle lucency seen in the proximal right fourth metatarsal and a mild increased sclerosis in the proximal fifth metatarsal. Also on a single image, there is a lucency seen in the lateral aspect of the calcaneus that is seen on the oblique image only. Fractures in these bones cannot be completely excluded. There is soft tissue swelling seen overlying the calcaneus within this region.,IMPRESSION: , Cannot exclude nondisplaced fractures in the lateral aspect of the calcaneus or at the base of the fourth and fifth metatarsals. Recommend correlation with site of pain in addition to conservative management and followup imaging. A phone call will be placed to the emergency room regarding these findings.

podiatry, sclerosis, calcaneus, metatarsal, foot series

Plantar fascitis/heel spur syndrome. The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.

Podiatry

Podiatry - Progress Note

SUBJECTIVE:, Mr. Sample Patient returns to the Sample Clinic with the chief complaint of painful right heel. The patient states that the heel has been painful for approximately two weeks, it is starts with the first step in the morning and gets worse with activity during the day. The patient states that he is currently doing no treatment for it. He states that most of his pain is along medial tubercle of the right calcaneus and extends to the medial arch. The patient states that he has no change in the past medical history since his last visit and denies any fever, chills, vomiting, headache, chest, or shortness of breath.,OBJECTIVE:, Upon removal of shoes and socks bilaterally, neurovascular status remains unchanged since the last visit. There is tenderness to palpation to the medial tubercle of the right foot. The pain is elicited along the medial arch as well. There are no open areas or signs of infection noted.,ASSESSMENT:, Plantar fascitis/heel spur syndrome, right foot.,PLAN:, The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate. He was given a low dye strapping and a heel lift was placed in his right shoe. The patient will be seen back in approximately one month for further evaluation if necessary. He was told to call if anything should occur before that. The patient was told to continue with the good work on his diabetic control.

podiatry, progress note, plantar fascitis, soap, dexamethasone phospate, heel lift, heel spur syndrome, lidocaine, low dye strapping, mixture of 1% lidocaine, dexamethasone, phospate, injections, heel

Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility.

Psychiatry / Psychology

Agitation - ER Visit

HISTORY OF PRESENT ILLNESS: This is a 91-year-old female who was brought in by family. Apparently, she was complaining that she felt she might have been poisoned at her care facility. The daughter who accompanied the patient states that she does not think anything is actually wrong, but she became extremely agitated and she thinks that is the biggest problem with the patient right now. The patient apparently had a little bit of dry heaves, but no actual vomiting. She had just finished eating dinner. No one else in the facility has been ill.,PAST MEDICAL HISTORY: Remarkable for previous abdominal surgeries. She has a pacemaker. She has a history of recent collarbone fracture.,REVIEW OF SYSTEMS: Very difficult to get from the patient herself. She seems to deny any significant pain or discomfort, but really seems not particularly intent on letting me know what is bothering her. She initially stated that everything was wrong, but could not specify any specific complaints. Denies chest pain, back pain, or abdominal pain. Denies any extremity symptoms or complaints.,SOCIAL HISTORY: The patient is a nonsmoker. She is accompanied here with daughter who brought her over here. They were visiting the patient when this episode occurred.,MEDICATIONS: Please see list.,ALLERGIES: NONE.,PHYSICAL EXAMINATION: VITAL SIGNS: The patient is afebrile, actually has a very normal vital signs including normal pulse oximetry at 99% on room air. GENERAL: The patient is an elderly frail looking little lady lying on the gurney. She is awake, alert, and not really wanted to answer most of the questions I asked her. She does have a tremor with her mouth, which the daughter states has been there for "many years". HEENT: Eye exam is unremarkable. Oral mucosa is still moist and well hydrated. Posterior pharynx is clear. NECK: Supple. LUNGS: Actually clear with good breath sounds. There are no wheezes, no rales, or rhonchi. Good air movement. CARDIAC: Without murmur. ABDOMEN: Soft. I do not elicit any tenderness. There is no abdominal distention. Bowel sounds are present in all quadrants. SKIN: Skin is without rash or petechiae. There is no cyanosis. EXTREMITIES: No evidence of any trauma to the extremities.,EMERGENCY DEPARTMENT COURSE: I had a long discussion with the family and they would like the patient receive something for agitation, so she was given 0.5 mg of Ativan intramuscularly. After about half an hour, I came back to talk to the patient and the family, the patient states that she feels better. Family states she seems more calm. They do not want to pursue any further workup at this time.,IMPRESSION: ACUTE EPISODE OF AGITATION.,PLAN: At this time, I had reviewed the patient's records and it is not particularly enlightening as to what could have triggered off this episode. The patient herself has good vital signs. She does not seem to have any specific acute process going on and seemed to feel comfortable after the Ativan was given, a small quantity was given to the patient. Family and daughter specifically did not want to pursue any workup at this point, which at this point I think is reasonable and we will have her follow up with ABC. She is discharged in stable condition.

psychiatry / psychology, acute episode of agitation, agitation,

A 44-year-old, 250-pound male presents with extreme pain in his left heel.

Podiatry

Plantar Fasciitis

S -, A 44-year-old, 250-pound male presents with extreme pain in his left heel. This is his chief complaint. He says that he has had this pain for about two weeks. He works on concrete floors. He says that in the mornings when he gets up or after sitting, he has extreme pain and great difficulty in walking. He also has a macular blotching of skin on his arms, face, legs, feet and the rest of his body that he says is a pigment disorder that he has had since he was 17 years old. He also has redness and infection of the right toes.,O -, The patient apparently has a pigmentation disorder, which may or may not change with time, on his arms, legs and other parts of his body, including his face. He has an erythematous moccasin-pattern tinea pedis of the plantar aspects of both feet. He has redness of the right toes 2, 3 and 4. Extreme exquisite pain can be produced by direct pressure on the plantar aspect of his left heel.,A -, 1. Plantar fasciitis.,

podiatry, plantar fasciitis, tinea pedis, tinea purpura, heel, fasciitis, plantar,

Plantar fascitis, left foot. Partial plantar fasciotomy.

Podiatry

Plantar Fasciotomy

PREOPERATIVE DIAGNOSIS:, Plantar fascitis, left foot.,POSTOPERATIVE DIAGNOSIS: , Plantar fascitis, left foot.,PROCEDURE PERFORMED: , Partial plantar fasciotomy, left foot.,ANESTHESIA:, 10 cc of 0.5% Marcaine plain with TIVA.,HISTORY: ,This 35-year-old Caucasian female presents to ABCD General Hospital with above chief complaint. The patient states she has extreme pain with plantar fascitis in her left foot and has attempted conservative treatment including orthotics without long-term relief of symptoms and desires surgical treatment. The patient has been NPO since mid night. Consent is signed and in the chart. No known drug allergies.,Details Of Procedure: An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported to the operating room and placed on the operating table in supine position with a safety belt across the stomach. Copious amounts of Webril were placed on the left ankle followed by blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 10 cc of 0.5% Marcaine plain was injected into the surgical site both medially and laterally across the plantar fascia. The foot was then prepped and draped in the usual sterile orthopedic fashion. An Esmarch bandage was applied for exsanguination and the pneumatic ankle tourniquet was inflated to 250 mmHg. The foot was then reflected on the operating, stockinet reflected, and the foot cleansed with a wet and dry sponge. Attention was then directed to the plantar medial aspect of the left heel. An approximately 0.75 cm incision was then created in the plantar fat pad over the area of maximal tenderness.,The incision was then deepened with a combination of sharp and blunt dissection until the plantar fascia was palpated. A #15 blade was then used to transect the medial and central bands of the plantar fascia. Care was taken to preserve the lateral fibroids. The foot was dorsiflexed against resistance as the fibers were released and there was noted to be increased laxity after release of the fibers on the plantar aspect of the foot indicating that plantar fascia has in fact been transacted. The air was then flushed with copious amounts of sterile saline. The skin incision was then closed with #3-0 nylon in simple interrupted fashion. Dressings consisted of #0-1 silk, 4 x 4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted throughout all digits of the left foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to the PACU with vital signs stable and vascular status intact to the left foot. Intraoperatively, an additional 80 cc of 1% lidocaine was injected for additional anesthesia in the case. The patient is to be nonweightbearing on the left lower extremity with crutches. The patient is given postoperative pain prescriptions for Vicodin ES, one q3-4h. p.o. p.r.n. for pain as well as Celebrex 200 mg one p.o. b.i.d. The patient is to follow-up with Dr. X as directed.

podiatry, foot, plantar fasciotomy, plantar fascitis, plantar fascia, plantar, fasciotomy, ankle, medially, fascitis, fascia

Toenails are discolored, thickened, and painful - Onychomycosis

Podiatry

Onychomycosis - H&P

CHIEF COMPLAINT (1/1):, This 59 year old female presents today complaining that her toenails are discolored, thickened, and painful. Duration: Condition has existed for 6 months. Severity: Severity of condition is worsening.,ALLERGIES: ,Patient admits allergies to dairy products, penicillin.,MEDICATION HISTORY:, None.,PAST MEDICAL HISTORY:, Past medical history is unremarkable.,PAST SURGICAL HISTORY:, Patient admits past surgical history of eye surgery in 1999.,SOCIAL HISTORY:, Patient denies alcohol use, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:, Unremarkable.,REVIEW OF SYSTEMS:, Psychiatric: (+) poor sleep pattern, Respiratory: (+) breathing difficulties, respiratory symptoms.,PHYSICAL EXAM:, Patient is a 59 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus. Toenails 1-5 bilateral appear crumbly, discolored - yellow, friable and thickened.,Cardiovascular: DP pulses palpable bilateral. PT pulses palpable bilateral. CFT immediate. No edema observed. Varicosities are not observed.,Skin: Skin temperature of the lower extremities is warm to cool, proximal to distal. No skin rash, subcutaneous nodules, lesions or ulcers observed.,Neurological: Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal.,Musculoskeletal: Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Inspection and palpation of bones, joints and muscles is unremarkable.,TEST RESULTS:, No tests to report at this time.,IMPRESSION:, Onychomycosis.,PLAN:, Debrided 10 nails.,PRESCRIPTIONS:, Penlac Dosage: 8% Topical Solution Sig:

Excision of neuroma, third interspace, left foot. Morton's neuroma, third interspace, left foot.

Podiatry

Neuroma Excision

PREOPERATIVE DIAGNOSIS: , Morton's neuroma, third interspace, left foot.,POSTOPERATIVE DIAGNOSIS:, Morton's neuroma, third interspace, left foot.,OPERATION PERFORMED: , Excision of neuroma, third interspace, left foot.,ANESTHESIA: , General (local was confirmed by surgeon).,HEMOSTASIS: , Ankle pneumatic tourniquet 225 mmHg.,TOURNIQUET TIME: , 18 minutes. Electrocautery was necessary.,INJECTABLES: , 50:50 mixture of 0.5% Marcaine and 1% Xylocaine, both plain. Also, 0.5 mL dexamethasone phosphate (4 mg/mL).,INDICATIONS: , Please see dictated H&P for specifics.,PROCEDURE: ,After proper identification was made, the patient was brought to the operating room and placed on the table in supine position. The patient was then placed under general anesthesia. A local block was then injected into the third ray of the left foot. The left foot was then prepped with chlorhexidine gluconate and then draped in the usual sterile technique. The left foot was then exsanguinated with an Esmarch bandage and elevated and an ankle pneumatic tourniquet was then inflated. Attention was then directed to the third interspace where a longitudinal incision was placed just proximal to the webspace. The incision was deepened via sharp and blunt dissection with care taken to protect all vital structures. Identification of the neuroma was made following plantar flexion of the digits. It was grasped with a hemostat and it was dissected in toto and removed. It was then sent to pathology. The area was then flushed with copious amounts of sterile saline. Closure was with 4-0 Vicryl in the subcutaneous tissue and then running subcuticular 4-0 nylon suture in the skin. Steri-Strips were then placed over that area. A sterile compressive dressing consisting of saline-soaked gauze, ABD, Kling, Coban was placed over the foot. The tourniquet was then released. Good flow was noted to return to all digits. The patient did tolerate the procedure well. He left the operating room with all vital signs stable and neurovascular status intact. The patient went to the recovery. The patient previously had been given both oral and written preoperative as well as postoperative instructions and a prescription for pain. The patient will follow up with me in approximately 4 days for dressing change.

podiatry, interspace, ankle pneumatic, pneumatic tourniquet, morton's neuroma, tourniquet, neuroma, foot, anesthesia,

Amputation distal phalanx and partial proximal phalanx, right hallux. Osteomyelitis, right hallux.

Podiatry

Phalanx Amputation

PREOPERATIVE DIAGNOSIS:, Osteomyelitis, right hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, right hallux.,PROCEDURE PERFORMED:, Amputation distal phalanx and partial proximal phalanx, right hallux.,ANESTHESIA:, TIVA/local.,HISTORY:, This 44-year-old male patient was admitted to ABCD General Hospital on 09/02/2003 with a diagnosis of osteomyelitis of the right hallux and cellulitis of the right lower extremity. The patient has a history of diabetes and has had a chronic ulceration to the right hallux and has been on outpatient antibiotics, which he failed. The patient after a multiple conservative treatments such as wound care antibiotics, the patient was given the option of amputation as a treatment for the chronic resistant osteomyelitis. The patient desires to attempt a surgical correction. The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X. The consent was available on the chart for review.,PROCEDURE IN DETAIL: , After patient was taken to the operating room via cart and placed on the operating table in the supine position, a safety strap was placed across his waist. Adequate IV sedation was administered by the Department of Anesthesia and a total of 3.5 cc of 1:1 mixture 1% lidocaine and 0.5% Marcaine plain were injected into the right hallux as a digital block. The foot was prepped and draped in the usual aseptic fashion lowering the operative field.,Attention was directed to the hallux where there was a full-thickness ulceration to the distal tip of the hallux measuring 0.5 cm x 0.5 cm. There was a ________ tract, which probed through the distal phalanx and along the sides of the proximal phalanx laterally. The toe was 2.5 times to the normal size. There were superficial ulcerations in the medial arch of both feet secondary to history of a burn, which were not infected. The patient had dorsalis pedis and posterior tibial pulses that were found to be +2/4 bilaterally preoperatively. X-ray revealed complete distraction of the distal phalanx and questionable distraction of the lateral aspect of the proximal phalanx. A #10 blade was used to make an incision down the bone in a transverse fashion just proximal to the head of the proximal phalanx. The incision was carried mediolaterally and plantarly encompassing the toe leaving a large amount of plantar skin intact. Next, the distal phalanx was disarticulated at the interphalangeal joint and removed. The distal toe was amputated and sent to laboratory for bone culture and sensitivity as well as tissue pathology. Next, the head of the proximal phalanx was inspected and found to be soft on the distal lateral portion as suspected. Therefore, a sagittal saw was used to resect approximately 0.75 cm of the distal aspect of head of the proximal phalanx. This bone was also sent off for culture and was labeled proximal margin. Next, the flexor hallucis longus tendon was identified and retracted as far as possible distally and transected. The flexor tendon distally was gray discolored and was not viable. A hemostat was used to inspect the flexor sheath to ensure no infection tracking up the sheath proximally. None was found. No purulent drainage or abscess was found. The proximal margin of the surgical site tissue was viable and healthy. There was no malodor. Anaerobic and aerobic cultures were taken and passed this as a specimen to microbiology. Next, copious amounts of gentamicin and impregnated saline were instilled into the wound.,A #3-0 Vicryl was used to reapproximate the deep subcutaneous layer to release skin tension. The plantar flap was viable and was debulked with Metzenbaum scissors. The flap was folded dorsally and reapproximated carefully with #3-0 nylon with a combination of simple interrupted and vertical mattress sutures. Iris scissors were used to modify and remodel the plantar flap. An excellent cosmetic result was achieved. No tourniquet was used in this case. The patient tolerated the above anesthesia and surgery without apparent complications. A standard postoperative dressing was applied consisting of saline-soaked Owen silk, 4x4s, Kerlix, and Coban. The patient was transported via cart to Postanesthesia Care Unit with vital signs able and vascular status intact to right foot. He will be readmitted to Dr. Katzman where we will continue to monitor his blood pressure and regulate his medications. Plan is to continue the antibiotics until further IV recommendations.,He will be nonweightbearing to the right foot and use crutches. He will elevate his right foot and rest the foot, keep it clean and dry. He is to follow up with Dr. X on Monday or Tuesday of next week.

podiatry, osteomyelitis, phalanx, phalanx amputation, proximal margin, plantar flap, distal phalanx, proximal phalanx, proximal, hallux, amputation, foot, plantarly, distal

Onychomycosis present, #1, #2, #3, #4, and #5 right and left.

Podiatry

Onychomycosis - 1

S: , The patient presents to podiatry clinic today at the request of her primary physician, Dr. XYZ for initial examination, evaluation, and treatment of her nails. The patient has last seen primary in December 2006.,PRIMARY MEDICAL HISTORY: , Edema, venous insufficiency, schizophrenia, and anemia.,ALLERGIES: , THE PATIENT HAS NO KNOWN ALLERGIES.,MEDICATIONS: , Refer to chart.,O: , The patient presents in wheelchair, verbal and alert. Vascular: She has absent pedal pulses bilaterally. Trophic changes include absent hair growth and mycotic nails. Skin texture is dry. Skin color is rubor. Classic findings include temperature change and edema +1. Nails: Hypertrophic with crumbly subungual debris, #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left.,A:,1. Onychomycosis present, #1, #2, #3, #4, and #5 right and left.,2. Peripheral vascular disease as per classic findings.,3. Pain on palpation.,P: , Nails #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left were debrided for length and thickness. The patient will be seen again at the request of the nursing staff for treatment of painful mycotic nails.

podiatry, debrided, thickness, mycotic nails, onychomycosis, nails,

A 49-year-old female with ankle pain times one month, without a specific injury.

Podiatry

MRI Foot - 3

EXAM:,MRI LEFT FOOT,CLINICAL:, A 49-year-old female with ankle pain times one month, without a specific injury. Patient complains of moderate to severe pain, worse with standing or walking on hard surfaces, with tenderness to palpation at the plantar aspect of the foot and midfoot region and tenderness over the course of the posterior tibialis tendon.,FINDINGS:,Received for second opinion interpretations is an MRI examination performed on 05/27/2005.,There is edema of the subcutis adipose space extending along the medial and lateral aspects of the ankle.,There is edema of the subcutis adipose space posterior to the Achilles tendon. Findings suggest altered biomechanics with crural fascial strains.,There is tendinosis of the posterior tibialis tendon as it rounds the tip of the medial malleolus with mild tendon thickening. There is possible partial surface tearing of the anterior aspect of the tendon immediately distal to the tip of the medial malleolus (axial inversion recovery image #16) which is a possible hypertrophic tear less than 50% in cross sectional diameter. The study has been performed with the foot in neutral position. Confirmation of this possible partial tendon tear would require additional imaging with the foot in a plantar flexed position with transaxial images of the posterior tibialis tendon as it rounds the tip of the medial malleolus oriented perpendicular to the course of the posterior tibialis tendon.,There is minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths consistent with flexor splinting but intrinsically normal tendons.,Normal peroneal tendons.,There is tendinosis of the tibialis anterior tendon with thickening but no demonstrated tendon tear. Normal extensor hallucis longus and extensor digitorum tendons.,Normal Achilles tendon. There is a low-lying soleus muscle that extends to within 2cm of the teno-osseous insertion of the Achilles tendon.,Normal distal tibiofibular syndesmotic ligamentous complex.,Normal lateral, subtalar and deltoid ligamentous complexes.,There are no erosions of the inferior neck of the talus and there are no secondary findings of a midfoot pronating force.,Normal plantar fascia. There is no plantar calcaneal spur.,There is venous engorgement of the plantar veins of the foot extending along the medial and lateral plantar cutaneous nerves which may be acting as intermittent entrapping lesions upon the medial and lateral plantar cutaneous nerves.,Normal tibiotalar, subtalar, talonavicular and calcaneocuboid articulations.,The metatarsophalangeal joint of the hallux was partially excluded from the field-of-view of this examination.,IMPRESSION:,Tendinosis of the posterior tibialis tendon with tendon thickening and possible surface fraying / tearing of the tendon immediately distal to the tip of the medial malleolus, however, confirmation of this finding would require additional imaging.,Minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths, consistent with flexor splinting.,Edema of the subcutis adipose space along the medial and lateral aspects of the ankle suggesting altered biomechanics and crural fascial strain.,Mild tendinosis of the tibialis anterior tendon with mild tendon thickening.,Normal plantar fascia and no plantar fasciitis.,Venous engorgement of the plantar veins of the foot which may be acting as entrapping lesions upon the medial and lateral plantar cutaneous nerves.

podiatry, lateral plantar cutaneous, plantar cutaneous nerves, posterior tibialis tendon, medial and lateral, subcutis adipose, adipose space, achilles tendon, tendon thickening, hallucis longus, lateral plantar, plantar cutaneous, cutaneous nerves, medial malleolus, posterior tibialis, tibialis tendon, plantar, tendon, posterior, flexor, tibialis, medial,

Pain and swelling in the right foot.

Podiatry

MRI Foot - 2

EXAM:,MRI RIGHT FOOT,CLINICAL:,Pain and swelling in the right foot.,FINDINGS: ,Obtained for second opinion interpretation is an MRI examination performed on 11-04-05.,There is a transverse fracture of the anterior superior calcaneal process of the calcaneus. The fracture is corticated however and there is an active marrow stress phenomenon. There is a small ganglion measuring approximately 8 x 5 x 5mm in size extending along the bifurcate ligament.,There is no substantial joint effusion of the calcaneocuboid articulation. There is minimal interstitial edema involving the short plantar calcaneal cuboid ligament.,Normal plantar calcaneonavicular spring ligament.,Normal talonavicular articulation.,There is minimal synovial fluid within the peroneal tendon sheaths.,Axial imaging of the ankle has not been performed orthogonal to the peroneal tendon distal to the retromalleolar groove. The peroneus brevis tendon remains intact extending to the base of the fifth metatarsus. The peroneus longus tendon can be identified in its short axis extending to its distal plantar insertion upon the base of the first metatarsus with minimal synovitis.,There is minimal synovial fluid within the flexor digitorum longus and flexor hallucis longus tendon sheath with pooling of the fluid in the region of the knot of Henry.,There is edema extending along the deep surface of the extensor digitorum brevis muscle.,Normal anterior, subtalar and deltoid ligamentous complex.,Normal naviculocuneiform, intercuneiform and tarsometatarsal articulations.,The Lisfranc’s ligament is intact.,The Achilles tendon insertion has been excluded from the field-of-view.,Normal plantar fascia and intrinsic plantar muscles of the foot.,There is mild venous distention of the veins of the foot within the tarsal tunnel.,There is minimal edema of the sinus tarsus. The lateral talocalcaneal and interosseous talocalcaneal ligaments are normal.,Normal deltoid ligamentous complex.,Normal talar dome and no occult osteochondral talar dome defect.,IMPRESSION:,Transverse fracture of the anterior calcaneocuboid articulation with cortication and cancellous marrow edema.,Small ganglion intwined within the bifurcate ligament.,Interstitial edema of the short plantar calcaneocuboid ligament.,Minimal synovitis of the peroneal tendon sheaths but no demonstrated peroneal tendon tear.,Minimal synovitis of the flexor tendon sheaths with pooling of fluid within the knot of Henry.,Minimal interstitial edema extending along the deep surface of the extensor digitorum brevis muscle.

Patient with right ankle pain.

Podiatry

MRI Ankle - 1

EXAM:,MRI RIGHT ANKLE,CLINICAL:,This is a 51 year old female who first came into the office 3/4/05 with right ankle pain. She stepped on ice the evening prior and twisted her ankle. PF's showed no frank fracture, dislocation, or subluxations.,FINDINGS:,Received for interpretation is an MRI examination performed on 4/28/2005.,There is a "high ankle sprain" of the distal tibiofibular syndesmotic ligamentous complex involving the anterior tibiofibular ligament with marked ligamentous inflammatory thickening and diffuse interstitial edema. There is osteoarthritic spur formation at the anterior aspect of the fibula with a small 2mm osseous structure within the markedly thickened anterior talofibular ligament suggesting a small ligamentous osseous avulsion. The distal tibiofibular syndesmotic ligamentous complex remains intact without a complete rupture. There is no widening of the ankle mortis. The posterior talofibular ligament remains intact.,There is marked ligamentous thickening of the anterior talofibular ligament of the lateral collateral ligamentous complex suggesting the sequela of a remote lateral ankle sprain. There is thickening of the posterior talofibular and calcaneofibular ligaments.,There is a flat retromalleolar sulcus.,There is a full-thickness longitudinal split tear of the peroneus brevis tendon within the retromalleolar groove. The tear extends to the level of the inferior peroneal retinaculum. There is anterior displacement of the peroneus longus tendon into the split peroneus tendon tear.,There is severe synovitis of the peroneus longus tendon sheath with prominent fluid distention. The synovitis extends to the level of the inferior peroneal retinaculum.,There is a focal area of chondral thinning of the hyaline cartilage of the medial talar dome with a focal area of subchondral plate cancellous marrow resorption consistent with and area of prior talar dome contusion but there is no focal osteochondral impaction or osteochondral defect.,There is minimal fluid within the tibiotalar articulation.,There is minimal fluid within the posterior subtalar articulation with mild anterior capsular prolapse. Normal talonavicular and calcaneocuboid articulations. The anterior superior calcaneal process is normal.,There is mild tenosynovitis of the posterior tibialis tendon sheath but an intrinsically normal tendon. There is an os navicularis (Type II synchondrosis) with an intact synchondrosis and no active marrow stress phenomenon.,Normal flexor digitorum longus tendon.,There is prominent fluid distention of the flexor hallucis longus tendon sheath with capsular distention proximal to the posterior talar processes with prominent fluid distention of the synovial sheath.,There is a loculated fluid collection within Kager’s fat measuring approximately 1 x 1 x 2.5cm in size, extending to the posterior subtalar facet joint consistent with a ganglion of either posterior subtalar facet origin or arising from the flexor hallucis longus tendon sheath.,There is mild tenosynovitis of the Achilles tendon with mild fusiform enlargement of the non-insertional Watershed zone of the Achilles tendon but there is no demonstrated tendon tear or tenosynovitis. There is a low-lying soleus muscle that extends to within 4cm of the teno-osseous insertion of the Achilles tendon. There is no Haglund’s deformity.,There is a plantar calcaneal spur measuring approximately 6mm in size, without a reactive marrow stress phenomenon. Normal plantar fascia.,IMPRESSION:,Partial high ankle sprain with diffuse interstitial edema of the anterior tibiofibular ligament with a ligamentous chip avulsion but without a disruption of the anterior tibiofibular ligament.,Marked ligamentous thickening of the lateral collateral ligamentous complex consistent with the sequela of a remote lateral ankle sprain.,Full-thickness longitudinal split tear of the peroneus brevis tendon with severe synovitis of the peroneal tendon sheath.,Post-traumatic deformity of the medial talar dome consistent with a prior osteochondral impaction injury but no osteochondral defect. Residual subchondral plate cancellous marrow edema.,Severe synovitis of the flexor hallucis longus tendon sheath with prominent fluid distention of the synovial sheath proximal to the posterior talar processes.,Septated cystic structure within Kager’s fat triangle extending along the superior aspect of the calcaneus consistent with a ganglion of either articular or synovial sheath origin.,Plantar calcaneal spur but no reactive marrow stress phenomenon.,Mild tendinosis of the Achilles tendon but no tendinitis or tendon tear.,Os navicularis (Type II synchondrosis) without an active marrow stress phenomenon.

Onychomycosis present, #1 right and #1 left.

Podiatry

Onychomycosis - 2

S:, The patient presents to Podiatry Clinic today for initial examination, evaluation, and treatment of her nails.,PRIMARY MEDICAL HISTORY:, Adenocarcinoma, delirium, recent dehydration, anemia, history of hypertension, and hyperlipidemia.,MEDICATIONS: , Refer to chart.,ALLERGIES: , PENICILLIN AND ASPIRIN.,O: , The patient presents in wheelchair, verbal and alert. Vascular: She has absent pedal pulses bilaterally. Trophic changes include absent hair growth and mycotic nails. Skin texture is dry and shiny. Skin color is rubor. Classic findings are temperature change and edema +1. Nails: Hypertrophic with crumbly subungual debris, # 1 right and #1 left.,A:,1. Onychomycosis present, #1 right and #1 left.,2. Peripheral vascular disease as per classic findings.,3. Pain on palpation.,P: , Nails #1 right and #1 left were debrided for length and thickness. All the nails were reduced. The patient will be seen at the request of the nursing staff for treatment of painful mycotic nails.

podiatry, length and thickness, mycotic nails, classic findings, onychomycosis, nails,

Pain and swelling in the right foot, peroneal tendon tear.

Podiatry

MRI Foot - 1

EXAM:,MRI/LOW EX NOT JNT RT W/O CONTRAST,CLINICAL:,Pain and swelling in the right foot, peroneal tendon tear.,FINDINGS:, Contours of marrow signal patterns of the regional bones are within normal range treating there is increased T2 signal within the soft tissues at the lateral margin of the cuboid bone. A small effusion is noted within the peroneal tendon sheath. There is a 3mm slight separation of the distal tip of the peroneus longus tendon from the lateral margin of the cuboid bone, consistent with an avulsion. There is no sign of cuboid fracture. The fifth metatarsal base appears intact. The calcaneus is also normal in appearance.,IMPRESSION: ,Findings consistent with an avulsion of the peroneus longus tendon from the insertion on the lateral aspect of cuboid bone.,

podiatry, peroneus longus tendon, peroneal tendon, lateral margin, peroneus longus, longus tendon, cuboid bone, foot, peroneal, peroneus, longus, avulsion, tendon, bones, cuboid,

Painful ingrown toenail, left big toe. Removal of an ingrown part of the left big toenail with excision of the nail matrix.

Podiatry

Ingrown Toenail Removal

PREOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,POSTOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,OPERATION: , Removal of an ingrown part of the left big toenail with excision of the nail matrix.,DESCRIPTION OF PROCEDURE: ,After obtaining informed consent, the patient was taken to the minor OR room and intravenous sedation with morphine and Versed was performed and the toe was blocked with 1% Xylocaine after having been prepped and draped in the usual fashion. The ingrown part of the toenail was freed from its bed and removed, then a flap of skin had been made in the area of the matrix supplying the particular part of the toenail. The matrix was excised down to the bone and then the skin flap was placed over it. Hemostasis had been achieved with a cautery. A tubular dressing was performed to provide a bulky dressing.,The patient tolerated the procedure well. Estimated blood loss was negligible. The patient was sent back to Same Day Surgery for recovery.

podiatry, toenail, nail matrix, ingrown toenail, painful, ingrown,

Excision of soft tissue mass, right foot. The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot.

Podiatry

Mass Excision - Foot

PREOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,POSTOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,PROCEDURE PERFORMED: , Excision of soft tissue mass, right foot.,HISTORY: ,The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot. The patient has had previous injections to the site which have caused the mass to decrease in size, however, the mass continues to be present and is irritated and painful with shoes. The patient has requested surgical intervention at this time.,PROCEDURE: ,After an IV was instituted by the Department of Anesthesia, the patient was escorted from the preoperative holding area to the operating room. The patient was then placed on the operating room table in the supine position and a towel was placed around the patient's abdomen and secured her to the table. Using copious amounts of Webril, a pneumatic ankle tourniquet was applied to her right ankle. Using a Skin Skribe, the area of the soft tissue mass was outlined over the dorsum of her foot. After adequate amount of anesthesia was provided by the Department of Anesthesia, a local ankle block was given using 10 cc of 4.5 mL of 1% lidocaine plain, 4.5 mL of 0.5% Marcaine plain and 1.0 mL of Solu-Medrol and the foot was scrubbed and prepped in a normal sterile orthopedic manner. Following this, the ankle was elevated and Esmarch bandage applied to exsanguinate the foot and the ankle tourniquet was inflated to 250 mmHg. The foot was then brought back down to the table using bandage scissors. The stockinette was reflected and the right foot was exposed. Using a fresh #10 blade, a curvilinear incision was performed over the dorsum of the right foot. Then using a #15 blade, the incision was deepened with care taken to identify and avoid or cauterize any bleeders which were noted. Following this, the incision was deepened using a combination of sharp and blunt dissection and the muscle belly of the extensor digitorum brevis muscle was identified. Further dissection was then performed in the medial direction in the area of the soft tissue mass. The intermediate dorsal cutaneous nerve was identified and gently retracted laterally. Large amounts of adipose tissue were noted medial to the belly of the extensor digitorum brevis muscle. Using careful dissection, adipose tissue in this area was removed and saved for pathology. Following removal of adipose tissue in this area and identification of no more adipose tissue, attention was directed lateral to the belly of the extensor digitorum brevis muscle, which was also noted to have large amounts of adipose tissue in this area as well. Using careful dissection, from the lateral border of the foot as much adipose tissue as possible was removed from this area as well and saved for pathology. There was noted to be no other fluid-filled masses or lesions identifiable in this area then between the slits of the extensor digitorum brevis muscle, careful dissection was performed to examine the underside of the belly of the muscle as well as structures beneath and no abnormal structures were identified here as well. Following this, feeling adequately that no other mass remained in the area, the incision was flushed using copious amounts of sterile saline. The wound was then reinspected and all remaining tissues appeared healthy including the subcutaneous tissue. The tendon and muscle belly of the extensor digitorum brevis muscle, the nerves of the intermediate dorsal cutaneous nerve and also the medial dorsal cutaneous nerve which were identified medially, all appeared intact. No deficits were noted. No abnormal appearing tissue was present within the surgical site. Following this, the skin edges were reapproximated using #4-0 Vicryl deep closure of the subcutaneous layer was performed. Then, using #4-0 nylon and simple interrupted suture, the skin was reapproximated and closed with care taken to ensure eversion of the skin edges and good approximation of the borders. The patient was also given 7 cc of 1% lidocaine plain throughout the procedure to augment local anesthesia. Following this, the wound was dressed using Xeroform gauze and 4x4s and was dressed using two ABD pads, dorsal and plantar for compression and using Kling, Kerlix and Coban. The patient then had the ankle tourniquet deflated with a total tourniquet time of 55 minutes at 250 mmHg and immediate hyperemia was noted to digits one through five of the right foot. The patient tolerated the procedure and anesthesia well and was noted to have vascular status intact. The patient was then escorted to the Postanesthesia Care Unit where she was placed in a surgical shoe. The patient was then given postoperative instructions to include ice and elevation to her right foot. The patient was cleared for ambulation as tolerated, but was instructed that with increased ambulation will come increased swelling and pain. The patient will follow up with Dr. X in his office on Tuesday, 08/26/03 for further follow up. The patient was given prescription for Vicoprofen #25 taken one tablet q.4h. p.r.n., moderate to severe pain and also prescription for Keflex #20 500 mg tablets to be taken b.i.d. x10 days. The patient was given a number for the Emergency Room and instructed to return if any sign or symptom of infection should present and the patient was educated as to the nature of these. The patient had no further questions and recovered without any complications in the Postanesthesia Care Unit.

podiatry, excision, digitorum brevis muscle, soft tissue mass, adipose tissue, soft tissue, mass, injections, foot, tissue, xeroform, dorsum, belly, extensor, digitorum, brevis, ankle, adipose, muscle,

This patient has reoccurring ingrown infected toenails.

Podiatry

Infected Toenails

S - ,This patient has reoccurring ingrown infected toenails. He presents today for continued care.,O - ,On examination, the left great toenail is ingrown on the medial and lateral toenail border. The right great toenail is ingrown on the lateral nail border only. There is mild redness and granulation tissue growing on the borders of the toes. One on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe. These lesions measure 0.5 cm in diameter each. I really do not understand why this young man continues to develop ingrown nails and infections.,A - ,1. Onychocryptosis.,

podiatry, infected toenails, onychocryptosis, benign lesions, toenail border, left great toe, neosporin ointment, hemostasis was achieved, ointment and absorbent, toenails, ingrown, lesions, benign, infected,

Procedure note on Keller Bunionectomy

Podiatry

Keller Bunionectomy

PROCEDURE: , Keller Bunionectomy.,For informed consent, the more common risks, benefits, and alternatives to the procedure were thoroughly discussed with the patient. An appropriate consent form was signed, indicating that the patient understands the procedure and its possible complications.,This 59 year-old female was brought to the operating room and placed on the surgical table in a supine position. Following anesthesia, the surgical site was prepped and draped in the normal sterile fashion.,Attention was then directed to the right foot where, utilizing a # 15 blade, a 6 cm. linear incision was made over the 1st metatarsal head, taking care to identify and retract all vital structures. The incision was medial to and parallel to the extensor hallucis longus tendon. The incision was deepened through subcutaneous underscored, retracted medially and laterally - thus exposing the capsular structures below, which were incised in a linear longitudinal manner, approximately the length of the skin incision. The capsular structures were sharply underscored off the underlying osseous attachments, retracted medially and laterally.,Utilizing an osteotome and mallet, the exostosis was removed, and the head was remodeled with the Liston bone forceps and the bell rasp. The surgical site was then flushed with saline. The base of the proximal phalanx of the great toe was osteotomized approximately 1 cm. distal to the base and excised to toto from the surgical site.,Superficial closure was accomplished using Vicryl 5-0 in a running subcuticular fashion. Site was dressed with a light compressive dressing. The tourniquet was released. Excellent capillary refill to all the digits was observed without excessive bleeding noted.,ANESTHESIA: , local.,HEMOSTASIS: , Accomplished with pinpoint electrocoagulation.,ESTIMATED BLOOD LOSS: , 10 cc.,MATERIALS:, None.,INJECTABLES:, Agent used for local anesthesia was Lidocaine 2% without epi.,PATHOLOGY:, Sent no specimen.,DRESSINGS: , Site was dressed with a light compressive dressing.,CONDITION: , Patient tolerated procedure and anesthesia well. Vital signs stable. Vascular status intact to all digits. Patient recovered in the operating room.,SCHEDULING: , Return to clinic in 2 week (s).

podiatry, keller bunionectomy, metatarsal head, incision, capsular, osteotome, compressive dressing, keller, bunionectomy,

MRI right ankle.

Podiatry

MRI Ankle - 2

EXAM:,MRI OF THE RIGHT ANKLE,CLINICAL:,Pain.,FINDINGS:,The bone marrow demonstrates normal signal intensity. There is no evidence of bone contusion or fracture. There is no evidence of joint effusion. Tendinous structures surrounding the ankle joint are intact. No abnormal mass or fluid collection is seen surrounding the ankle joint.,IMPRESSION,: NORMAL MRI OF THE RIGHT ANKLE.

podiatry, ankle joint, bone, mri, ankle

Right hallux abductovalgus deformity. Right McBride bunionectomy. Right basilar wedge osteotomy with OrthoPro screw fixation.

Podiatry

McBride Bunionectomy & Wedge Osteotomy

PREOPERATIVE DIAGNOSIS:, Right hallux abductovalgus deformity.,POSTOPERATIVE DIAGNOSIS:, Right hallux abductovalgus deformity.,PROCEDURES PERFORMED:,1. Right McBride bunionectomy.,2. Right basilar wedge osteotomy with OrthoPro screw fixation.,ANESTHESIA: , Local with IV sedation.,HEMOSTASIS: , With pneumatic ankle cuff.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in a supine position. The right foot was prepared and draped in usual sterile manner. Anesthesia was achieved utilizing a 50:50 mixture of 2% lidocaine plain with 0.5 Marcaine plain infiltrated just proximal to the first metatarsocuneiform joint. Hemostasis was achieved utilizing a pneumatic ankle Tourniquet placed above the right ankle and inflated to a pressure of 225 mmHg. At this time, attention was directed to the dorsal aspect of the right first metatarsophalangeal joint where dorsal linear incision approximately 3 cm in length was made. The incision was deepened within the same plain taking care of the Bovie and retracted all superficial nerves and vessels as necessary. The incision was then carried down to the underlying capsular structure once again taking care of the Bovie and retracted all superficial nerves and vessels as necessary. The capsular incision following the same outline as the skin incision was made and carried down to the underlying bony structure. The capsule was then freed from the underling bony structure utilizing sharp and blunt dissection. Using a microsagittal saw, the medial and dorsal very prominent bony eminence were removed and the area was inspected for any remaining bony prominences following resection of bone and those noted were removed using a hand rasp. At this time, attention was directed to the first inner space using sharp and blunt dissection. Dissection was carried down to the underling level of the adductor hallucis tendon, which was isolated and freed from its phalangeal, sesamoidal, and metatarsal attachments. The tendon was noted to lap the length and integrity for transfer and at this time was tenotomized taking out resection of approximately 0.5 cm to help prevent any re-fibrous attachment. At this time, the lateral release was stressed and was found to be complete. The extensor hallucis brevis tendon was then isolated using blunt dissection and was tenotomized as well taking out approximately 0.5-cm resection. The entire area was copiously flushed 3 times using a sterile saline solution and was inspected for any bony prominences remaining and it was noted that the base of the proximal phalanx on the medial side due to the removal of the extensive buildup of the metatarsal head was going to be very prominent in nature and at this time was removed using a microsagittal saw. The area was again copiously flushed and inspected for any abnormalities and/or prominences and none were noted. At this time, attention was directed to the base of the first metatarsal where a second incision was made approximately 4 cm in length. The incision was deepened within the same plain taking care of Bovie and retracted all superficial nerves and vessels as necessary. The incision was then carried down to the level of the metatarsal and using sharp and blunt dissection periosteal capsule structures were freed from the base of the metatarsal and taking care to retract the long extensive tendon and any neurovascular structures to avoid any disruption. At this time, there was a measurement made of 1 cm just distal to the metatarsocuneiform joint on the medial side and 2 cm distal to the metatarsocuneiform joint from the lateral aspect of the joint. At this time, 0.5 cm was measured distal to that lateral measurement and using microsagittal saw, a wedge osteotomy was taken from the base with the apex of the osteotomy being medial, taking care to keep the medial cortex intact as a hinge. The osteotomy site was feathered down until the osteotomy site could be closed with little tension on it and at this time using an OrthoPro screw 3.0 x 22 mm. The screw was placed following proper technique. The osteotomy site was found to be fixated with absolutely no movement and good stability upon manual testing. A very tiny gap on the lateral aspect of the osteotomy site was found and this was filled in packing it with the cancellous bone that was left over from the wedge osteotomy. The packing of the cancellous bone was held in place with bone wax. The entire area was copiously flushed 3 times using a sterile saline solution and was inspected and tested again for any movement of the osteotomy site or any gapping and then removed. At this time, a deep closure was achieved utilizing #2-0 Vicryl suture, subcuticular closure was achieved using #4-0 Vicryl suture, and skin repair was achieved at both surgical sites with #5-0 nylon suture in a running interlocking fashion. The hallux was found to have excellent movement upon completion of the osteotomy and the second procedure of the McBride bunionectomy and the metatarsal was found to stay in excellent alignment with good stability at the proximal osteotomy site. At this time, the surgical site was postoperatively injected with 0.5 Marcaine plain as well as dexamethasone 4 mg primarily. The surgical sites were then dressed with sterile Xeroform, sterile 4x4s, cascading, and Kling with a final protective layer of fiberglass in a nonweightbearing cast fashion. The tourniquet was dropped and color and temperature of all digits returned to normal. The patient tolerated the anesthesia and the procedure well and left the operating room in stable condition.,The patient has been given written and verbal postoperative instructions and has been instructed to call if she has any questions, problems, or concerns at any time with the numbers provided. The patient has also been warned a number of times the importance of elevation and no weightbearing on the surgical foot.,

podiatry, hallux, abductovalgus, bunionectomy, mcbride, basilar, wedge, osteotomy, orthopro, screw, fixation, wedge osteotomy

Resection of infected bone, left hallux, proximal phalanx, and distal phalanx. Osteomyelitis, left hallux.

Podiatry

Hallux Infected Bone Resection

PREOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,PROCEDURES PERFORMED: , Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.,ANESTHESIA: , TIVA/Local.,HISTORY:, This 77-year-old male presents to ABCD preoperative holding area after keeping himself NPO since mid night for surgery on his infected left hallux. The patient has a history of chronic osteomyelitis and non-healing ulceration to the left hallux of almost 10 years' duration. He has failed outpatient antibiotic therapy and conservative methods. At this time, he desires to attempt surgical correction. The patient is not interested in a hallux amputation at this time; however, he is consenting to removal of infected bone. He was counseled preoperatively about the strong probability of the hallux being a "floppy tail" after the surgery and accepts the fact. The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL: ,The patient's wound was debrided with a #15 blade and down to good healthy tissue preoperatively. The wound was on the planar medial, distal and dorsal medial. The wound's bases were fibrous. They did not break the bone at this point. They were each approximately 0.5 cm in diameter. After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with safety straps placed across his waist for his protection.,Due to the patient's history of diabetes and marked calcifications on x-ray, a pneumatic ankle tourniquet was not applied. Next, a total of 3 cc of a 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain was used to infiltrate the left hallux and perform a digital block. Next, the foot was prepped and draped in the usual aseptic fashion. It was lowered in the operative field and attention was directed to the left hallux after the sterile stockinet was reflected. Next, a #10 blade was used to make a linear incision approximately 3.5 cm in length along the dorsal aspect of the hallux from the base to just proximal to the eponychium. Next, the incision was deepened through the subcutaneous tissue. A heavy amount of bleeding was encountered. Therefore, a Penrose drain was applied at the tourniquet, which failed. Next, an Esmarch bandage was used to exsanguinate the distal toes and forefoot and was left in the forefoot to achieve hemostasis. Any small veins crossing throughout the subcutaneous layer were ligated via electrocautery. Next, the medial and lateral margins of the incision were under marked with a sharp dissection down to the level of the long extension tendon. The long extensor tendon was thickened and overall exhibited signs of hypertrophy. The transverse incision through the long extensor tendon was made with a #15 blade. Immediately upon entering the joint, yellow discolored fluid was drained from the interphalangeal joint. Next, the extensor tendon was peeled dorsally and distally off the bone. Immediately the head of the proximal phalanx was found to be lytic, disease, friable, crumbly, and there were free fragments of the medial aspect of the bone, the head of the proximal phalanx. This bone was removed with a sharp dissection. Next, after adequate exposure was obtained and the collateral ligaments were released off the head of proximal phalanx, a sagittal saw was used to resect the approximately one-half of the proximal phalanx. This was passed off as the infected bone specimen for microbiology and pathology. Next, the base of the distal phalanx was exposed with sharp dissection and a rongeur was used to remove soft crumbly diseased medial and plantar aspect at the base of distal phalanx. Next, there was diseased soft tissue envelope around the bone, which was also resected to good healthy tissue margins. The pulse lavage was used to flush the wound with 1000 cc of gentamicin-impregnated saline. Next, cleaned instruments were used to take a proximal section of proximal phalanx to label a clean margin. This bone was found to be hard and healthy appearing. The wound after irrigation was free of all debris and infected tissue. Therefore anaerobic and aerobic cultures were taken and sent to microbiology. Next, OsteoSet beads, tobramycin-impregnated, were placed. Six beads were placed in the wound. Next, the extensor tendon was re-approximated with #3-0 Vicryl. The subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique. Next, the skin was closed with #4-0 nylon in a horizontal mattress technique.,The Esmarch bandage was released and immediate hyperemic flush was noted at the digits. A standard postoperative dressing was applied consisting of 4 x 4s, Betadine-soaked #0-1 silk, Kerlix, Kling, and a loosely applied Ace wrap. The patient tolerated the above anesthesia and procedure without complications. He was transported via a cart to the Postanesthesia Care Unit. His vitals signs were stable and vascular status was intact. He was given a medium postop shoe that was well-formed and fitting. He is to elevate his foot, but not apply ice. He is to follow up with Dr. X. He was given emergency contact numbers. He is to continue the Vicodin p.r.n. pain that he was taking previously for his shoulder pain and has enough of the medicine at home. The patient was discharged in stable condition.

podiatry, osteomyelitis, proximal phalanx, distal phalanx, infected bone, proximal, bone, phalanx, healing, hallux, infected, tissue, distal,

Incision and drainage and removal of foreign body, right foot. The patient has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.

Podiatry

I&D & Foreign Body Removal

PREOPERATIVE DIAGNOSIS:, Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body, right foot.,PROCEDURE PERFORMED:,1. Incision and drainage, right foot.,2. Removal of foreign body, right foot.,HISTORY: , This 7-year-old Caucasian male is an inpatient at ABCD General Hospital with a history of falling off his bike and having a root ________ angle inside of his foot. The patient has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.,PROCEDURE:, An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported to the operating room and placed on the operating table in a supine position with a safety strap across his lap. General anesthesia was administered by the Department of Anesthesia. The foot was then prepped and draped in the usual sterile orthopedic fashion. The stockinette was reflected and the foot was cleansed with wet and dry sponge. There was noted to be some remaining periwound erythema. There was noted to be some mild crepitation about 2 cm proximal from the entry wound. The entry wound was noted to be over the third metatarsal head dorsally. Upon inspection of the wound, there was noted to be hard foreign filling substance deep within the wound. The entry site from the foreign body was extended proximally approximately about 0.5 cm. At this time, a large wooden foreign body was visualized and removed with a straight stat.,The area was carefully inspected for any remaining piece of foreign body. Several small pieces were noted and they were removed. The area was palpated and there was no more remaining foreign body noted. At this time, the wound was inspected thoroughly. There was noted to be an area along the third metatarsal head more distally that did probe to the bone. There was no purulent drainage expressed. Area was flushed with copious amounts of sterile saline. Pulse lavage was performed with 3 liters of plain sterile saline. Wound cultures were obtained, aerobic and aerobic. The wound was then again inspected for any remaining foreign body or purulent drainage. None was noticed. The wound was packed with sterile new gauze packing lately and dressings consisted of 4x4s, ABDs, Kling, and Kerlix.,The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to the PACU with vital signs stable and vascular status intact. The patient is to be readministered to the pediatrics where daily dressing changes will be performed by podiatry. The patient had a postoperative pain prescription written for Tylenol, Elixir with codeine as needed.

podiatry, incision and drainage, removal of foreign body, purulent drainage, foreign body, metatarsal head, orthopedic, metatarsal, i&d, incision, drainage, foot

Gangrene osteomyelitis, right second toe. The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The patient has history of previous right foot infection requiring first ray resection.

Podiatry

Gangrene Surgery

PREOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,POSTOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,OPERATIVE REPORT: ,The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The patient has history of previous right foot infection requiring first ray resection. The patient has ulcerations of right second toe dorsally at the proximal interphalangeal joint, which has failed to respond to conservative treatment. The patient now has exposed bone and osteomyelitis in the second toe. The patient has been on IV antibiotics as an outpatient and has failed to respond to these and presents today for surgical intervention.,After an IV was started by the Department of Anesthesia, the patient was taken back to the operating room and placed on the operative table in the supine position. A restraint belt was placed around the patient's waist using copious amounts of Webril and an ankle pneumatic tourniquet was placed around the patient's right ankle and the patient was made comfortable by the Department of Anesthesia. After adequate amounts of sedation had been given to the patient, we administered a block of 10 cc of 0.5% Marcaine plain in proximal digital block around the second digit. The foot and ankle were then prepped in the normal sterile orthopedic manner. The foot was elevated and an Esmarch bandage applied to exsanguinate the foot. The tourniquet was then inflated to 250 mmHg and the foot was brought back onto the table. Using Band-Aid scissors, the stockinet was cut and reflected and using a wet and dry sponge, the foot was wiped, cleaned, and the second toe identified.,Using a skin scrape, a racket type incision was planned around the second toe to allow also remodelling of previous operative site. Using a fresh #10 blade, skin incision was made circumferentially in the racket-shaped manner around the second digit. Then, using a fresh #15 blade, the incision was deepened and was taken down to the level of the second metatarsophalangeal joint. Care was taken to identify bleeders and cautery was used as necessary for hemostasis. After cleaning up all the soft tissue attachments, the second digit was disarticulated down to the level of the metatarsophalangeal joint. The head of the second metatarsal was inspected and was noted to have good glistening white cartilage with no areas of erosion evident by visual examination. Attention was then directed to closure of the wound. All remaining tissue was noted to be healthy and granular in appearance with no necrotic tissue evident. Areas of subcutaneous tissue were then removed through a sharp dissection in order to allow better approximation of the skin edges. Due to long-standing lower extremity lymphedema and postoperative changes on previous surgery, I thought that we were unable to close the incision in entirety. Therefore, after copious amounts of irrigation using sterile saline, it was determined to use modified dental rolls using #4-0 gauze to remove tension from the skin. Deep vertical mattress sutures were used in order to reapproximate more closely, the skin edges and bring the plantar flap of skin up to the dorsal skin. This was obtained using #2-0 nylon suture. Following this, the remaining exposed tissue from the wound was covered using moist to dry saline soaked 4 x 4 gauze. The wound was then dressed using 4 x 4 gauze fluffed with abdominal pads, then using Kling and Kerlix and an ACE bandage to provide compression. The tourniquet was deflated at 42 minutes' time and hemostasis was noted to be achieved. The ACE bandage was extended up to just below the knee and no bleeding striking to the bandages was appreciated. The patient tolerated the procedure well and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact, as was evidenced by capillary bleeding, which was present during the procedure. Sedation was given postoperative introductions, which include to remain nonweightbearing to her right foot. The patient was instructed to keep the foot elevated and to apply ice behind her knee as necessary, no more than 20 minutes each hour. The patient was instructed to continue her regular medications. The patient was to continue IV antibiotic course and was given prescription for Vicoprofen to be taken q.4h. p.r.n. for moderate to severe pain #30. The patient will followup with Podiatry on Monday morning at 8:30 in the Podiatry Clinic for dressing change and evaluation of her foot at that time.,The patient was instructed as to signs and symptoms of infection, was instructed to return to the Emergency Department immediately if these should present. The second digit was sent to Pathology for gross and micro.

podiatry, dorsally, toe, ulcerations, foot infection, ray resection, metatarsophalangeal joint, ace bandage, gangrene osteomyelitis, foot, infection, gangrene, digital,

Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot. Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.

Podiatry

Foreign Body Removal - Foot - 1

PREOPERATIVE DIAGNOSES:,1. Cellulitis with associated abscess, right foot.,2. Foreign body, right foot.,POSTOPERATIVE DIAGNOSES:,1. Cellulitis with associated abscess, right foot.,2. Foreign body, right foot.,PROCEDURE PERFORMED:,1. Irrigation debridement.,2. Removal of foreign body of right foot.,ANESTHESIA:, Spinal with sedation.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,GROSS FINDINGS: , Include purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old Caucasian male with a history of uncontrolled diabetes mellitus. The patient states that he was working in his garage over the past few days when he noticed some redness and edema in his right foot. He notes some itching as well as increasing pain and redness in the right foot and presented to ABCD General Hospital Emergency Room. He was evaluated by the Emergency Room staff as well as the medical team and the Department of Orthopedics. It was noted upon x-ray a foreign body in his foot and he had significant amount of cellulitis as well ________ right lower extremity. After a long discussion held with the patient, it was elected to proceed with irrigation debridement and removal of the foreign body.,PROCEDURE: , After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained. The operative extremity was then confirmed with the patient, operative surgeon, the Department of Anesthesia and nursing staff. The patient was then transferred to preoperative area to Operative Suite #5 and placed on the operating table in supine position. All bony prominences were well padded at this time. The Department of Anesthesia was administered spinal anesthetic to the patient. Once this anesthesia was obtained, the patient's right lower extremity was sterilely prepped and draped in the usual sterile fashion. Upon viewing of the plantar aspect of the foot, there was noted to be a swollen ecchymotic area with a small hole in it, which purulent fluid was coming from. At this time, after all bony and soft tissue landmarks were identified as well as the localization of the pus, a 2 cm longitudinal incision was made directly over this area, which was located between the second and third metatarsal heads. Upon incising this, there was a foul smelling purulent fluid, which flowed from this region. Aerobic and anaerobic cultures were taken as well as gram stain. The area was explored and it ________ to the dorsum of the foot. There was no obvious joint involvement. After all loculations were broken, 3 liters antibiotic-impregnated fluid were pulse-evac through the wound. The wound was again inspected with no more gross purulent or necrotic appearing tissue. The wound was then packed with an iodoform gauge and a sterile dressing was applied consisting of 4x4s, floss, and Kerlix covered by an Ace bandage. At this time, the Department of Anesthesia reversed the sedation. The patient was transferred back to the hospital gurney to Postanesthesia Care Unit. The patient tolerated the procedure well and there were no complications.,DISPOSITION: ,The patient will be followed on a daily basis for possible repeat irrigation debridement.

podiatry, removal of foreign body, purulent material, metatarsal, cellulitis, abscess, kerlix, foreign body, foot, irrigation, debridement, purulent,

Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot.

Podiatry

Foot Lesions

S -, An 84-year-old diabetic female, 5'7-1/2" tall, 148 pounds, history of hypertension and diabetes. She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot. She also has a left great toenail that is giving her problems as well.,O - ,Plantar to the left first metatarsal head is a very panful hyperkeratotic lesion that measures 1.1 cm in diameter. There is a second lesion plantar to the fifth plantarflex metatarsal head which also measures 1.1 cm in diameter. These lesions have become so painful that the patient is now having difficulty walking wearing shoes or even doing gardening. The first and fifth metatarsal heads are plantarflexed. Vibratory sensation appears to be absent. Dorsal pedal pulses are nonpalpable. Varicose veins are visible to the skin on the patient's feet that are very thin, almost transparent. The medial aspect of the left great toenail has dried blood under the nail. The nail itself is very opaque, loose from the nailbed almost rotten, opaque, discolored, hypertrophic. All of the patient's toenails are elongated and discolored and opaque as well. There is dried blood under the medial aspect of the left great toenail.,A - ,1. Painful feet.,

podiatry, painful left foot, lesions, plantar, metatarsal head, hyperkeratotic lesion, toenail, nail matrix, metatarsal, metatarsal heads, foot, painful

Abscess of the left foot, etiology unclear at this time. Possibility of foreign body.

Podiatry

Foot Infection Management

REASON FOR CONSULTATION: ,Management for infection of the left foot.,HISTORY: , The patient is a 26-year-old short Caucasian male who appears in excellent health, presented a week ago as he felt some pain in the ball of his left foot. He noticed a small dark spot. He did not remember having had any injuries to that area specifically no puncture wounds. He had not been doing any outdoor works or activities. No history of working outdoors, has not been to the beach or to the lake, has not been out of town. His swelling progressed so he went to see Dr. X 4 days ago. The area was debrided in the office and he was placed on Keflex. It was felt that may be he had a foreign body, but nothing was found in the office and x-ray was negative for opaque foreign bodies. His foot got worse with more swelling and at this time purulent, too red and was admitted to the hospital today, is scheduled for surgical exploration this evening. Ancef and Cipro were prescribed today. He denies any fever, chills, red streaks, lymphadenitis. He had a tetanus shot in 2002 most recently. He had childhood asthma. He uses alcohol socially. He works full time. He is an electrician.,ALLERGIES:, ACCUTANE.,PHYSICAL EXAMINATION,GENERAL: Well-developed, well-nourished adult Caucasian male in no acute distress.,VITAL SIGNS: His weight is 190 pounds, height 69 inches, temperature 98, respirations 20, pulse 78, and blood pressure 143/63, O2 sat 98% on room air.,HEENT: Mouth unremarkable.,NECK: Supple.,LUNGS: Clear.,HEART: Regular rate rhythm. No murmur or gallop.,ABDOMEN: Soft and nontender.,EXTREMITIES: Left foot on the plantar side by the head of the first metatarsal has an open wound of about 10 mm in diameter with thick reddish purulent discharge and surrounding edema. There is bloodied blister around it. The area is tender to touch, warm with a slight edema of the rest of the foot with very faint erythema. There is some mild intertrigo between the fourth and fifth left toes. Palpable pedal pulses. Leg unremarkable. No femoral or inguinal lymphadenopathy.,LABORATORY: , Labs show white cell count of 6300, hemoglobin 13.6, platelet count of _____ with 80 monos, 17 eos _____, creatinine 1.3, BUN of 16, glucose 110. Calcium, ferritin, albumin, bilirubin, ALT, AST, alkaline phosphatase are normal. PT and PTT normal and the sed rate was 35 mm per hour.,IMPRESSION: ,Abscess of the left foot, etiology unclear at this time. Possibility of foreign body.,RECOMMENDATIONS/PLAN: , He is going to be discharged in about half-an-hour. Cultures, Gram stain, fungal cultures, and smear to be obtained. I have changed his antibiotic to vancomycin plus Maxipime. He is currently on tetanus immunizations so no need for booster at this time.,

podiatry, accutane, possibility of foreign body, foot etiology, foreign body, infection, foot, abscess,

Excision of foreign body, right foot and surrounding tissue. This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. The wire entered his foot.

Podiatry

Foreign Body Removal - Foot

PREOPERATIVE DIAGNOSIS: , Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body in the right foot.,PROCEDURE PERFORMED:, Excision of foreign body, right foot and surrounding tissue.,ANESTHESIA: , TIVA and local.,HISTORY:, This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. The wire entered his foot. His family physician attempted to remove the wire, but it only became deeper in the foot. The wound eventually healed, but a scar tissue was formed. The patient has had constant pain with ambulation intermittently since the incident occurred. He desires attempted surgical removal of the wire. The risks and benefits of the procedure have been explained to the patient in detail by Dr. X. The consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position with a safety strap placed across his waist for his protection.,A pneumatic ankle tourniquet was applied about the right ankle over copious amounts of Webril for the patient's protection. After adequate IV sedation was administered by the Department of Anesthesia, a total of 12 cc of 0.5% Marcaine plain was used to administer an ankle block. Next, the foot was prepped and draped in the usual aseptic fashion. An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered into the operative field and the sterile stockinet was reflected. Attention was directed to the plantar aspect of the foot where approximately a 5 mm long cicatrix was palpated and visualized. This was the origin and entry point of the previous puncture wound from the wire. This cicatrix was found lateral to the plantar aspect of the first metatarsal between the first and second metatarsals in a nonweightbearing area. Next, the Xi-scan was draped and brought into the operating room. A #25 gauge needles under fluoroscopy were inserted into the plantar aspect of the foot and three planes to triangulate the wire. Next, a #10 blade was used to make approximately a 3 cm curvilinear "S"-shaped incision. Next, the #15 blade was used to carry the incision through the subcutaneous tissue. The medial and lateral margins of the incision were undermined. Due to the small nature of the foreign body and the large amount of fat on the plantar aspect of the foot, the wires seemed to serve no benefit other then helping with the incision planning. Therefore, they were removed. Once the wound was opened, a hemostat was used to locate the wire very quickly and the wire was clamped. A second hemostat was used to clamp the wire. A #15 blade was used to carefully transect the fatty tissue around the tip of the hemostats, which were visualized in the base of the wound. The wire quickly came into visualization. It measured approximately 4 mm in length and was approximately 1 mm in diameter. The wire was green colored and metallic in nature. It was removed with the hemostat and passed off as a specimen to be sent to Pathology for identification. The wire was found at the level of deep fascia at the capsular level just plantar to the deep transverse intermetatarsal ligament. Next, copious amounts of sterile gentamicin impregnated saline was instilled in the wound for irrigation and the wound base was thoroughly cleaned and inspected. Next, a #3-0 Vicryl was used to throw two simple interrupted deep sutures to remove the dead space. Next, #4-0 Ethibond was used to close the skin in a combination of simple interrupted and horizontal mattress suture technique. The standard postoperative dressing consisting of saline-soaked Owen silk, 4x4s, Kling, Kerlix, and Coban were applied. The pneumatic ankle tourniquet was released. There was immediate hyperemic flush to the digits noted. The patient's anesthesia was reversed. He tolerated the above anesthesia and procedure without complications. The patient was transported via cart to the Postanesthesia Care Unit.,Vital signs were stable and vascular status was intact to the right foot. He was given OrthoWedge shoe. Ice was applied behind the knee and his right lower extremity was elevated on to pillows. He was given standard postoperative instructions consisting of rest, ice and elevation to the right lower extremity. He is to be non-weightbearing for three weeks, at which time, the wound will be evaluated and sutures will be removed. He is to follow up with Dr. X on 08/22/2003 and was given emergency contact number to call if problems arise. He was given a prescription for Tylenol #4, #30 one p.o. q.4-6h. p.r.n., pain as well as Celebrex 200 mg #30 take two p.o. q.d. p.c., with 200 mg 12 hours later as a rescue dose. He was given crutches. He was discharged in stable condition.

podiatry, foreign body removal, excision of foreign body, ankle tourniquet, plantar aspect, foreign body, foot, ankle, plantar, wound,

The patient presents for evaluation at the request of his primary physician for treatment for dystrophic nails.

Podiatry

Dystrophic Nails

S: , The patient presents for evaluation at the request of his primary physician for treatment for nails. He has last seen the primary physician in December 2006.,PRIMARY MEDICAL HISTORY:, Femoral embolectomy, GI bleed, hypertension, PVD, hypothyroid, GERD, osteoarthritis, diabetes, CAD, renal artery stenosis, COPD, and atrial fibrillation.,MEDICATIONS:, Refer to chart.,O: , The patient presents in wheelchair, verbal and alert. Vascular: He has absent pedal pulses bilaterally. Trophic changes include absent hair growth and dystrophic nails. Skin texture is dry and shiny. Skin color is rubor. Classic findings include temperature change and edema +2. Nails: Thickened and hypertrophic, #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left.,A:,1. Dystrophic nails.,2. Peripheral vascular disease as per classic findings.,3. Pain on palpation.,4. Diabetes.,P: ,Nails #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left were debrided. The patient will be seen at the request of the nursing staff for therapeutic treatment of dystrophic nails.

podiatry, debrided, nails, dystrophic nails, dystrophic

Patient dropped a weight on the dorsal aspects of his feet.

Podiatry

Foot Pain

CHIEF COMPLAINT: , Foot pain.,HISTORY OF PRESENT ILLNESS: , This is a 17-year-old high school athlete who swims for the swimming team. He was playing water polo with some of his teammates when he dropped a weight on the dorsal aspects of his feet. He was barefoot at that time. He had been in the pool practicing an hour prior to this injury. Because of the contusions and abrasions to his feet, his athletic trainer brought in him to the urgent care. He is able to bear weight; however, complains of pain in his toes. The patient did have some avulsion of the skin across the second and third toes of the left foot with contusions across the second, third, and fourth toes and dorsum of the foot. According to the patient, he was at his baseline state of health prior to this acute event.,PAST MEDICAL HISTORY: , Significant for attention deficit hyperactivity disorder.,PAST SURGICAL HISTORY: ,Positive for wisdom tooth extraction.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: ,He does not use alcohol, tobacco or illicit drugs. He plays water polo for the school team.,IMMUNIZATION HISTORY: , All immunizations are up-to-date for age.,REVIEW OF SYSTEMS: , The pertinent review of systems is as noted above; the remaining review of systems was reviewed and is noted to be negative.,PRESENT MEDICATIONS: , Provigil, Accutane and Rozerem.,ALLERGIES: ,None.,PHYSICAL EXAMINATION:,GENERAL: This is a pleasant white male in no acute distress.,VITAL SIGNS: He is afebrile. Vitals are stable and within normal limits.,HEENT: Negative for acute evidence of trauma, injury or infection.,LUNGS: Clear.,HEART: Regular rate and rhythm with S1 and S2.,ABDOMEN: Soft.,EXTREMITIES: There are some abrasions across the dorsum of the right foot including the second, third and fourth toes. There is some mild tenderness to palpation. However, there are no clinical fractures. Distal pulses are intact. The left foot notes superficial avulsion lacerations to the third and fourth digit. There are no subungual hematomas. Range of motion is decreased secondary to pain. No obvious fractures identified.,BACK EXAM: Nontender.,NEUROLOGIC EXAM: He is alert, awake and appropriate without deficit.,RADIOLOGY: , AP, lateral, and oblique views of the feet were conducted per Radiology, which were negative for acute fractures and significant soft tissue swelling or bony injuries.,On reevaluation, the patient was resting comfortably. He was informed of the x-ray findings. The patient was discharged in the care of his mother with a preliminary diagnosis of bilateral foot contusions with superficial avulsion lacerations, not requiring surgical repair.,DISCHARGE MEDICATIONS: , Darvocet.,The patient's condition at discharge was stable. All medications, discharge instructions and follow-up appointments were reviewed with the patient/family prior to discharge. The patient/family understood the instructions and was discharged without further incident.

An 83-year-old diabetic female presents today stating that she would like diabetic foot care.

Podiatry

Diabetic Foot Care

S - ,An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,O - ,On examination, the lateral aspect of her left great toenail is deeply ingrown. Her toenails are thick and opaque. Vibratory sensation appears to be intact. Dorsal pedal pulses are 1/4. There is no hair growth seen on her toes, feet or lower legs. Her feet are warm to the touch. All of her toenails are hypertrophic, opaque, elongated and discolored.,A - ,1. Onychocryptosis.,

podiatry, onychocryptosis, onychomycosis, great toenail, diabetic foot care, diabetic foot, foot, toenail, ingrown, toenails, diabetic,

A 60-year-old female presents today for care of painful calluses and benign lesions.

Podiatry

Bunions and Calluses

S -, A 60-year-old female presents today for care of painful calluses and benign lesions.,O -, On examination, the patient has bilateral bunions at the first metatarsophalangeal joint. She states that they do not hurt. No pain appears to be produced by active or passive range of motion or palpation and direct pressure of the first metatarsophalangeal joint bilaterally. The patient has a bilateral pinch callus on the medial aspect of both great toes and there are calluses along the medial aspect of the right foot. She has a small intractable plantar keratoma, plantar to her left second metatarsal head, which measures 0.5 cm in diameter. This is a central plug. She also has a very, very painful lesion plantar to her right fourth metatarsal head which measures 3.1 x 1.8 cm in diameter. This is a hyperkeratotic lesion that extends deep into the tissue with interrupted skin lines.,A - ,1. Bilateral bunions.,

podiatry, painful calluses, hibiclens, scrubbed, ointment and absorbent, heloma durum, plantar aspect, minimal hemostasis, neosporin ointment, absorbent dressing, benign lesions, metatarsophalangeal, bunions, calluses, plantar,

Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat. Sharp excision of left distal foot plantar fascia.

Podiatry

Debridement - Foot Ulcer

PREOPERATIVE DIAGNOSES,1. Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint.,2. Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx.,3. Plantar fascitis of left distal lateral foot.,POSTOPERATIVE DIAGNOSES,1. Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint.,2. Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx.,3. Plantar fascitis of left distal lateral foot.,OPERATION PERFORMED,1. Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat.,2. Sharp excision of left distal foot plantar fascia.,ANESTHESIA:, None required.,INDICATIONS:, The patient is a 51-year-old diabetic female with severe peripheral vascular disease, who has had angioplasties and single perineal artery runoff to the left leg who developed gangrene of her left fifth toe requiring left fifth ray amputation. She has developed cellulitis of the lateral foot with osteomyelitis and now requires debridement of the local fascitis and necrotic tissue to evaluate for current infectious status and prepare for future amputation.,PROCEDURE IN DETAIL:, The procedure was performed in the patient's room. The dressing was removed exposing about a 4 cm x 2.5 cm left distal lateral foot fifth ray amputation open wound. Distally, there is infarcted left fourth metatarsophalangeal joint capsule, as well as plantar fat below the joint.,She has neuropathy allowing debridement of the tissues.,Using sharp scissors and forceps all the necrotic fat and joint capsule area was easily debrided. There was complete infarction of the lateral joint capsule and the head of the phalanx, as well as distal metatarsal head were chronically infected.,The wound was packed with 4x4 gauze pads and dry gauze pads were placed between the toes followed by Kerlix roll pad.,The patient suffered no complications from the procedure.

podiatry, plantar fascia, foot ulcer, interosseous, metatarsal, cellulitis, amputation, osteomyelitis, plantar fascitis, joint capsule, ray amputation, debridement, plantar, foot

Bunion, left foot. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot.

Podiatry

Bunionectomy & Akin Osteotomy

PREOPERATIVE DIAGNOSIS: , Bunion, left foot.,POSTOPERATIVE DIAGNOSIS: ,Bunion, left foot.,PROCEDURE PERFORMED:,1. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation.,2. Akin osteotomy with internal wire fixation of left foot.,HISTORY: , This 19-year-old Caucasian female presents to ABCD General Hospital with the above chief complaint. The patient states she has had worsening bunion deformity for as long as she could not remember. She does have a history of Charcot-Marie tooth disease and desires surgical treatment at this time.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap. Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in a Mayo block type fashion surrounding the lower left first metatarsal. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated from the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating field. The stockinette was reflected, the foot was cleansed with a wet and dry sponge. Approximately 5 cm incision was made dorsomedially over the first metatarsal.,The incision was then deepened with #15 blade. All vessels encountered were ligated for hemostasis. Care was taken to preserve the extensor digitorum longus tendon. The capsule over the first metatarsal phalangeal then was identified where a dorsal capsular incision was then created down to the level of bone. Capsule and periosteum was reflected off the first metatarsal head. At this time, the cartilage was inspected and noted to be white, shiny, and healthy cartilage. There was noted to be a prominent medial eminence. Attention was then directed to first interspace where a combination of blunt and sharp dissection was done to perform a standard lateral release. The abductor tendon attachments were identified and transected. The lateral capsulotomy was performed. The extensor digitorum brevis tendon was identified and transected. Attention was then directed to the prominent medial eminence, which was resected with a sagittal saw. Intraoperative assessment of pes was performed and pes was noted to be normal.,At this time, a regional incision was carried more approximately about 1.5 cm. The capsular incision was then extended and the proximal capsule and periosteum were reflected off the first metatarsal. The first metatarsal cuneiform joint was identified. A 0.45 K-wire was then inserted into the base of the first metatarsal approximately 1 cm from the first cuneiform joint perpendicular to the weightbearing surface. This K-wire was used as an access guide for a Juvaro type oblique base wedge osteotomy. The sagittal saw was then used to creat a closing base wedge osteotomy with the apex being proximal medial. The osteotomy site was then feathered and tilted with tight estimation of the bony edges. The cortical hinge was maintained. A 0.27 x 24 mm screw was then inserted in a standard AO fashion. At this time, there was noted to be tight compression of the osteotomy site. A second 2.7 x 16 mm screw was then inserted more distally in the standard AO fashion with compression noted. The ________ angle was noted to be significantly released. Reciprocating rasp was then used to smoothen any remaining sharp edges. The 0.45 k-wire was removed. The foot was loaded and was noted to fill the remaining abduction of the hallux. At this time, it was incised to perform an Akin osteotomy.,Original incision was then extended distally approximately 1 cm. The incision was then deepened down to the level of capsule over the base of the proximal phalanx. Again care was taken to preserve the extensor digitorum longus tendon. The capsule was reflected off of the base of the proximal phalanx. An Akin osteotomy was performed with the apex being lateral and the base being medial. After where the bone was resected, it was feathered until tight compression was noted without tension at the osteotomy site. Care was taken to preserve the lateral hinge. At 1.5 wire passed and a drill was then used to create drill hole proximal and distally to the osteotomy site in order for passage of 28 gauge monofilament wire. The #28 gauge monofilament wire was passed through the drill hole and tightened down until compression and tight ________ osteotomy site was noted. The remaining edge of the wire was then buried in the medial most distal drill hole. The area was then inspected and the foot was noted with significant reduction of the bunion deformity. The area was then flushed with copious amounts of sterile saline. Capsule was closed with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl in order to decrease tension of the incision site. A running #5-0 subcuticular stitch was then performed. Steri-Strips were applied. Total of 1 cc dexamethasone phosphate was then injected into the surgical site. Dressings consisted of Owen silk, 4x4s, Kling, Kerlix. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot. Posterior splint was then placed on the patient in the operating room.,The patient tolerated the above procedure and anesthesia well without complications. The patient was transferred back to the PACU with vital signs stable and vascular status intact to the left foot. The patient was given postoperative instructions to be strictly nonweightbearing on the left foot. The patient was given postop pain prescriptions for Vicodin and instructed to take one q.4-6h. p.r.n. for pain as well as Naprosyn 500 mg p.o. q. b.i.d. The patient is to follow-up with Dr. X in his office in four to five days as directed.

podiatry, bunionectomy, akin osteotomy, internal wire fixation, internal screw fixation, osteotomy, metatarsal, metatarsal osteotomy, extensor digitorum, drill hole, osteotomy site, foot

Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.

Podiatry

Arthroplasty - Hammertoe

PREOPERATIVE DIAGNOSIS:, Hammertoe deformity of the right second digit.,POSTOPERATIVE DIAGNOSIS: , Hammertoe deformity of the right second digit.,PROCEDURE PERFORMED: , Arthroplasty of the right second digit.,The patient is a 77-year-old Hispanic male who presents to ABCD Hospital for surgical correction of a painful second digit hammertoe. The patient has failed attempts at conservative treatment and is unable to wear shoes without pain to his second toe. The patient presents n.p.o. since mid night last night and consented to sign in the chart. H&P is complete.,PROCEDURE IN DETAIL:, After an IV was instituted by the Department of Anesthesia in the preoperative holding area, the patient was escorted to the operating room and placed on the table in the supine position. Using Webril, the distal leg and ankle was padded and a ankle pneumatic tourniquet was placed around the right ankle, but left deflated at this time. Restraining, a lap belt was then placed around the patient's abdomen while laying on the table. After adequate anesthesia was administered by the Department of Anesthesia, a local digital block using 5 cc of 0.5% Marcaine plain was used to provide local anesthesia. The foot was then prepped and draped in the normal sterile orthopedic manner. The foot was then elevated and Esmarch bandage was applied, after which time the tourniquet was inflated to 250 mmHg. The foot was then brought down to the level of the table and stockinet was cut and reflected after the Esmarch bandage was removed. A wet and dry sponge was then used to cleanse the operative site and using a skin skribe a dorsal incisional line was outlined extending from the proximal phalanx over the proximal interphalangeal joint on to the middle phalanx.,Then using a fresh #15 blade, a dorsolinear incision was made, partial thickness through the skin after testing anesthesia with one to two pickup. Then using a fresh #15 blade, incision was deepened and using medial to lateral pressure, the incision was opened into the subcutaneous tissue. Care was taken to reflect the subcutaneous tissue from the underlying deep fascia to mobilize the skin. This was performed with the combination of blunt and dull dissection. Care was taken to avoid proper digital arteries and neurovascular bundles as were identified. Attention was then directed to the proximal interphalangeal joint and after identifying the joint line, a transverse linear incision was made over the dorsal surface of the joint. The medial and lateral sides of the joint capsule were then also incised on the superior half in order to provide increased exposure. Following this, the proximal portion of the transected extensor digitorum longus tendon was identified using an Adson-Brown pickup. It was elevated with fresh #15 blade. The tendon and capsule was reflected along with the periosteum from the underlying bone dorsally. Following this, the distal portion of the tendon was identified in a like manner. The tendon and the capsule as well as the periosteal tissue was reflected from the dorsal surface of the bone. The proximal interphalangeal joint was then distracted and using careful technique, #15 blade was used to deepen the incision and while maintaining close proximity to the bone and condyles, the lateral and medial collateral ligaments were freed up from the side of the proximal phalanx head.,Following this, the head of the proximal phalanx was known to have adequate exposure and was freed from soft tissues. Then using a sagittal saw with a #139 blade, the head of he proximal phalanx was resected. Care was taken to avoid the deep flexor tendon. The head of the proximal phalanx was taken with the Adson-Brown and using a #15 blade, the plantar periosteal tissue was freed up and the head was removed and sent to pathology. The wound was then flushed using a sterile saline with gentamicin and the digit was noted to be in good alignment. The digit was also noted to be in rectus alignment. Proximal portion of the tendon was shortened to allow for removal of the redundant tendon after correction of the deformity. Then using a #3-0 Vicryl suture, three simple interrupted sutures were placed for closure of the tendon and capsular tissue. Then following this, #4-0 nylon was used in a combination of horizontal mattress and simple interrupted sutures to close the skin. The toe was noted to be in good alignment and then 1 cc of dexamethasone phosphate was injected into the incision site. Following this, the incision was dressed using a sterile Owen silk soaked in saline and gentamicin. The toe was bandaged using 4 x 4s, Kling, and Coban. The tourniquet was deflated and immediate hyperemia was noted to the digits I through V of the right foot.,The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit where the patient was given postoperative surgical shoe. Total tourniquet time for the case was 30 minutes. While in the recovery, the patient was given postoperative instructions to include, ice and elevation to his right foot. The patient was given pain medications of Tylenol #3, quantity 30 to be taken one to two tablets every six to eight hours as necessary for moderate to severe pain. The patient was also given prescription for cane to aid in ambulation. The patient will followup with Dr. X on Tuesday in his office for postoperative care. The patient was instructed to keep the dressings clean, dry, and intact and to not remove them before his initial office visit. The patient tolerated the procedure well and the anesthesia with no complications.

podiatry, hammertoe deformity, arthroplasty, digit, proximal interphalangeal joint, periosteal tissue, interrupted sutures, interphalangeal joint, proximal phalanx, proximal, painful, tourniquet, hammertoe, phalanx, head, incisional, tendon

Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Akin bunionectomy, right toe with internal wire fixation.

Podiatry

Bunionectomy & Osteotomy

PREOPERATIVE DIAGNOSES:,1. Hallux valgus, right foot.,2. Hallux interphalangeus, right foot.,POSTOPERATIVE DIAGNOSES:,1. Hallux valgus, right foot.,2. Hallux interphalangeus, right foot.,PROCEDURES PERFORMED:,1. Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2. Akin bunionectomy, right toe with internal wire fixation.,ANESTHESIA: , TIVA/local.,HISTORY: ,This 51-year-old female presents to ABCD preoperative holding area after keeping herself NPO since mid night for a surgery on her painful bunion through her right foot. The patient has a history of gradual onset of a painful bunion over the past several years. She has tried conservative methods such as wide shoes, accommodative padding on an outpatient basis with Dr. X all of which have provided inadequate relief. At this time, she desires attempted surgical correction. The risks versus benefits of the procedure have been discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operative table in supine position and a safety strap was placed across her waist for her protection. Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was placed over the Webril.,After adequate IV sedation was administered by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 0.5% Marcaine plain and 1% Lidocaine plain was injected into the foot in a standard Mayo block fashion. The foot was elevated off the table. Esmarch bandages were used to exsanguinate the right foot. The pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered in the operative field and the sterile stockinet was reflected. A sterile Betadine was wiped away with a wet and dry sponge and one toothpick was used to test anesthesia, which was found to be adequate. Attention was directed to the first metatarsophalangeal joint, which was found to be contracted, laterally deviated, and had decreased range of motion. A #10 blade was used to make a 4 cm dorsolinear incision. A #15 blade was used to deepen the incision through the subcutaneous layer. All superficial subcutaneous vessels were ligated with electrocautery. Next, a linear capsular incision was made down the bone with a #15 blade. The capsule was elevated medially and laterally off the metatarsal head and the metatarsal head was delivered into the wound. A hypertrophic medial eminence was resected with a sagittal saw taking care not to strike the head. The medial plantar aspect of the metatarsal head had some erosive changes and eburnation. Next, a 0.45 inch Kirschner wire was placed with some access guide slightly plantar flexing the metatarsal taking care not to shorten it. A sagittal saw was used to make a long-arm Austin osteotomy in the usual fashion. Standard lateral release was also performed as well as a lateral capsulotomy freeing the fibular sesamoid complex.,The capital head was shifted laterally and impacted on the residual metatarsal head. Nice correction was achieved and excellent bone to bone contact was achieved. The bone stock was slightly decreased, but adequate. Next, a 0.45 inch Kirschner wire was used to temporarily fixate the metatarsal capital fragment. A 2.7 x 18 mm Synthes cortical screw was thrown using standard AO technique. Excellent rigid fixation was achieved. A second 2.0 x 80 mm Synthes fully threaded cortical screw was also thrown using standard AO technique at the proximal aspect of the metatarsal head. Again, an excellent rigid fixation was obtained and the screws were tight. The temporary fixation was removed. A medial overhanging bone was resected with a sagittal saw. The foot was loaded and the hallux was found to have an interphalangeus deformity present.,A sagittal saw was used to make a proximal cut in approximately 1 cm dorsal to the base of the proximal phalanx, leaving a lateral intact cortical hinge. A distal cut parallel with the nail base was performed and a standard proximal Akin osteotomy was done.,After the wedge bone was removed, the saw blade was reinserted and used to tether the osteotomy with counter-pressure used to close down the osteotomy. A #15 drill blade was used to drill two converging holes on the medial aspect of the bone. A #28 gauge monofilament wire was inserted loop to loop and pulled through the bone. The monofilament wire was twisted down and tapped into the distal drill hole. The foot was loaded again and the toe had an excellent cosmetic straight appearance and the range of motion of the first metatarsophalangeal joint was then improved. Next, reciprocating rasps were used to smooth all bony surfaces. Copious amounts of sterile saline was used to flush the joint. Next, a #3-0 Vicryl was used to reapproximate the capsular periosteal tissue layer. Next, #4-0 Vicryl was used to close the subcutaneous layer. #5-0 Vicryl was used to the close the subcuticular layer in a running fashion. Next, 1 cc of dexamethasone phosphate was then instilled in the joint. The Steri-Strips were applied followed by standard postoperative dressing consisting of Owen silk, 4 x 4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits. The patient tolerated the above anesthesia and procedure without complications. She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot. She is to be partial weightbearing with crutches. She is to follow with Dr. X. She was given emergency contact numbers and instructions to call if problems arise. She was given prescription for Vicodin ES #25 one p.o. q.4-6h. p.r.n. pain and Naprosyn one p.o. b.i.d. 500 mg. She was discharged in stable condition.

podiatry, hallux interphalangeus, osteotomy, bunionectomy, akin, wire fixation, screw fixation, painful bunion, metatarsophalangeal joint, pneumatic ankle, metatarsal head, foot, toe, sagittal, metatarsal

Austin/akin bunionectomy, right foot. Bunion, right foot. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.

Podiatry

Bunionectomy - Austin - Akin

PREOPERATIVE DIAGNOSIS:, Bunion, right foot.,POSTOPERATIVE DIAGNOSIS:, Bunion, right foot.,PROCEDURE PERFORMED:, Austin/akin bunionectomy, right foot.,HISTORY: , This 77-year-old African-American female presents to ABCD General Hospital with the above chief complaint. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful. The patient has attempted conservative treatment without long-term relief of symptoms and desires surgical treatment.,PROCEDURE DETAILS:, An IV was instituted by Department of Anesthesia in the preop holding area. The patient was transported to the operating room and placed on the operating table in the supine position with a safety strap across her lap. Copious amounts of Webril were placed around the right ankle followed by blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain was injected in a Mayo block type fashion. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated to the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was inflated to 250 mmHg. The foot was lowered to the operating field and the stockinet was reflected. The foot was cleansed with wet and dry sponge.,Attention was directed to the bunion deformity on the right foot. An approximately 6 cm dorsal medial incision was created over the first metatarsophalangeal joint. The incision was then deepened with a #15 blade. All vessels encountered were ligated with hemostasis. The skin and subcutaneous tissue were then undermined off of the capsule medially. A dorsal linear capsular incision was then created over the first metatarsophalangeal joint. The periosteum and capsule were then reflected off of the first metatarsal. There was noted to be a prominent medial eminence. The articular cartilage was healthy for patient's age and race. Attention was then directed to the first interspace where a lateral release was performed.. A combination of sharp and blunt dissection was carried out until the adductor tendon insertions were identified. The adductor tendons were transected as well as a lateral capsulotomy was performed. The extensor digitorum brevis tendon was identified and transected. Care was taken to preserve the extensor hallucis longus to make sure that tendon that was transected was the extensor hallucis brevis at the _______ digitorum. Extensor hallucis brevis tendon was transected and care was taken to preserve the extensor halucis longus tendon. Attention was then directed to medial eminence, which was resected with a sagittal saw. Sagittal was then used to create a long dorsal arm outside the Austin type osteotomy and the first metatarsal. The head of the first metatarsal was then translocated laterally until correction of the intermetatarsal angle was noted. The head was intact. A 0.45 K-wire was inserted through subcutaneously from proximal medial to distal lateral. A second K-wire was then inserted from distal lateral to proximal plantar medial. Adequate fixation was noted at the osteotomy site. The K-wires were bent, cut, and pin caps were placed. Attention was then directed to the proximal phalanx of the hallux. The capsular periostem was reflected off of the base of the proximal phalanx. A sagittal was then used to create an akin osteotomy closing wedge. The apex was lateral and the base of the wedge was medial. The wedge was removed in the total and the osteotomy site was then feathered until closure was achieved without compression. Two 0.45 K-wires were then inserted, one from distal medial to proximal lateral and the second from distal lateral to proximal medial across the osteotomy site. Adequate fixation was noted at the osteotomy site and the osteotomy was closed. The toe was noted to be in a markedly more rectus position. Sagittal saw was then used to resect the remaining prominent medial eminence. The area was then smoothed with a reciprocating rasp. There was noted to be a small osteophytic formation laterally over first metatarsal head that was removed with a rongeur and smoothed with a reciprocating rasp. The area was then inspected for any remaining short bony edges, none were noted.,Copious amounts of sterile saline was then used to flush the surgical site. The capsule was closed with #3-0 Vicryl. Subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular #5-0 Vicryl. Steri-Strips were applied and 1 cc of dexamethasone phosphate was injected into the surgical site.,Dressings consisted of #0-1 silk, copious Betadine, 4 x 4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the right foot. A _______ cast was then applied postoperatively. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported from the operating room to the PACU with vital signs stable and vascular status intact to the right foot. The patient was given postoperative pain prescription for Tylenol #3 and instructed to take one q4-6h. p.o. p.r.n. for pain. The patient is to follow up with Dr. X in his office as directed.

podiatry, austin/akin bunionectomy, hallucis brevis, bunion deformity, extensor hallucis, osteotomy site, foot, austin, bunionectomy

A simple note on Athlete's foot, tinea pedis, a very common fungal skin infection of the foot.

Podiatry

Athlete's Foot

ATHLETE'S FOOT, TINEA PEDIS,, is a very common fungal skin infection of the foot. It often first appears between the toes. It can be a one-time occurrence or it can be chronic. The fungus, known as Trichophyton, thrives under warm, damp conditions so people whose feet sweat a great deal are more susceptible. It is easily transmitted in showers and pool walkways. Those people with immunosuppressive conditions, such as diabetes mellitus, are also more susceptible to athlete's foot.,SIGNS AND SYMPTOMS:,* Itchy feet.,* White or red and soft scaling on feet, usually in between toes.,* Small blisters may be present.,* Bad foot odor.,* Very rare involvement of hands and simultaneously (called an Id reaction).,TREATMENT:,* Diagnosis is via symptoms or sometimes by examining skin scrapings under a microscope.. A bacterial infection may also be suspected in which case a skin culture will confirm this.,* Try a non-prescription antifungal powder or cream available in drugstores; your doctor can prescribe a stronger topical antifungal medication if necessary.,* Oral antibiotics may be prescribed for a possible bacterial infection.,* Keep feet as dry as possible! Change socks twice a day if necessary and wear those made of natural fibers, such as cotton. Go barefoot when you have a chance or wear sandals. Dry thoroughly in between toes after swimming or bathing.,* A special powder to absorb moisture on feet is also available in drugstores. Ask the pharmacist about this.,* Spray your shower at home with a 10% bleach solution after bathing. This may help decrease the chance that other family members will be infected.,* Wear sandals or thongs in public showers and around pools.,* Keep in mind that it may take up to a month or more to get rid of your athlete's foot. Be diligent in using the antifungal medication. Unfortunately, recurrence of athlete's foot is common. Luckily, the condition does not cause serious problems for the majority of people who have it.,* Call the office if your athlete's foot spreads or worsens despite treatment.,PLANTAR FASCIAL STRETCHES,1. Raise toes toward you while bending your ankle as high as you can.,2. Hold this position for 15 seconds.,3. Alternate doing this with the opposite foot 10 times.,4. Perform this exercise 2- 3 times a day.,WOUND CARE INSTRUCTIONS,1. Clean the area daily with soap and water.,2. Every day apply a thin coat of polysporin ointment.,3. Change the dressing daily and keep the area covered with an adhesive bandage until completely healed.,4. Notify the office if you have any increasing wound pain or any evidence of infection.

podiatry, tinea pedis, infection, foot, athlete's foot, trichophyton, itchy, athlete's foot tinea pedis, fungal skin infection, fungal, athlete's,

Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Proximal interphalangeal joint arthroplasty, bilateral fifth toes. Distal interphalangeal joint arthroplasty, bilateral third and fourth toes. Flexor tenotomy, bilateral third toes.

Podiatry

Bunionectomy & Flexor Tenotomy

PREOPERATIVE DIAGNOSES:,1. Hallux abductovalgus, right foot.,2. Hammertoe, bilateral third, fourth, and fifth toes.,POSTOPERATIVE DIAGNOSES:,1. Hallux abductovalgus, right foot.,2. Hammertoe, bilateral third, fourth, and fifth toes.,PROCEDURE PERFORMED:,1. Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2. Proximal interphalangeal joint arthroplasty, bilateral fifth toes.,3. Distal interphalangeal joint arthroplasty, bilateral third and fourth toes.,4. Flexor tenotomy, bilateral third toes.,HISTORY:, This is a 36-year-old female who presented to ABCD preoperative holding area after keeping herself n.p.o. since mid night for surgery on her painful bunion to her right foot and her painful hammertoes to both feet. The patient has a history of sharp pain, which is aggravated by wearing shoes and ambulation. She has tried multiple conservative methods and treatment such as wide shoes and accommodative padding, all of which provided inadequate relief. At this time, she desires attempted surgical correction. The risks versus benefits of the procedure have been discussed in detail by Dr. Kaczander with the patient and the consent is available on the chart.,PROCEDURE IN DETAIL:, After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with a safety strap placed across her waist for her protection.,Copious amounts of Webril were applied about both ankles and a pneumatic ankle tourniquet was applied over the Webril. After adequate IV sedation was administered, a total of 18 cc of a 0.5% Marcaine plain was used to anesthetize the right foot, performing a Mayo block and a bilateral third, fourth, and fifth digital block. Next, the foot was prepped and draped in the usual aseptic fashion bilaterally. The foot was elevated off the table and an Esmarch bandage was used to exsanguinate the right foot. The pneumatic ankle tourniquet was elevated on the right foot to 200 mmHg. The foot was lowered into operative field and the sterile stockinet was reflected proximally. Attention was directed to the right first metatarsophalangeal joint, it was found to be contracted and there was lateral deviation of the hallux. There was decreased range of motion of the first metatarsophalangeal joint. A dorsolinear incision was made with a #10 blade, approximately 4 cm in length. The incision was deepened to the subcutaneous layer with a #15 blade. Any small veins traversing the subcutaneous layer were ligated with electrocautery. Next, the medial and lateral wound margins were undermined sharply. Care was taken to avoid the medial neurovascular bundle and the lateral extensor hallucis longus tendon. Next, the first metatarsal joint capsule was identified. A #15 blade was used to make a linear capsular incision down to the bone. The capsular periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound. The PASA was found to be within normal limits. There was a hypertrophic medial eminence noted. A sagittal saw was used to remove the hypertrophic medial eminence. A 0.045 inch Kirschner wire was placed into the central medial aspect of the metatarsal head as an access guide. A standard lateral release was performed. The fibular sesamoid was found to be in the interspace, but was relocated onto the metatarsal head properly. Next, a sagittal saw was used to perform a long arm Austin osteotomy. The K-wire was removed. The capital fragment was shifted laterally and impacted into the head. A 0.045 inch Kirschner wire was used to temporarily fixate the osteotomy. A 2.7 x 16 mm Synthes, fully threaded cortical screw was throne using standard AO technique. A second screw was throne, which was a 2.0 x 12 mm Synthes cortical screw. Excellent fixation was achieved and the screws tightly perched the bone. Next, the medial overhanging wedge was removed with a sagittal saw. A reciprocating rasp was used to smooth all bony prominences. The 0.045 inch Kirschner wire was removed. The screws were checked again for tightness and found to be very tight. The joint was flushed with copious amounts of sterile saline. A #3-0 Vicryl was used to close the capsular periosteal tissues with simple interrupted suture technique. A #4-0 Vicryl was used to close the subcutaneous layer in a simple interrupted technique. A #5-0 Monocryl was used to close the skin in a running subcuticular fashion.,Attention was directed to the right third digit, which was found to be markedly contracted at the distal interphalangeal joint. A #15 blade was used to make two convergent semi-elliptical incisions over the distal interphalangeal joint. The incision was deepened with a #15 blade. The wedge of skin was removed in full thickness. The long extensor tendon was identified and the distal and proximal borders of the wound were undermined. The #15 blade was used to transect the long extensor tendon, which was reflected proximally. The distal interphalangeal joint was identified and the #15 blade was placed in the joint and the medial and lateral collateral ligaments were released. Crown and collar scissors were used to release the planar attachment to the head of the middle phalanx. Next, a double action bone cutter was used to resect the head of the middle phalanx. The toe was dorsiflexed and was found to have an excellent rectus position. A hand rasp was used to smooth all bony surfaces. The joint was flushed with copious amounts of sterile saline. The flexor tendon was found to be contracted, therefore, a flexor tenotomy was performed through the dorsal incision. Next, #3-0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures. A #4-0 nylon was used to close the skin and excellent cosmetic result was achieved.,Attention was directed to the fourth toe, which was found to be contracted at the distal interphalangeal joint and abducted and varus rotated. An oblique skin incision with two converging semi-elliptical incisions was created using #15 blade. The rest of the procedure was repeated exactly the same as the above paragraph to the third toe on the right foot. All the same suture materials were used. However, there was no flexor tenotomy performed on this toe, only on the third toe bilaterally.,Attention was directed to the fifth right digit, which was found to be contracted at the proximal interphalangeal joint. A linear incision approximately 2 cm in length was made with a #15 blade over the proximal interphalangeal joint. Next, a #15 blade was used to deepen the incision to the subcutaneous layer. The medial and lateral margins were undermined sharply to the level of the long extensor tendon. The proximal interphalangeal joint was identified and the tendon was transected with the #15 blade. The tendon was reflected proximally, off the head of the proximal phalanx. The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound. A double action bone nibbler was used to remove the head of the proximal phalanx. A hand rasp was used to smooth residual bone. The joint was flushed with copious amounts of saline. A #3-0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures. A #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress sutures.,A standard postoperative dressing consisting of saline-soaked #0-1 silk, 4 x 4s, Kerlix, Kling, and Coban were applied. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.,Attention was directed to the left foot. The foot was elevated off the table and exsanguinated with an Esmarch bandage and the pneumatic ankle tourniquet was elevated to 200 mmHg. Attention was directed to the left fifth toe, which was found to be contracted at the proximal interphalangeal joint. The exact same procedure, performed to the right fifth digit, was performed on this toe, with the same materials being used for suture and closure.,Attention was then directed to the left fourth digit, which was found to contracted and slightly abducted and varus rotated. The exact same procedure as performed to the right fourth toe was performed, consisting of two semi-elliptical skin incisions in an oblique angle. The same suture material were used to close the incision.,Attention was directed to the left third digit, which was found to be contracted at the distal interphalangeal joint. The same procedure performed on the right third digit was also performed. The same suture materials were used to close the wound and the flexor tenotomy was also performed at this digit. A standard postoperative dressing was also applied to the left foot consisting of the same materials as described for the right foot. The pneumatic tourniquet was released and immediate hyperemic flush was noted to the digits. The patient tolerated the above anesthesia and procedure without complications. She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the foot. She was given postoperative shoes and will be partial weighbearing with crutches. She was admitted short-stay to Dr. Kaczander for pain control. She was placed on Demerol 50 and Vistaril 25 mg IM q3-4h. p.r.n. for pain. She will have Vicodin 5/500 one to two p.o. q.4-6h. p.r.n. for moderate pain. She was placed on Subq. heparin and given incentive spirometry 10 times an hour. She will be discharged tomorrow. She is to ice and elevate both feet today and rest as much as possible.,Physical Therapy will teach her crutch training today. X-rays were taken in the postoperative area and revealed excellent position of the screws and correction of bunion deformity as well as the hammertoe deformities.

podiatry, hallux abductovalgus, hammertoe, bunionectomy, flexor, tenotomy, interphalangeal, arthroplasty, screw fixation, osteotomy, interphalangeal joint arthroplasty, distal interphalangeal joint, interphalangeal joint, flexor tenotomy, proximal interphalangeal, joint arthroplasty, distal interphalangeal, distal, blade, proximal, foot, joint, toes, tendon,

Tailor's bunion, right foot. Removal of bone, right fifth metatarsal head.

Podiatry

Bone Removal - Metatarsal Head

PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS: ,Tailor's bunion, right foot.,PROCEDURE PERFORMED: , Removal of bone, right fifth metatarsal head.,ANESTHESIA: ,TIVA/local.,HISTORY: , This 60-year-old male presents to ABCD Preoperative Holding Area after keeping himself n.p.o., since mid night for surgery on his painful right Tailor's bunion. The patient has a history of chronic ulceration to the right foot which has been treated on an outpatient basis with conservative methods Dr. X. At this time, he desires surgical correction as the ulcer has been refractory to conservative treatment. Incidentally, the ulcer is noninfective and practically healed at this date. The consent is available on the chart for review and Dr. X has discussed the risks versus benefits of this procedure to the patient in detail.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room, placed on the operating table in supine position and a safety strap was placed across his waist for his protection. A pneumatic ankle tourniquet was applied about the right foot over copious amount of Webril for the patient's protection. After adequate IV sedation was administered by the Department of Anesthesia, a total of 10 cc of 1:1 mixture of 1% lidocaine and 0.5% Marcaine plain were administered into the right fifth metatarsal using a Mayo type block technique. Next, the foot was prepped and draped in the usual aseptic fashion. An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered in the operating field and a sterile stockinet was reflected. The Betadine was cleansed with saline-soaked gauze and dried. Anesthesia was tested with a one tooth pickup and found to be adequate. A #10 blade was used to make 3.5 cm linear incision over the fifth metatarsophalangeal joint. A #15 blade was used to deepen the incision to the subcutaneous layer. Care was taken to retract the extensor digitorum longus tendon medially and the abductor digiti minimi tendon laterally. Using a combination of sharp and blunt dissection, the medial and lateral edges of the wound were undermined down to the level of the capsule and deep fascia. A linear capsular incision was made with a #15 blade down to the bone. The capsular periosteal tissues were elevated off the bone with a #15 blade. Metatarsal head was delivered into the wound. There was hypertrophic exostosis noted laterally as well as a large bursa in the subcuteneous tissue layer. The ulcer on the skin was approximately 2 x 2 mm, it was partial skin thickness and did not probe. A sagittal saw was used to resect the hypertrophic lateral eminence. The hypertrophic bone was split in half and one half was sent to Pathology and the other half was sent to Microbiology for culture and sensitivity. Next, a reciprocating rasp was used to smoothen all bony surfaces. The bone stock had an excellent healthy appearance and did not appear to be infected. Copious amount of sterile gentamicin impregnated saline were used to flush the wound. The capsuloperiosteal tissues were reapproximated with #3-0 Vicryl in simple interrupted technique. The subcutaneous layer was closed with #4-0 Vicryl in simple interrupted technique. Next, the skin was closed with #4-0 nylon in a horizontal mattress suture technique. A standard postoperative dressing was applied consisting of Betadine-soaked Owen silk, 4x4s, Kerlix, and Kling. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted at the digits. The patient tolerated the above anesthesia and procedure without complications. He was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot. He was given a postop shoe and will be full weightbearing. He has prescription already at home for hydrocodone and does not need to refill. He is to follow up with Dr. X and was given emergency contact numbers. He was discharged in stable condition.

podiatry, pneumatic ankle, metatarsal head, tailor's bunion, head, pneumatic, ulceration, metatarsal, bone

Acute foot or ankle sprain, possible small fracture.

Podiatry

Ankle pain

CHIEF COMPLAINT:, Ankle pain.,HISTORY OF PRESENT ILLNESS: ,The patient is a pleasant 17-year-old gentleman who was playing basketball today in gym. Two hours prior to presentation, he started to fall and someone stepped on his ankle and kind of twisted his right ankle and he cannot bear weight on it now. It hurts to move or bear weight. No other injuries noted. He does not think he has had injuries to his ankle in the past.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , He does not drink or smoke.,ALLERGIES: , Unknown.,MEDICATIONS: , Adderall and Accutane.,REVIEW OF SYSTEMS: , As above. Ten systems reviewed and are negative.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 97.6, pulse 70, respirations 16, blood pressure 120/63, and pulse oximetry 100% on room air.,GENERAL:

podiatry, accutane, foot or ankle sprain, ankle sprain, ankle, sprain, splint, fracture,

Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe. Bunion left foot and hammertoe, left second toe.

Podiatry

Bunionectomy & Metatarsal Osteotomy

PREOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,POSTOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,PROCEDURE PERFORMED:,1. Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left.,2. Arthroplasty left second toe.,HISTORY: ,This 39-year-old female presents to ABCD General Hospital with the above chief complaint. The patient states that she has had bunion for many months. It has been progressively getting more painful at this time. The patient attempted conservative treatment including wider shoe gear without long-term relief of symptoms and desires surgical treatment.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preop holding area. The patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap. Copious amount of Webril were placed around the left ankle followed by a blood pressure cuff. After adequate sedation was achieved by the Department of Anesthesia, a total of 15 cc of 0.5% Marcaine plain was injected in a Mayo and digital block to the left foot. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated from the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating table. The stockinette was reflected. The foot was cleansed with wet and dry sponge. Attention was then directed to the first metatarsophalangeal joint of the left foot. An incision was created over this area approximately 6 cm in length. The incision was deepened with a #15 blade. All vessels encountered were ligated for hemostasis. The skin and subcutaneous tissue was then dissected from the capsule. Care was taken to preserve the neurovascular bundle. Dorsal linear capsular incision was then created. The capsule was then reflected from the head of the first metatarsal. Attention was then directed to the first interspace where a lateral release was performed. A combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected. A lateral capsulotomy was performed. Attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence. The incision was then extended proximally with further dissection down to the level of the bone. Two 0.45 K-wires were then inserted as access guides for the SCARF osteotomy. A standard SCARF osteotomy was then performed. The head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle. After adequate reduction of the bunion deformity was noted, the bone was temporarily fixated with a 0.45 K-wire. A 3.0 x 12 mm screw was then inserted in the standard AO fashion with compression noted. A second 3.0 x 14 mm screw was also inserted with tight compression noted. The remaining prominent medial eminence medially was then resected with a sagittal saw. Reciprocating rasps were then used to smooth any sharp bony edges. The temporary fixation wires were then removed. The screws were again checked for tightness, which was noted. Attention was directed to the medial capsule where a medial capsulorrhaphy was performed. A straight stat was used to assist in removing a portion of the capsule. The capsule was then reapproximated with #2-0 Vicryl medially. Dorsal capsule was then reapproximated with #3-0 Vicryl in a running fashion. The subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular stitch with #5-0 Vicryl. The skin was then closed with #4-0 nylon in a horizontal mattress type fashion.,Attention was then directed to the left second toe. A dorsal linear incision was then created over the proximal phalangeal joint of the left second toe. The incision was deepened with a #15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally. An incision was made on either side of the extensor digitorum longus tendon. A curved mosquito stat was then used to reflex the tendon laterally. The joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx. A sagittal saw was then used to resect the head of the proximal head. The bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto. The extensor digitorum longus tendon was inspected and noted to be intact. Any sharp edges were then smoothed with reciprocating rasp. The area was then flushed with copious amounts of sterile saline. The skin was then reapproximated with #4-0 nylon. Dressings consisted of Owen silk, 4x4s, Kling, Kerlix, and Coban. Pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to PACU with vital signs stable and vascular status intact to the left foot. The patient is to follow up with Dr. X in his clinic as directed.

podiatry, hammertoe, osteotomy, internal screw fixation, scarf type, extensor digitorum, metatarsal osteotomy, foot, toe, metatarsal, bunionectomy,

Incision and drainage, first metatarsal head, left foot with culture and sensitivity.

Podiatry

Abscess with Cellulitis - Discharge Summary

ADMITTING DIAGNOSIS:, Abscess with cellulitis, left foot.,DISCHARGE DIAGNOSIS:, Status post I&D, left foot.,PROCEDURES:, Incision and drainage, first metatarsal head, left foot with culture and sensitivity.,HISTORY OF PRESENT ILLNESS:, The patient presented to Dr. X's office on 06/14/07 complaining of a painful left foot. The patient had been treated conservatively in office for approximately 5 days, but symptoms progressed with the need of incision and drainage being decided.,MEDICATIONS:, Ancef IV.,ALLERGIES:, ACCUTANE.,SOCIAL HISTORY:, Denies smoking or drinking.,PHYSICAL EXAMINATION: , Palpable pedal pulses noted bilaterally. Capillary refill time less than 3 seconds, digits 1 through 5 bilateral. Skin supple and intact with positive hair growth. Epicritic sensation intact bilateral. Muscle strength +5/5, dorsiflexors, plantar flexors, invertors, evertors. Left foot with erythema, edema, positive tenderness noted, left forefoot area.,LABORATORY: , White blood cell count never was abnormal. The remaining within normal limits. X-ray is negative for osteomyelitis. On 06/14/07, the patient was taken to the OR for incision and drainage of left foot abscess. The patient tolerated the procedure well and was admitted and placed on vancomycin 1 g q.12h after surgery and later changed Ancef 2 g IV every 8 hours. Postop wound care consists of Aquacel Ag and dry dressing to the surgical site everyday and the patient remains nonweightbearing on the left foot. The patient progressively improved with IV antibiotics and local wound care and was discharged from the hospital on 06/19/07 in excellent condition.,DISCHARGE MEDICATIONS: , Lorcet 10/650 mg, dispense 24 tablets, one tablet to be taken by mouth q.6h as needed for pain. The patient was continued on Ancef 2 g IV via PICC line and home health administration of IV antibiotics.,DISCHARGE INSTRUCTIONS: , Included keeping the foot elevated with long periods of rest. The patient is to wear surgical shoe at all times for ambulation and to avoid excessive ambulation. The patient to keep dressing dry and intact, left foot. The patient to contact Dr. X for all followup care, if any problems arise. The patient was given written and oral instruction about wound care before discharge. Prior to discharge, the patient was noted to be afebrile. All vitals were stable. The patient's questions were answered and the patient was discharged in apparent satisfactory condition. Followup care was given via Dr. X' office.

podiatry, accutane, metatarsal head left foot, abscess with cellulitis, culture and sensitivity, incision and drainage, metatarsal head, foot, cellulitis, ancef, abscess, incision, drainage,

Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.

Podiatry

Arthroplasty

PREOPERATIVE DIAGNOSES:,1. Hammertoe deformity, left fifth digit.,2. Ulceration of the left fifth digit plantolaterally.,POSTOPERATIVE DIAGNOSIS:,1. Hammertoe deformity, left fifth toe.,2. Ulceration of the left fifth digit plantolaterally.,PROCEDURE PERFORMED:,1. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally.,2. Excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.,OPERATIVE PROCEDURE IN DETAIL: , The patient is a 38-year-old female with longstanding complaint of painful hammertoe deformity of her left fifth toe. The patient had developed ulceration plantarly after being scheduled for removal of a plantar mass in the same area. The patient elects for surgical removal of this ulceration and correction of her hammertoe deformity at this time.,After an IV was instituted by the Department of Anesthesia, the patient was escorted to the OR where the patient was placed on the Operating Room table in the supine position. After adequate amount of IV sedation was administered by Anesthesia Department, the patient was given a digital block to the left fifth toe using 0.5% Marcaine plain with 1% lidocaine plain in 1:1 mixture totaling 6 cc. Following this, the patient was draped and prepped in a normal sterile orthopedic manner. An ankle tourniquet was placed on the left ankle and the left foot was elevated and Esmarch bandage applied to exsanguinate the foot. The ankle tourniquet was then inflated to 230 mmHg and then was brought back down to the level of the table. The stockinette was then cut and reflected and held in place using towel clamp.,The skin was then cleansed using the wet and dry Ray-Tec sponge and then the plantar lesion was outlined. The lesion measured 1 cm in diameter at the level of the skin and a 3 cm elliptical incision line was drawn on the surface of the skin in the plantolateral aspect of the left fifth digit. Then using a fresh #15 blade, skin incision was made. Following this, the incision was then deepened using a fresh #15 blade down to the level of the subcutaneous tissue. Using a combination of sharp and blunt dissection, the skin was reflected distally and proximally to the lesion. The lesion appeared well encapsulated with fibrous tissue and through careful dissection using combination of sharp and drill instrumentation the ulceration was removed in its entirety. The next further exploration was performed to ensure that no residual elements of the fibrous capsular tissue remained within. The lesion extended from the level of the skin down to the periosteal tissue of the middle and distal phalanx, however, did not show any evidence of extending beyond the level of a periosteum. Remaining tissues were inspected and appeared healthy. The lesion was placed in the specimen container and sent to pathology for microanalysis as well as growth. Attention was then directed to the proximal interphalangeal joint of the left fifth digit and using further dissection with a #15 blade, the periosteum was reflected off the lateral aspect of the proximal ________ median phalanx. The capsule was also reflected to expose the prominent lateral osseous portion of this joint. Using a sagittal saw and #139 blade, the lateral osseous prominence was resected. This was removed in entirety. Then using power-oscillating rasp, the sharp edges were smoothed and recontoured to the desirable anatomic condition. Then the incision and wound was flushed using copious amounts of sterile saline with gentamycin. Following this, the bone was inspected and appeared to be healthy with no evidence of involvement from the removed aforementioned lesion.,Following this, using #4-0 nylon in a combination of horizontal mattress and simple interrupted sutures, the lesion wound was closed and skin was approximated well without tension to the surface skin. Following this, the incision site was dressed using Owen silk, 4x4s, Kling, and Coban in a normal fashion. The tourniquet was then deflated and hyperemia was noted to return to digits one through five of the left foot. The patient was then escorted from the operative table into the Postanesthesia Care Unit. The patient tolerated the procedure and anesthesia well and was brought to the Postanesthesia Care Unit with vital signs stable and vascular status intact. In the recovery, the patient was given a surgical shoe as well as given instructions for postoperative care to include rest ice and elevation as well as the patient was given prescription for Naprosyn 250 mg to be taken three times daily as well as Vicodin ES to be taken q.6h. as needed.,The patient will follow-up on Friday with Dr. X in office for further evaluation. The patient was also given instructions as to signs of infection and to monitor her operative site. The patient was instructed to keep daily dressings intact, clean, dry, and to not remove them.

podiatry, hammertoe deformity, plantolaterall, ulceration, arthroplasty, plantar ulceration, interphalangeal, painful hammertoe, proximal interphalangeal joint, interphalangeal joint, digit, toe, blade, deformity, incision, hammertoe, lesion

Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis.

Physical Medicine - Rehab

Therapeutic Recreation Initial Evaluation

HISTORY:, Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis.,Patient is currently living in ABC with his son as this was closer his to his job. At discharge, he will live with his spouse in a new job. The home is single level with no steps.,Prior to admission, his wife reports that he was independent with all activities. He was working full time for an oil company.,Past medical history includes hypertension and diabetes, mental status, and dysphagia.,Ability to follow instruction/rules: Not able to identify cognitive status as of yet.,COMMUNICATION SKILLS: , No initiation of conversation. He answered 1 yes/no question.,PHYSICAL STATUS:, Fall/safety. Aspiration precautions.,Endurance: Ball activities 4 to 5 minutes. Restorator 25 minutes. Standing and rolling type of 3 minutes.,LEISURE LIFESTYLE:,Level of participation/activities involved in: Reading and housework.,INFORMATION OBTAINED:, Interview, observation, and chart review.,TREATMENT PLAN: ,Treatment plan and goals were discussed with patient along with identification of results of FUNCTIONAL ASSESSMENT OF CHARACTERISTICS FOR THERAPEUTIC RECREATION identifying need for intervention in the following problem areas: Patient scored 10/11 in physical domain due to decreased endurance. He scored 11/11 in the cognitive and social domain.,Patient will attend 1 session per day focusing on: Endurance activities.,Patient will attend 1-2 group sessions per week focusing on leisure awareness and postdischarge resources.,GOALS:,PATIENT GOALS: , Not able to identify, but cooperative with all activities. He answered yes that he enjoyed the restorator.,SHORT TERM GOALS/ONE WEEK GOALS:,1. Patient to increase tolerance for ball activities to 7 minutes.,2. Patient provided to use the restorator as he enjoys and it is good for endurance.,LONG TERM GOALS:, Patient to increase standing tolerance, standing leisure activities to 7 to 10 minutes.,Patient has concurred with the above treatment planning goals.

physical medicine - rehab, endurance, ball activities, therapeutic recreation, hemiparesis, tolerance, recreation, restorator, leisure, therapeutic,

Status post brain tumor removal. The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.

Physical Medicine - Rehab

Physical Therapy - Brain Tumor Removal

DIAGNOSIS:, Status post brain tumor removal.,HISTORY:, The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. The patient reports that on 10/24/08 she had a brain tumor removed and had left-sided weakness. The patient was being seen in physical therapy from 11/05/08 to 11/14/08 then she began having complications. The patient reports that she was admitted to Hospital on 12/05/08. At that time, they found massive swelling on the brain and a second surgery was performed. The patient then remained in acute rehab until she was discharged to home on 01/05/09. The patient's husband, Al, is also present and he reports that during rehabilitation the patient did have a DVT in the left calf that has since been resolved.,PAST MEDICAL HISTORY: , Unremarkable.,MEDICATIONS: ,Coumadin, Keppra, Decadron, and Glucophage.,SUBJECTIVE: , The patient reports that the pain is not an issue at this time. The patient states that her primary concern is her left-sided weakness as related to her balance and her walking and her left arm weakness.,PATIENT GOAL: ,To increase strength in her left leg for better balance and walking.,OBJECTIVE:,RANGE OF MOTION: Bilateral lower extremities are within normal limits.,STRENGTH: Bilateral lower extremities are grossly 5/5 with one repetition, except left hip reflexion 4+/5.,BALANCE: The patient's balance was assessed with a Berg balance test. The patient has got 46/56 points, which places her at moderate risk for falls.,GAIT: The patient ambulates with contact guard assist. The patient ambulates with a reciprocal gait pattern with good bilateral foot clearance. However, the patient has been reports that with increased fatigue, left footdrop tends to occur. A 6-minute walk test will be performed at the next visit due to time constraints.,ASSESSMENT: , The patient is a 64-year-old female referred to Physical Therapy status post brain surgery. Examination indicates deficits in strength, balance, and ambulation. The patient will benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN: , The patient will be seen three times per week for 4 weeks and then reduce it to two times per week for 4 additional weeks. Interventions include:,1. Therapeutic exercise.,2. Balance training.,3. Gait training.,4. Functional mobility training.,SHORT TERM GOAL TO BE COMPLETED IN 4 WEEKS:,1. The patient is to tolerate 30 repetitions of all lower extremity exercises.,2. The patient is to improve balance with a score of 50/56 points.,3. The patient is to ambulate 1000 feet in a 6-minute walk test with standby assist.,LONG TERM GOAL TO BE ACHIEVED IN 8 WEEKS:,1. The patient is to ambulate independently within her home and standby to general supervision within the community.,2. Berg balance test to be 52/56.,3. The patient is to ambulate a 6-minute walk test for 1500 feet independently including safe negotiation of corners and busy areas.,4. The patient is to demonstrate safely stepping over and around objects without loss of balance.,Prognosis for the above-stated goals is good. The above treatment plan has been discussed with the patient and her husband. They are in agreement.

Ankle sprain, left ankle. The patient tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.

Physical Medicine - Rehab

Physical Therapy - Ankle Sprain

DIAGNOSIS: , Ankle sprain, left ankle.,HISTORY: , The patient is a 31-year-old female who was referred to Physical Therapy secondary to a fall on 10/03/08. The patient states that she tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.,PAST MEDICAL HISTORY: , Significant for hypertension, asthma, and cervical cancer. The cervical cancer was diagnosed as 15 years old. The patient states that her cancer is "dormant.",MEDICATIONS:,1. Hydrochlorothiazide.,2. Lisinopril.,3. Percocet.,The patient states that the Percocet helps to take the edge of her pain, but does not completely eliminate it.,SUBJECTIVE: , The patient rates the pain at 2/10 on the pain analog scale. The patient states that with elevation and rest, her pain subsides.,FUNCTIONAL ACTIVITIES/HOBBIES: , Currently limited including basic household chores and activities, this does increases her pain. The patient states she also recently joined Weight Watchers and was involved in a walking routine and is currently unable to participate in this activity.,WORK STATUS: , The patient is currently on medical leave as a paraprofessional. The patient states that she works as a teacher's aide in the school system and is required to complete extensive walking and standing activities. The patient states that she is primarily on her feet while at work and rarely has a sitting break for extensive period of time. The patient's goal is to be able to stand and walk without pain.,SOCIAL HISTORY: ,The patient lives in a private home with children and her father. The patient states that she does have stairs to negotiate without the use of a railing. She states that she is able to manage the stairs, however, is very slow with her movement. The patient smokes 1-1/2 packs of cigarettes a day and does not have a history of regular exercise routine.,OBJECTIVE: , Upon observation, the patient is a very obese female who is ambulating with significant antalgic gait pattern and altered normal gait due to the pain as well as the walking boot. Upon inspection of the left ankle, it appears to have swelling, unsure if this swelling is secondary to injury or water retention as the patient states she has significant water retention. When compared to right ankle edema, it is approximately equal. There is no evidence of discoloration or temperature. The patient states that she had no bruising at the time of injury.,Active range of motion of left ankle is as follows: Dorsiflexion is 6 degrees past neutral and plantar flexion is 54 degrees, eversion 20 degrees, and inversion is 30 degrees. Left ankle dorsiflexion lacks 10 degrees from neutral and plantar flexion is 36 degrees, this motion is very painful. The patient was tearful during this activity. Eversion is 3 degrees and inversion is 25 degrees. The patient states this movement was difficult, but not painful. Strength testing of the right lower extremity is grossly 4+-5/5 and left ankle is 2/5 as the patient is unable to obtain full range of motion.,PALPATION: , The patient is very tender to palpation primarily along the lateral malleolus of the left ankle.,JOINT PLAY: , Unable to be assessed secondary to the patient's extreme tenderness and guarding of the ankle joint.,SPECIAL TESTS:, A 6-minute walk test. The patient was able to ambulate approximately 600 feet while wearing her walking boot prior to her pain significantly increasing in the ankle and requiring the test to be stopped.,ASSESSMENT: ,The patient would benefit from skilled physical therapy intervention as a trial of treatment in order to address the following problem list:,1. Increased pain.,2. Decreased range of motion.,3. Decreased strength.,4. Decreased ability to complete work task and functional activities in the home.,5. Decreased gait pattern.,SHORT-TERM GOALS TO BE COMPLETED IN 3 WEEKS:,1. The patient will demonstrate independence with home exercise program.,2. The patient will ambulate without her boot for 48 hours in order to decrease reliance upon the boot for ankle stabilization.,3. The patient will achieve left ankle dorsiflexion to neutral and plantar flexion to 45 degrees without significant increase in pain.,4. The patient will demonstrate 3/5 strength of the left ankle.,5. The patient will tolerate the completion of the 6-minute walk test without the use of a boot with minimal increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN 6 WEEKS:,1. The patient will report 0/10 pain in the 48-hour period without the use of medication and without wearing her boot.,2. The patient will return to go through the work without the use of the walking boot with report of minimal increase in pain and discomfort.,PROGNOSIS:, Fair for above-stated goals with full compliance to home exercise program and therapy treatment as well as the patient motivation.,PLAN: , The patient to be seen three times a week for 6 weeks for the following:

The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis. The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area. The patient was transferred from the hospital to a nursing home and lived there for 1 year. The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.

Physical Medicine - Rehab

Physical Therapy - Osteoarthritis

DIAGNOSIS: , Left knee osteoarthritis.,HISTORY: , The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis. The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area. The patient was transferred from the hospital to a nursing home and lived there for 1 year. Prior to this incident, the patient was ambulating independently with a pickup walker throughout her home. Since that time, the patient has only been performing transverse and has been unable to ambulate. The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.,PAST MEDICAL HISTORY: , High blood pressure, obesity, right patellar fracture with pin in 1990, and history of blood clots.,MEDICATIONS: ,Naproxen, Plavix, and stool softener.,MEDICAL DIAGNOSTICS: , The patient states that she had an x-ray of the knee in 2007 and was diagnosed with osteoarthritis.,SUBJECTIVE:, The patient reports that when seated and at rest, her knee pain is 0/10. The patient states that with active motion of the left knee, the pain in the anterior portion increases to 5/10.,PATIENT'S GOAL: , To transfer better and walk 5 feet from her bed to the couch.,INSPECTION: , The right knee has a large 8-inch long and very wide tight scar with adhesions to the underlying connective tissue due to her patellar fracture and surgery following an MVA in 1990, bilateral knees are very large due to obesity. There are no scars, bruising or increased temperature noted in the left knee.,RANGE OF MOTION: , Active and passive range of motion of the right knee is 0 to 90 degrees and the left knee, 0 to 85 degrees. Pain is elicited during active range of motion of the left knee.,PALPATION: , Palpation to the left knee elicits pain around the patellar tendon and to each side of this area.,FUNCTIONAL MOBILITY: ,The patient reports that she transfers with standby to contact-guard assist in the home from her bed to her wheelchair and return. The patient is able to stand modified independent from wheelchair level and tolerates at least 15 seconds of standing prior to needing to sit down due to the left knee pain.,ASSESSMENT: ,The patient is a 58-year-old female with left knee osteoarthritis. Examination indicates deficits in pain, muscle endurance, and functional mobility. The patient would benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN: ,The patient will be seen two times per week for an initial 4 weeks with re-assessment at that time for an additional 4 weeks if needed.,INTERVENTIONS INCLUDE:,1. Modalities including electrical stimulation, ultrasound, heat, and ice.,2. Therapeutic exercise.,3. Functional mobility training.,4. Gait training.,LONG-TERM GOALS TO BE ACHIEVED IN 4 WEEKS:,1. The patient is to have increased endurance in bilateral lower extremities as demonstrated by being able to perform 20 repetitions of all lower extremity exercises in seated and supine positions with minimum 2-pound weight.,2. The patient is to perform standby assist transfer using a pickup walker.,3. The patient is to demonstrate 4 steps of ambulation using forward and backward using a pickup walker or front-wheeled walker.,4. The patient is to report maximum 3/10 pain with weightbearing of 2 minutes in the left knee.,LONG-TERM GOALS TO BE ACHIEVED IN 8 WEEKS:,1. The patient is to be independent with the home exercise program.,2. The patient is to tolerate 20 reps of standing exercises with pain maximum of 3/10.,3. The patient is to ambulate 20 feet with the most appropriate assistive device.,PROGNOSIS TO THE ABOVE-STATED GOALS:, Fair to good.,The above treatment plan has been discussed with the patient. She is in agreement.

The patient is a 26-year-old female, referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back.

Physical Medicine - Rehab

Physical Therapy - Low Back Pain

HISTORY OF PRESENT ILLNESS: , The patient is a 26-year-old female, referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back. The patient stated initial injury occurred eight years ago, when she fell at a ABC Store. The patient stated she received physical therapy, one to two visits and received modality treatment only, specifically electrical stimulation and heat pack per patient recollection. The patient stated that she has had continuous low-back pain at varying degrees for the past eight years since that fall. The patient gave birth in August 2008 and since the childbirth, has experienced low back pain. The patient also states that she fell four to five days ago, while mopping her floor. The patient stated that she landed on her tailbone and symptoms have increased since that fall. The patient stated that her initial physician examination with Dr. X was on 01/10/09, and has a followup appointment on 02/10/09.,PAST MEDICAL HISTORY: , The patient denies high blood pressure, diabetes, heart disease, lung disease, thyroid, kidney, or bladder dysfunctions. The patient stated that she quit smoking prior to her past childbirth and is currently not pregnant. The patient has had a C-section and also an appendectomy. The patient was involved in a motor vehicle accident four to five years ago and at that time, the patient did not require any physical therapy nor did she report any complaints of increased back pain following that accident.,MEDICATIONS: , Patient currently states she is taking:,1. Vicodin 500 mg two times a day.,2. Risperdal.,3. Zoloft.,4. Stool softeners.,5. Prenatal pills.,DIAGNOSTIC IMAGERY: ,The patient states she has not had an MRI performed on her lumbar spine. The patient also states that Dr. X took x-rays two weeks ago, and no fractures were found at that time. Per physician note, dated 12/10/08, Dr. X dictated that the x-ray showed an anterior grade 1 spondylolisthesis of L5 over S1, and requested Physical Therapy to evaluate and treat.,SUBJECTIVE: ,The patient states that pain is constant in nature with a baseline of 6-7/10 with pain increasing to 10/10 during the night or in cold weather. The patient states that pain is dramatically less, when the weather is warmer. The patient also states that pain worsens as the day progresses, in that she also hard time getting out of bed in the morning. The patient states that she does not sleep at night well and sleeps less than one hour at a time.,Aggravating factors include, sitting for periods greater than 20 minutes or lying supine on her back. Easing factors include side lying position in she attempts to sleep.,OBJECTIVE: , AGE: 26 years old. HEIGHT: 5 feet 2 inches. WEIGHT: The patient is an obese 26-year-old female.,ACTIVE RANGE OF MOTION: , Lumbar spine, flexion, lateral flexion and rotation all within functional limits without complaints of pain or soreness while performing them during evaluation.,PALPATION: ,The patient complained of bilateral SI joint point tenderness. The patient also complained of left greater trochanter hip point tenderness. The patient also complained of bilateral paraspinal tenderness on cervical spine to lumbar spine.,STRENGTH: ,RIGHT LOWER EXTREMITY:,Knee extension 5/5, hip flexion 5/5, knee flexion 4/5, internal and external hip rotation was 4/5. With manual muscle testing of knee flexion, hip, internal and external rotation, the patient reports an increase in right SI joint pain to 8/10.,LEFT LOWER EXTREMITY:,Hip flexion 5/5, knee extension 5/5, knee flexion 4/5, hip internal and external rotation 4/5, with slight increase in pain level with manual muscle testing and resistance. It must be noted that PT did not apply as much resistance during manual muscle testing, secondary to the 8/10 pain elicited during the right lower extremity.,NEUROLOGICAL: ,The patient subjectively complains of numbness with tingling in her bilateral extremities when she sits longer than 25 minutes. However, they subside when she stands. The patient did complain of this numbness and tingling during the evaluation and the patient was seated for a period of 20 minutes. Upon standing, the patient stated that the numbness and tingling subsides almost immediately. The patient stated that Dr. X told her that he believes that during her past childbirth when the epidural was being administered that there was a possibility that a sensory nerve may have been also affected during the epidural less causing the numbness and tingling in her bilateral lower extremities. The patient does not demonstrate any sensation deficits with gentle pressure to the lumbar spine and during manual muscle testing.,GAIT: ,The patient ambulated out of the examination room, while carrying her baby in a car seat.,ASSESSMENT: ,The patient is a 26-year-old overweight female, referred to Physical Therapy for low back pain. The patient presents with lower extremity weakness, which may be contributing to her lumbosacral pain, in that she has poor lumbar stabilization with dynamic ADLs, transfers, and gait activity when fatigued. At this time, the patient may benefit from skilled physical therapy to address her decreased strength and core stability in order to improve her ADL, transfer, and mobility skills.,PROGNOSIS: , The patient's prognosis for physical therapy is good for dictated goals.,SHORT-TERM GOALS TO BE ACHIEVED IN TWO WEEKS:,1. The patient will be able to sit for greater than 25 minutes without complaints of paraesthesia or pain in her bilateral lower extremities or bilateral SI joints.,2. The patient will increase bilateral hip internal and external rotation to 4/5 with SI joint pain less than or equal to 5/10.,3. The patient will report 25% improvement in her functional and ADL activities.,4. Pain will be less than 4/10 while performing __________ while at PT session.,LONG-TERM GOALS TO BE ACCOMPLISHED IN ONE MONTH:,1. The patient will be independent with home exercise program.,2. Bilateral hamstring, bilateral hip internal and external rotation strength to be 4+/5 with SI joint pain less than or equal to 2/10, while performing manual muscle test.,3. The patient will report 60% improvement or greater in functional transfers in general ADL activity.,4. The patient will be able to sit greater than or equal to 45 minutes without complaint of lumbosacral pain.,5. The patient will be able to sleep greater than 2 hours without pain.,TREATMENT PLAN:,1. Therapeutic exercises to increase lower extremity strength and assist with lumbar sacral stability.

Patient was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms. The patient would benefit from skilled physical therapy intervention.

Physical Medicine - Rehab

Physical Therapy - Back Pain

DIAGNOSIS: , Low back pain and degenerative lumbar disk.,HISTORY:, The patient is a 59-year-old female, who was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms. The patient states that this occurred in October 2008 as well as November 2008. The patient has a history of low back pain, secondary to a fall that originally occurred in 2006. The patient states that she slipped on a newly waxed floor and fell on her tailbone and low back region. The patient then had her second fall in March 2006. The patient states that she was qualifying on the range with a handgun and lost her footing and states that she fell more due to weakness in her lower extremities rather than loss of balance.,PAST MEDICAL HISTORY:, Past medical history is significant for allergies and thyroid problems.,PAST SURGICAL HISTORY: , The patient has a past surgical history of appendectomy and hysterectomy.,MEDICATIONS:,1. TriCor.,2. Vytorin.,3. Estradiol.,4. Levothyroxine.,5. The patient is also taking ibuprofen 800 mg occasionally as needed for pain management. The patient states she rarely takes this and does not like to take pain medication if at all possible. The patient states that she has had uncomplicated pregnancies in the past.,SOCIAL HISTORY:, The patient states she lives in a single-level home with her husband, who is in good health and is able to assist with any tasks or activities the patient is having difficulty with. The patient rates her general health as excellent and denies any smoking and reports very occasional alcohol consumption. The patient does state that she has completed exercises on a daily basis of one to one and a half hours a day. However, has not been able to complete these exercise routine since approximately June 2008, secondary to back pain. The patient is working full-time as a project manager, and is required to do extensive walking at various periods during a workday.,MEDICAL IMAGING:, The patient states that she has had an MRI recently performed; however, the results are not available at the time of the evaluation. The patient states she is able to bring the report in upon next visit.,SUBJECTIVE: ,The patient rates her pain at 7/10 on a Pain Analog Scale, 0 to 10, 10 being worse. The patient describes her pain as a deep aching, primarily on the right lower back and gluteal region. Aggravating factors include stairs and prolonged driving, as well as general limitations with home tasks and projects. The patient states she is a very active individual and is noticing extreme limitations with ability to complete home tasks and projects she used to be able to complete.,NEUROLOGICAL SYMPTOMS:, The patient reports having occasional shooting pains into the lower extremities. However, these are occurring less frequently and is now occurring more frequently in the right versus the left lower extremity when they do occur.,FUNCTIONAL ACTIVITIES AND HOBBIES: , Include exercising and general activities.,PATIENT'S GOAL: , The patient would like to improve her overall body movements and return to daily exercise routine as able and well maintaining safety.,OBJECTIVE: , Upon observation, the patient ambulates independently without the use of assistive device. However, does present with mild limp and favoring the left lower extremity after extensive standing and walking activity. The patient does have mild difficulty transferring from the seated position to standing. However, once is upright, the patient denies any increased pain or symptoms.,ACTIVE RANGE OF MOTION OF LUMBAR SPINE: ,Forward flexion is 26 cm, fingertip to floor, lateral side bend, fingertip to floor is 52.5 cm bilaterally.,STRENGTH: , Strength is grossly 4/5. The patient denies any significant tenderness to palpation. However, does have mild increase in tenderness on the right versus left. A six-minute walk test revealed painful symptoms and achiness occurring after approximately 400 feet of walking. The patient was able to continue; however, stopped after 700 feet. There were two minutes remaining in the six-minute walk test. The patient does have tight hamstrings as well as a negative slump test.,ASSESSMENT: , The patient would benefit from skilled physical therapy intervention in order to address the following problem list.,PROBLEM LIST:,1. Increased pain.,2. Decreased ability to complete tasks and hobbies.,3

Synovitis - anterior cruciate ligament tear of the left knee. The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient fell in a grocery store. He reports slipping on a grape that was on the floor.

Physical Medicine - Rehab

Physical Therapy - Synovitis

DIAGNOSIS:, Synovitis/anterior cruciate ligament tear of the left knee.,HISTORY: , The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient states that on 10/02/08, the patient fell in a grocery store. He reports slipping on a grape that was on the floor. The patient states he went to the emergency room and then followed up with his primary care physician. The patient was then ultimately referred to Physical Therapy. After receiving a knee brace, history and information was received through a translator as the patient is Spanish speaking only.,PAST MEDICAL HISTORY: , Past medical history is unremarkable.,MEDICAL IMAGING: , Medical imaging is significant for x-rays and MRIs. The report was available at the time of the evaluation. The patient reports abnormal posterior horn of medial meniscus consistent with knee degenerative change and possibly tears.,MEDICATIONS:,1. Tramadol.,2. Diclofenac.,3. Advil.,4. Tylenol.,SUBJECTIVE: , The patient rates his pain at 6/10 on the Pain Analog Scale, primarily with ambulation. The patient does deny pain at night. The patient does present with his knee brace on the exterior of his __________ leg and appears to be on backboard.,FUNCTIONAL ACTIVITIES AND HOBBIES: ,Functional activities and hobbies that are currently limited include any work as the patient is currently unemployed and is looking for a job; however, his primary skills are of a laborer and a street broker for new homes.,OBJECTIVE: ,Upon observation, the patient is ambulating with a significant antalgic gait pattern. However, he is not using any assistive device. The knee brace was corrected and the patient and his wife demonstrated understanding and knowledge of how to place the knee brace on correctly.,ACTIVE RANGE OF MOTION: , Active range of motion of the left knee is 0 to 105 degrees with pain during range of motion. Right knee active range of motion is 0 to 126 degrees.,STRENGTH: ,Strength is 3/5 for left knee, 4+/5 for right knee. The patient denies any pain upon light and deep palpation at the knee joints. There is no evidence of temperature change, increased swelling or any discoloration at the left knee joint. The patient does not appear to have instability at this time with formal tests at the left knee joint.,SPECIAL TESTS: ,The patient performed a six-minute walk test. He was able to complete 600 feet; however, had to stop this test at approximately five minutes, secondary to significant increase in pain.,ASSESSMENT:, The patient would benefit from skilled physical therapy intervention in order to address the following problem list:,1. Increased pain.,2. Decreased range of motion.,3. Decreased strength.,4. Decreased ability to perform functional activities and work tasks.,5. Decreased ambulation tolerance.,SHORT-TERM GOALS TO BE COMPLETED IN THREE WEEKS:,1. Patient will demonstrate independence with the home exercise program.,2. Patient will report maximum pain of 2/10 on a Pain Analog Scale within a 24-hour period.,3. The patient will demonstrate left knee active range of motion, 0 to 120 degrees, without significant increase in pain during motion.,4. The patient will demonstrate 4/5 strength for the left knee.,5. The patient will complete 800 feet in a six-minute walk test without significant increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN SIX WEEKS:,1. The patient will demonstrate bilateral knee active range of motion, 0 to 130 degrees.,2. The patient will demonstrate 5/5 lower extremity strength bilaterally without significant increase in pain.,3. Patient will complete 1000 feet in a six-minute walk test without increase in pain and tolerate full completion of the six minutes.,4. The patient will improve confidence with ability to perform work activity, when the situation improves and resolves.,PROGNOSIS: ,Prognosis is good for above-stated goals, with compliance to a home exercise program and treatment.,SESSION PLAN: , The patient to be seen two to three times a week for six weeks for the following:,1. Therapeutic exercise with home exercise program.

Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.

Physical Medicine - Rehab

Physical Therapy - Outpatient Rehab

SUMMARY: ,The patient has attended physical therapy from 11/16/06 to 11/21/06. The patient has 3 call and cancels and 3 no shows. The patient has been sick for several weeks due to a cold as well as food poisoning, so has missed many appointments.,SUBJECTIVE: ,The patient states pain still significant, primarily 1st seen in the morning. The patient was evaluated 1st thing in the morning and did not take his pain medications, so objective findings may reflect that. The patient states overall functionally he is improving where he is able to get out in the house and visit and do activities outside the house more. The patient does feel like he is putting on more muscle girth as well. The patient states he is doing well with his current home exercise program and feels like pool therapy is also helping as well.,OBJECTIVE: , Physical therapy has consisted of:,1. Pool therapy incorporating endurance and general lower and upper extremity strengthening.,2. Clinical setting incorporating core stabilization and general total body strengthening and muscle wasting.,3. The patient has just begun this, so it is on a very beginners level at this time.,ASSESSMENT, DONE ON 12/21/06,STRENGTH,Activities

Status post left hip fracture and hemiarthroplasty. Rehab transfer as soon as medically cleared.

Physical Medicine - Rehab

Hip Fracture - Rehab Consult

ADMISSION DIAGNOSIS: , Left hip fracture.,CHIEF COMPLAINT: , Diminished function, secondary to the above.,HISTORY: , This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay. He had left hip fracture identified on x-rays at that time. Pain and inability to ambulate brought him in. He was evaluated and then underwent medical consultation as well, where they found a history of resolving pneumonia, hypertension, chronic obstructive pulmonary disease, congestive heart failure, hypothyroidism, depression, anxiety, seizure and chronic renal failure, as well as anemia. His medical issues are under good control. The patient underwent left femoral neck fixation with hemiarthroplasty on that left side on 05/06/03. The patient has had some medical issues including respiratory insufficiency, perioperative anemia, pneumonia, and hypertension. Cardiology has followed closely, and the patient has responded well to medical treatment, as well as physical therapy and occupational therapy. He is gradually tolerating more activities with less difficulties, made good progress and tolerated more consistent and more prolonged interventions.,PAST MEDICAL HISTORY: , Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation. Remote history of subdural hematoma precluding the use of Coumadin. History of depression, panic attacks on Doxepin. Perioperative anemia. Swallowing difficulties.,ALLERGIES:, Zyloprim, penicillin, Vioxx, NSAIDs.,CURRENT MEDICATIONS,1. Heparin.,2. Albuterol inhaler.,3. Combivent.,4. Aldactone.,5. Doxepin.,6. Xanax.,7. Aspirin.,8. Amiodarone.,9. Tegretol.,10. Synthroid.,11. Colace.,SOCIAL HISTORY: , Lives in a 1-story home with 1 step down; wife is there. Speech and language pathology following with current swallowing dysfunction. He is minimum assist for activities of daily living, bed mobility.,REVIEW OF SYSTEMS:, Currently negative for headache, nausea and vomiting, fevers, chills or shortness of breath or chest pain.,PHYSICAL EXAMINATION,HEENT: Oropharynx clear.,CV: Regular rate and rhythm without murmurs, rubs or gallops.,LUNGS: Clear to auscultation bilaterally.,ABDOMEN: Nontender, nondistended. Bowel sounds positive.,EXTREMITIES: Without clubbing, cyanosis, or edema.,NEUROLOGIC: There are no focal motor or sensory losses to the lower extremities. Bulk and tone normal in the lower extremities. Wound site has healed well with staples out.,IMPRESSION ,1. Status post left hip fracture and hemiarthroplasty.,2. History of panic attack, anxiety, depression.,3. Myocardial infarction with stent placement.,4. Hypertension.,5. Hypothyroidism.,6. Subdural hematoma.,7. Seizures.,8. History of chronic obstructive pulmonary disease. Recent respiratory insufficiency.,9. Renal insufficiency.,10. Recent pneumonia.,11. O2 requiring.,12. Perioperative anemia.,PLAN: , Rehab transfer as soon as medically cleared.

Encephalopathy related to normal-pressure hydrocephalus.

Physical Medicine - Rehab

Encephalopathy - Rehab Consult

ADMITTING DIAGNOSIS: , Encephalopathy related to normal-pressure hydrocephalus.,CHIEF COMPLAINT:, Diminished function secondary to above.,HISTORY: ,This pleasant gentleman was recently admitted to ABCD Medical Center and followed by the neurosurgical staff, including Dr. X, where normal-pressure hydrocephalus was diagnosed. He had a shunt placed and was stabilized medically. He has gotten a return of function to the legs and was started on some early therapy. Significant functional limitations have been identified and ongoing by the rehab admission team. Significant functional limitations have been ongoing. He will need to be near-independent at home for periods of time, and he is brought in now for rehabilitation to further address functional issues, maximize skills and safety and allow a safe disposition home.,PAST MEDICAL HISTORY: , Positive for prostate cancer, intermittent urinary incontinence and left hip replacement.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS,1. Tylenol as needed. ,2. Peri-Colace b.i.d.,SOCIAL HISTORY:, He is a nonsmoker and nondrinker. Prior boxer. He lives in a home where he would need to be independent during the day. Family relatives intermittently available. Goal is to return home to an independent fashion to that home setting.,FUNCTIONAL HISTORY: , Prior to admission was independent with activities of daily living and ambulatory skills. Presently, he has resumed therapies and noted to have supervision levels for most activities of daily living. Memory at minimal assist. Walking at supervision., REVIEW OF SYSTEMS: ,Negative for headaches, nausea, vomiting, fevers, chills, shortness of breath or chest pain currently. He has had some dyscoordination recently and headaches on a daily basis, most days, although the Tylenol does seem to control that pain.,PHYSICAL EXAMINATION,VITAL SIGNS: The patient is afebrile with vital signs stable.,HEENT: Oropharynx clear, extraocular muscles are intact.,CARDIOVASCULAR: Regular rate and rhythm, without murmurs, rubs or gallops.,LUNGS: Clear to auscultation bilaterally.,ABDOMEN: Nontender, nondistended, positive bowel sounds.,EXTREMITIES: Without clubbing, cyanosis, or edema. The calves are soft and nontender bilaterally.,NEUROLOGIC: No focal, motor or sensory losses through the lower extremities. He moves upper and lower extremities well. Bulk and tone normal in the upper and lower extremities. Cognitively showing intact with appropriate receptive and expressive skills.,IMPRESSION ,

Nerve conduction screen demonstrates borderline median sensory and borderline distal median motor responses in both hands. The needle EMG examination is remarkable for rather diffuse active denervation changes in most muscles of the right upper and right lower extremity tested.

Physical Medicine - Rehab

EMG/Nerve Conduction Study - 9

NERVE CONDUCTION TESTING AND EMG EVALUATION,1. Right median sensory response 3.0, amplitude 2.5, distance 100.,2. Right ulnar sensory response 2.1, amplitude 1, distance 90.,3. Left median sensory response 3.0, amplitude 1.2, distance 100.,4. Left median motor response distal 4.2, proximal 9, amplitude 2.2, distance 290, velocity 60.4 m/sec.,5. Right median motor response distal 4.3, proximal 9.7, amplitude 2, and velocity 53.7 m/sec.,6. Right ulnar motor response distal 2.5, proximal 7.5, amplitude 2, distance 300, velocity 60 m/sec.,NEEDLE EMG TESTING,1. ,RIGHT BICEPS:, Fibrillations 0, fasciculations occasional, positive waves 0. Motor units, increased needle insertional activity and mild decreased number of motor units firing.,2. ,RIGHT TRICEPS:, Fibrillations 1+, fasciculations occasional to 1+, positive waves 1+. Motor units, increased needle insertional activity and decreased number of motor units firing.,3. ,EXTENSOR DIGITORUM:, Fibrillations 0, fasciculations rare, positive waves 0, motor units probably normal.,4. ,FIRST DORSAL INTEROSSEOUS: , Fibrillations 2+, fasciculations 1+, positive waves 2+. Motor units, decreased number of motor units firing.,5. ,RIGHT ABDUCTOR POLLICIS BREVIS:, Fibrillations 1+, fasciculations 1+, positive waves 0. Motor units, decreased number of motor units firing.,6. , FLEXOR CARPI ULNARIS:, Fibrillations 1+, occasionally entrained, fasciculations rare, positive waves 1+. Motor units, decreased number of motor units firing.,7. ,LEFT FIRST DORSAL INTEROSSEOUS:, Fibrillations 1+, fasciculations 1+, positive waves occasional. Motor units, decreased number of motor units firing.,8. ,LEFT EXTENSOR DIGITORUM:, Fibrillations 1+, fasciculations 1+. Motor units, decreased number of motor units firing.,9. ,RIGHT VASTUS MEDIALIS:, Fibrillations 1+ to 2+, fasciculations 1+, positive waves 1+. Motor units, decreased number of motor units firing.,10. ,ANTERIOR TIBIALIS: , Fibrillations 2+, occasionally entrained, fasciculations 1+, positive waves 1+. Motor units, increased proportion of polyphasic units and decreased number of motor units firing. There is again increased needle insertional activity.,11. ,RIGHT GASTROCNEMIUS:, Fibrillations 1+, fasciculations 1+, positive waves 1+. Motor units, marked decreased number of motor units firing.,12. ,LEFT GASTROCNEMIUS:, Fibrillations 1+, fasciculations 1+, positive waves 2+. Motor units, marked decreased number of motor units firing.,13. ,LEFT VASTUS MEDIALIS: , Fibrillations occasional, fasciculations occasional, positive waves 1+. Motor units, decreased number of motor units firing.,IMPRESSION:

Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.

Physical Medicine - Rehab

Occupational Therapy Discharge Summary

DIAGNOSES: , Traumatic brain injury, cervical musculoskeletal strain.,DISCHARGE SUMMARY: , The patient was seen for evaluation on 12/11/06 followed by 2 treatment sessions. Treatment consisted of neuromuscular reeducation including therapeutic exercise to improve range of motion, strength, and coordination; functional mobility training; self-care training; cognitive retraining; caregiver instruction; and home exercise program. Goals were not achieved, as the patient was admitted to inpatient rehabilitation center.,RECOMMENDATIONS: , Discharged from OT this date, as the patient has been admitted to Inpatient Rehabilitation Center.,Thank you for this referral.

physical medicine - rehab, musculoskeletal strain, occupational therapy, traumatic, brain, cervical, musculoskeletal, rehabilitation,

Patient with a past medical history of a left L5-S1 lumbar microdiskectomy with complete resolution of left leg symptoms.

Physical Medicine - Rehab

EMG/Nerve Conduction Study - 6

HISTORY:, The patient is a 46-year-old right-handed gentleman with a past medical history of a left L5-S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms, who now presents with a four-month history of gradual onset of right-sided low back pain with pain radiating down into his buttock and posterior aspect of his right leg into the ankle. Symptoms are worsened by any activity and relieved by rest. He also feels that when the pain is very severe, he has some subtle right leg weakness. No left leg symptoms. No bowel or bladder changes.,On brief examination, full strength in both lower extremities. No sensory abnormalities. Deep tendon reflexes are 2+ and symmetric at the patellas and absent at both ankles. Positive straight leg raising on the right.,MRI of the lumbosacral spine was personally reviewed and reveals a right paracentral disc at L5-S1 encroaching upon the right exiting S1 nerve root.,NERVE CONDUCTION STUDIES:, Motor and sensory distal latencies, evoked response amplitudes, and conduction velocities are normal in the lower extremities. The right common peroneal F-wave is minimally prolonged. The right tibial H reflex is absent.,NEEDLE EMG:, Needle EMG was performed on the right leg, left gastrocnemius medialis muscle, and right lumbosacral paraspinal muscles using a disposable concentric needle. It revealed spontaneous activity in the right gastrocnemius medialis, gluteus maximus, and lower lumbosacral paraspinal muscles. There was evidence of chronic denervation in right gastrocnemius medialis and gluteus maximus muscles.,IMPRESSION: , This electrical study is abnormal. It reveals an acute right S1 radiculopathy. There is no evidence for peripheral neuropathy or left or right L5 radiculopathy.,Results were discussed with the patient and he is scheduled to follow up with Dr. X in the near future.

physical medicine - rehab, microdiskectomy, needle emg, nerve conduction studies, lumbosacral paraspinal muscles, lumbar microdiskectomy, lower extremities, lumbosacral paraspinal, paraspinal muscles, gluteus maximus, leg symptoms, gastrocnemius medialis, emg/nerve, conduction, lumbosacral, needle, gastrocnemius, medialis, muscles,

A woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities. Abnormal electrodiagnostic study.

Physical Medicine - Rehab

EMG/Nerve Conduction Study - 8

REFERRING DIAGNOSIS: , Motor neuron disease.,PERTINENT HISTORY AND EXAMINATION:, Briefly, the patient is an 83-year-old woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.,SUMMARY: ,The right median sensory response showed a borderline normal amplitude for age with mild slowing of conduction velocity. The right ulnar sensory amplitude was reduced with slowing of the conduction velocity. The right radial sensory amplitude was reduced with slowing of the conduction velocity. The right sural and left sural sensory responses were absent. The right median motor response showed a prolonged distal latency across the wrist, with proximal slowing. The distal amplitude was very reduced, and there was a reduction with proximal stimulation. The right ulnar motor amplitude was borderline normal, with slowing of the conduction velocity across the elbow. The right common peroneal motor response showed a decreased amplitude when recorded from the EDB, with mild slowing of the proximal conduction velocity across the knee. The right tibial motor response showed a reduced amplitude with prolongation of the distal latency. The left common peroneal response recorded from the EDB showed a decreased amplitude with mild distal slowing. The left tibial motor response showed a decreased amplitude with a borderline normal distal latency. The minimum F-wave latencies were normal with the exception of a mild prolongation of the ulnar F-wave latency, and the tibial F-wave latency as indicated above. With repetitive nerve stimulation, there was no significant decrement noted in either the right nasalis or the right trapezius muscles. Concentric needle EMG studies were performed in the right lower extremity, right upper extremity, thoracic paraspinals, and in the tongue. There was evidence of increased insertional activity in the right tibialis anterior muscle, with evidence of fasciculations noted in several lower and upper extremity muscles and in the tongue. In addition, there was evidence of increased amplitude, long duration and polyphasic motor units with a decreased recruitment noted in most muscles tested as indicated in the table above.,INTERPRETATION: , Abnormal electrodiagnostic study. There is electrodiagnostic evidence of a disorder of the anterior motor neurons affecting at least four segments. There is also evidence of a more generalized neuropathy that seems to be present in both the upper and lower extremities. There is also evidence of a right median mononeuropathy at the wrist and a right ulnar neuropathy at the elbow. Even despite the patient's age, the decrease in sensory responses is concerning, and makes it difficult to be certain about the diagnosis of motor neuron disease. However, the overall changes on the needle EMG would be consistent with a diagnosis of motor neuron disease. The patient will return for further evaluation.

physical medicine - rehab, electrodiagnostic study, electrodiagnostic, edb, latency, nerve conduction study, emg, motor neuron disease, distal latency, motor response, motor, amplitude, conduction

A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.

Physical Medicine - Rehab

EMG/Nerve Conduction Study - 3

HISTORY: , The patient is a 56-year-old right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident in September of 2005. At that time, she did not notice any specific injury. Five days later, she started getting abnormal right low back pain. At this time, it radiates into the buttocks down the posterior aspect of her thigh and into the right lateral aspect of her calf. Symptoms are worse when sitting for any length of time, such as driving a motor vehicle. Mild symptoms when walking for long periods of time. Relieved by standing and lying down. She denies any left leg symptoms or right leg weakness. No change in bowel or bladder function. Symptoms have slowly progressed. She has had Medrol Dosepak and analgesics, which have not been very effective. She underwent a spinal epidural injection, which was effective for the first few hours, but she had recurrence of the pain by the next day. This was done four and a half weeks ago.,On examination, lower extremities strength is full and symmetric. Straight leg raising is normal.,OBJECTIVE:, Sensory examination is normal to all modalities. Full range of movement of lumbosacral spine. Mild tenderness over lumbosacral paraspinal muscles and sacroiliac joint. Deep tendon reflexes are 2+ and symmetric at the knees, 2 at the left ankle and 1+ at the right ankle.,NERVE CONDUCTION STUDIES:, Motor and sensory distal latencies, evoked response, amplitudes, conduction velocities, and F-waves are normal in the lower extremities. Right tibial H-reflex is slightly prolonged when compared to the left tibial H-reflex.,NEEDLE EMG:, Needle EMG was performed in both lower extremities and lumbosacral paraspinal muscles using the disposable concentric needle. It revealed increased insertional activity in the right mid and lower lumbosacral paraspinal muscles as well as right peroneus longus muscle. There were signs of chronic denervation in right tibialis anterior, peroneus longus, gastrocnemius medialis, and left gastrocnemius medialis muscles.,IMPRESSION: , This electrical study is abnormal. It reveals the following:,1. A mild right L5 versus S1 radiculopathy.,2. Left S1 nerve root irritation. There is no evidence of active radiculopathy.,3. There is no evidence of plexopathy, myopathy or peripheral neuropathy.,MRI of the lumbosacral spine was personally reviewed and reveals bilateral L5-S1 neuroforaminal stenosis, slightly worse on the right. Results were discussed with the patient and her daughter. I would recommend further course of spinal epidural injections with Dr. XYZ. If she has no response, then surgery will need to be considered. She agrees with this approach and will followup with you in the near future.

physical medicine - rehab, emg, nerve conduction study, radiculopathy, peripheral neuropathy, nerve root irritation, motor vehicle accident, lumbosacral paraspinal muscles, spinal epidural, lumbosacral spine, peroneus longus, gastrocnemius medialis, lower extremities, emg/nerve, conduction, needle

EMG/Nerve Conduction Study showing sensory motor length-dependent neuropathy consistent with diabetes, severe left ulnar neuropathy, and moderate-to-severe left median neuropathy,

Physical Medicine - Rehab

EMG/Nerve Conduction Study - 4

NERVE CONDUCTION STUDIES:, Bilateral ulnar sensory responses are absent. Bilateral median sensory distal latencies are prolonged with a severely attenuated evoked response amplitude. The left radial sensory response is normal and robust. Left sural response is absent. Left median motor distal latency is prolonged with attenuated evoked response amplitude. Conduction velocity across the forearm is mildly slowed. Right median motor distal latency is prolonged with a normal evoked response amplitude and conduction velocity. The left ulnar motor distal latency is prolonged with a severely attenuated evoked response amplitude both below and above the elbow. Conduction velocities across the forearm and across the elbow are prolonged. Conduction velocity proximal to the elbow is normal. The right median motor distal latency is normal with normal evoked response amplitudes at the wrist with a normal evoked response amplitude at the wrist. There is mild diminution of response around the elbow. Conduction velocity slows across the elbow. The left common peroneal motor distal latency evoked response amplitude is normal with slowed conduction velocity across the calf and across the fibula head. F-waves are prolonged.,NEEDLE EMG: , Needle EMG was performed on the left arm and lumbosacral and cervical paraspinal muscles as well as middle thoracic muscles using a disposable concentric needle. It revealed spontaneous activity in lower cervical paraspinals, left abductor pollicis brevis, and first dorsal interosseous muscles. There were signs of chronic reinnervation in triceps, extensor digitorum communis, flexor pollicis longus as well first dorsal interosseous and abductor pollicis brevis muscles.,IMPRESSION: , This electrical study is abnormal. It reveals the following:,1. A sensory motor length-dependent neuropathy consistent with diabetes.,2. A severe left ulnar neuropathy. This is probably at the elbow, although definitive localization cannot be made.,3. Moderate-to-severe left median neuropathy. This is also probably at the carpal tunnel, although definitive localization cannot be made.,4. Right ulnar neuropathy at the elbow, mild.,5. Right median neuropathy at the wrist consistent with carpal tunnel syndrome, moderate.,6. A left C8 radiculopathy (double crush syndrome).,7. There is no evidence for thoracic radiculitis.,The patient has made very good response with respect to his abdominal pain since starting Neurontin. He still has mild allodynia and is waiting for authorization to get insurance coverage for his Lidoderm patch. He is still scheduled for MRI of C-spine and T-spine. I will see him in followup after the above scans.

physical medicine - rehab, emg, nerve conduction study, nerve conduction studies, needle emg, electrical study, neuropathy, ulnar neuropathy, median neuropathy, severely attenuated evoked response, normal evoked response amplitude, attenuated evoked response amplitude, median motor distal latency, motor distal latency, abductor pollicis, pollicis brevis, dorsal interosseous, carpal tunnel, conduction, emg/nerve, needle,

The patient is status post C3-C4 anterior cervical discectomy and fusion.

Physical Medicine - Rehab

EMG/Nerve Conduction Study - 5

She has an extensive past medical history of rheumatoid arthritis, fibromyalgia, hypertension, hypercholesterolemia, and irritable bowel syndrome. She has also had bilateral carpal tunnel release.,On examination, normal range of movement of C-spine. She has full strength in upper and lower extremities. Normal straight leg raising. Reflexes are 2 and symmetric throughout. No Babinski. She has numbness to light touch in her right big toe.,NERVE CONDUCTION STUDIES: The right median palmar sensory distal latencies are minimally prolonged with minimally attenuated evoked response amplitude. Bilateral tibial motor nerves could not be obtained (technical). The remaining nerves tested revealed normal distal latencies, evoked response amplitudes, conduction velocities, F-waves, and H. reflexes.,NEEDLE EMG: Needle EMG was performed on the right arm and leg and lumbosacral and cervical paraspinal muscles and the left FDI. It revealed 2+ spontaneous activity in the right APB and FDI and 1+ spontaneous activity in lower cervical paraspinals, lower and middle lumbosacral paraspinals, right extensor digitorum communis muscle, and right pronator teres. There was evidence of chronic denervation in the right first dorsal interosseous, pronator teres, abductor pollicis brevis, and left first dorsal interosseous.,IMPRESSION: This electrical study is abnormal. It reveals the following:,1. An active right C8/T1 radiculopathy. Electrical abnormalities are moderate.,2. An active right C6/C7 radiculopathy. Electrical abnormalities are mild.,3. Evidence of chronic left C8/T1 denervation. No active denervation.,4. Mild right lumbosacral radiculopathies. This could not be further localized because of normal EMG testing in the lower extremity muscles.,5. There is evidence of mild sensory carpal tunnel on the right (she has had previous carpal tunnel release).,Results were discussed with the patient. It appears that she has failed conservative therapy and I have recommended to her that she return to Dr. X for his assessment for possible surgery to her C-spine. She will continue with conservative therapy for the mild lumbosacral radiculopathies.

physical medicine - rehab, emg, nerve conduction study, needle emg, paraspinal muscles, radiculopathy, electrical abnormalities, carpal tunnel release, evoked response, lumbosacral radiculopathies, conservative therapy, carpal tunnel, conduction, emg/nerve,

A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.

Physical Medicine - Rehab

EMG/Nerve Conduction Study - 2

HISTORY: , The patient is a 78-year-old right-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg. She was undergoing a spinal epidural injection about a month ago and had worsening of right low back pain, which radiates down into her buttocks and down to posterior aspect of her thigh into her knee. This has required large amounts of opioid analgesics to control. She has been basically bedridden because of this. She was brought into hospital for further investigations.,PHYSICAL EXAMINATION: , On examination, she has positive straight leg rising on the right with severe shooting, radicular type pain with right leg movement. Difficult to assess individual muscles, but strength is largely intact. Sensory examination is symmetric. Deep tendon reflexes reveal hyporeflexia in both patellae, which probably represents a cervical myelopathy from prior cord compression. She has slightly decreased right versus left ankle reflexes. The Babinski's are positive. On nerve conduction studies, motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in lower extremities.,NEEDLE EMG: , Needle EMG was performed on the right leg and lumbosacral paraspinal muscles using a disposable concentric needle. It reveals the spontaneous activity in right peroneus longus and gastrocnemius medialis muscles as well as the right lower lumbosacral paraspinal muscles. There is evidence of denervation in right gastrocnemius medialis muscle.,IMPRESSION: , This electrical study is abnormal. It reveals the following:,1. Inactive right S1 (L5) radiculopathy.,2. There is no evidence of left lower extremity radiculopathy, peripheral neuropathy or entrapment neuropathy.,Results were discussed with the patient and she is scheduled for imaging studies in the next day.

physical medicine - rehab, needle emg, radiculopathy, electrical study, emg, nerve conduction study, cervical spinal stenosis, lumbosacral paraspinal muscles, gastrocnemius medialis muscles, spinal stenosis, post decompression, lumbosacral paraspinal, paraspinal muscles, gastrocnemius medialis, medialis muscles, decompression, emg/nerve, conduction, cervical, spinal, needle, muscles,

1-month-old for a healthy checkup - Well child check

Pediatrics - Neonatal

Well-Child Check - 7

SUBJECTIVE:, This is a 1-month-old who comes in for a healthy checkup. Mom says things are gone very well. He is kind of acting like he has got a little bit of sore throat but no fevers. He is still eating well. He is up to 4 ounces every feeding. He has not been spitting up. Voiding and stooling well.,PAST MEDICAL HISTORY:, Reviewed, very healthy.,CURRENT MEDICATIONS:, None.,ALLERGIES TO MEDICINES:, None.,DIETARY: , His formula fed on Enfamil Lipil. Voiding and stooling well. Growth chart reviewed with Mom.,DEVELOPMENTAL:, He is starting to track with his eyes. He is smiling a little bit, moving hands and feet symmetrically.,PHYSICAL EXAMINATION:, In general well-developed, well-nourished male in no acute distress.,DERMATOLOGIC: Without rash or lesion.,HEENT: Head normocephalic and atraumatic. Anterior fontanel soft and flat. Eyes: Pupils equal, round and reactive to light. Extraocular movements intact. Red reflexes present bilaterally. Does appear to have conjugate gaze. Ears: Tympanic membranes are pink to gray, translucent, neutral position, normal light reflex and mobility. Nares are patent, pink mucosa, moist. Oropharynx clear with pink mucosa, normal moisture.,NECK: Supple without masses.,CHEST: Clear to auscultation and percussion with easy respirations and no accessory muscle use.,CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, heaves or gallops.,ABDOMEN: Soft, nontender, nondistended without hepatosplenomegaly.,GU EXAM: Normal Tanner I male. Testes descended bilaterally. No hernias noted.,EXTREMITIES: Pink and warm. Moving all extremities well. No subluxation of the hips and leg creases appear symmetric.,NEUROLOGIC: Alert, otherwise nonfocal. 2+ deep tendon reflexes at the knees. Fixes and follows appropriately to both voice and face.,ASSESSMENT:, Well child check.,PLAN:,1. Diet, growth and safety discussed.,2. Immunizations discussed and updated with hepatitis B.,3. Return to clinic at two months of age. Call if problems.

Patient had movor vehicle accirdent and may have had a brief loss of consciousness. Shortly thereafter she had some blurred vision, Since that time she has had right low neck pain and left low back pain.

Physical Medicine - Rehab

EMG/Nerve Conduction Study - 7

HISTORY: , The patient is a 34-year-old right-handed female who states her symptoms first started after a motor vehicle accident in September 2005. She may have had a brief loss of consciousness at the time of the accident since shortly thereafter she had some blurred vision, which lasted about a week and then resolved. Since that time she has had right low neck pain and left low back pain. She has been extensively worked up and treated for this. MRI of the C & T spine and LS spine has been normal. She has improved significantly, but still complains of pain. In June of this year she had different symptoms, which she feels are unrelated. She had some chest pain and feeling of tightness in the left arm and leg and face. By the next morning she had numbness around her lips on the left side and encompassing the whole left arm and leg. Symptoms lasted for about two days and then resolved. However, since that time she has had intermittent numbness in the left hand and leg. The face numbness has completely resolved. Symptoms are mild. She denies any previous similar episodes. She denies associated dizziness, vision changes incoordination, weakness, change in gait, or change in bowel or bladder function. There is no associated headache.,Brief examination reveals normal motor examination with no pronator drift and no incoordination. Normal gait. Cranial nerves are intact. Sensory examination reveals normal facial sensation. She has normal and symmetrical light touch, temperature, and pinprick in the upper extremities. In the lower extremities she has a feeling of dysesthesia in the lateral aspect of the left calf into the lateral aspect of the left foot. In this area she has normal light touch and pinprick. She describes it as a strange unusual sensation.,NERVE CONDUCTION STUDIES: , Motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in the left arm and leg.,NEEDLE EMG: , Needle EMG was performed in the left leg, lumbosacral paraspinal, right tibialis anterior, and right upper thoracic paraspinal muscles using a disposable concentric needle. It revealed normal insertional activity, no spontaneous activity, and normal motor unit action potential form in all muscles tested.,IMPRESSION: , This electrical study is normal. There is no evidence for peripheral neuropathy, entrapment neuropathy, plexopathy, or lumbosacral radiculopathy. EMG was also performed in the right upper thoracic paraspinal where she has experienced a lot of pain since the motor vehicle accident. This was normal.,Based on her history of sudden onset of left face, arm, and leg weakness as well as a normal EMG and MRI of her spine I am concerned that she had a central event in June of this year. Symptoms are now very mild, but I have ordered an MRI of the brain with and without contrast and MRA of the head and neck with contrast to further elucidate her symptoms. Once she has the test done she will phone me and further management will be based on the results.

physical medicine - rehab, nerve conduction studies, motor, sensory, distal latencies, evoked response, conduction velocities, needle emg, loss of consciousness, motor vehicle accident, thoracic paraspinal, needle, paraspinal, conduction,

The patient with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.

Physical Medicine - Rehab

EMG/Nerve Conduction Study - 1

HISTORY: , The patient is a 52-year-old right-handed female with longstanding bilateral arm pain, which is predominantly in the medial aspect of her arms and hands as well as left hand numbness, worse at night and after doing repetitive work with her left hand. She denies any weakness. No significant neck pain, change in bowel or bladder symptoms, change in gait, or similar symptoms in the past. She is on Lyrica for the pain, which has been somewhat successful.,Examination reveals positive Phalen's test on the left. Remainder of her neurological examination is normal.,NERVE CONDUCTION STUDIES: ,The left median motor distal latency is prolonged with normal evoked response amplitude and conduction velocity. The left median sensory distal latency is prolonged with an attenuated evoked response amplitude. The right median sensory distal latency is mildly prolonged with a mildly attenuated evoked response amplitude. The right median motor distal latency and evoked response amplitude is normal. Left ulnar motor and sensory and left radial sensory responses are normal. Left median F-wave is normal.,NEEDLE EMG:, Needle EMG was performed on the left arm, right first dorsal interosseous muscle, and bilateral cervical paraspinal muscles. It revealed spontaneous activity in the left abductor pollicis brevis muscle. There is increased insertional activity in the right first dorsal interosseous muscle. Both interosseous muscles showed signs of reinnervation. Left extensor digitorum communis muscle showed evidence of reduced recruitment. Cervical paraspinal muscles were normal.,IMPRESSION: , This electrical study is abnormal. It reveals the following: A left median neuropathy at the wrist consistent with carpal tunnel syndrome. Electrical abnormalities are moderate-to-mild bilateral C8 radiculopathies. This may be an incidental finding.,I have recommended MRI of the spine without contrast and report will be sent to Dr. XYZ. She will follow up with Dr. XYZ with respect to treatment of the above conditions.

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History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. She has had no associated weakness.

Physical Medicine - Rehab

EMG/Nerve Conduction Study

HISTORY:, The patient is a 52-year-old female with a past medical history of diet-controlled diabetes, diffuse arthritis, plantar fasciitis, and muscle cramps who presents with a few-month history of numbness in both big toes and up the lateral aspect of both calves. Symptoms worsened considerable about a month ago. This normally occurs after being on her feet for any length of time. She was started on amitriptyline and this has significantly improved her symptoms. She is almost asymptomatic at present. She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. She has had no associated weakness.,On brief examination, straight leg raising is normal. The patient is obese. There is mild decreased vibration and light touch in distal lower extremities. Strength is full and symmetric. Deep tendon reflexes at the knees are 2+ and symmetric and absent at the ankles.,NERVE CONDUCTION STUDIES: , Bilateral sural sensory responses are absent. Bilateral superficial sensory responses are present, but mildly reduced. The right radial sensory response is normal. The right common peroneal and tibial motor responses are normal. Bilateral H-reflexes are absent.,NEEDLE EMG:, Needle EMG was performed on the right leg and lumbosacral paraspinal muscles and the left tibialis posterior using a concentric disposable needle. It revealed increased insertional activity in the right tibialis posterior muscle with signs of mild chronic denervation in bilateral peroneus longus muscles and the right tibialis posterior muscle. Lumbar paraspinals were attempted, but were too painful to get a good assessment.,IMPRESSION: ,This electrical study is abnormal. It reveals the following:,1. A very mild, purely sensory length-dependent peripheral neuropathy.,2. Mild bilateral L5 nerve root irritation. There is no evidence of active radiculopathy.,Based on the patient's history and exam, her new symptoms are consistent with mild bilateral L5 radiculopathies. Symptoms have almost completely resolved over the last month since starting Elavil. I would recommend MRI of the lumbosacral spine if symptoms return. With respect to the mild neuropathy, this is probably related to her mild glucose intolerance/early diabetes. However, I would recommend a workup for other causes to include the following: Fasting blood sugar, HbA1c, ESR, RPR, TSH, B12, serum protein electrophoresis and Lyme titer.

physical medicine - rehab, nerve conduction studies, needle emg, numbness, tibialis posterior muscle, sensory responses, muscle, tibialis, toes

A 3-month well-child check.

Pediatrics - Neonatal

Well-Child Check - 6

SUBJECTIVE:, Patient presents with Mom and Dad for her 5-year 3-month well-child check. Family has not concerns stating patient has been doing well overall since last visit. Taking in a well-balanced diet consisting of milk and dairy products, fruits, vegetables, proteins and grains with minimal junk food and snack food. No behavioral concerns. Gets along well with peers as well as adults. Is excited to start kindergarten this upcoming school year. Does attend daycare. Normal voiding and stooling pattern. No concerns with hearing or vision. Sees the dentist regularly. Growth and development: Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development. See Denver II form in the chart.,ALLERGIES:, None.,MEDICATIONS: , None.,FAMILY SOCIAL HISTORY:, Unchanged since last checkup. Lives at home with mother, father and sibling. No smoking in the home.,REVIEW OF SYSTEMS:, As per HPI; otherwise negative.,OBJECTIVE:,Vital Signs: Weight 43 pounds. Height 42-1/4 inches. Temperature 97.7. Blood pressure 90/64.,General: Well-developed, well-nourished, cooperative, alert and interactive 5-year -3month-old white female in no acute distress.,HEENT: Atraumatic, normocephalic. Pupils equal, round and reactive. Sclerae clear. Red reflex present bilaterally. Extraocular muscles intact. TMs clear bilaterally. Oropharynx: Mucous membranes moist and pink. Good dentition.,Neck: Supple, no lymphadenopathy.,Chest: Clear to auscultation bilaterally. No wheeze or crackles. Good air exchange.,Cardiovascular: Regular rate and rhythm. No murmur. Good pulses bilaterally.,Abdomen: Soft, nontender. Nondistended. Positive bowel sounds. No masses or organomegaly.,GU: Tanner I female genitalia. Femoral pulses equal bilaterally. No rash.,Extremities: Full range of motion. No cyanosis, clubbing or edema.,Back: Straight. No scoliosis.,Integument: Warm, dry and pink without lesions.,Neurological: Alert. Good muscle tone and strength. Cranial nerves II-XII grossly intact. DTRs 2+/4+ bilaterally.,ASSESSMENT/PLAN:,1. Well 5-year 3-month-old white female.,2. Anticipatory guidance for growth and diet development and safety issues as well as immunizations. Will receive MMR, DTaP and IPV today. Discussed risks and benefits as well as possible side effects and symptomatic treatment. Gave 5-year well-child check handout to mom. Completed school pre-participation physical. Copy in the chart. Completed vision and hearing screening. Reviewed results with family.,3. Follow up in one year for next well-child check or as needed for acute care.

pediatrics - neonatal, denver ii, child check, mom, diet, growth, denver, family, development, child, check,

1-year well child check.

Pediatrics - Neonatal

Well-Child Check - 4

SUBJECTIVE:, The patient presents with Mom and Dad for her 1-year well child check. The family has no concerns stating the patient has been doing well overall since the last visit taking in a well-balanced diet consisting of formula transitioning to whole milk, fruits, vegetables, proteins and grains. Normal voiding and stooling pattern. No concerns with hearing or vision. Growth and development: Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction as well as speech and language development. See Denver II form in the chart.,PAST MEDICAL HISTORY:, Allergies: None. Medications: Tylenol this morning in preparation for vaccines and a multivitamin daily.,FAMILY SOCIAL HISTORY:, Unchanged since last checkup.,REVIEW OF SYSTEMS:, As per HPI; otherwise negative.,OBJECTIVE:, Weight 24 pounds 1 ounce. Height 30 inches. Head circumference 46.5 cm. Temperature afebrile.,General: A well-developed, well-nourished, cooperative, alert and interactive 1-year-old white female smiling, happy and drooling.,HEENT: Atraumatic, normocephalic. Anterior fontanel is closed. Pupils equally round and reactive. Sclerae are clear. Red reflex present bilaterally. Extraocular muscles intact. TMs are clear bilaterally. Oropharynx: Mucous membranes are moist and pink. Good dentition. Drooling and chewing with teething behavior today. Neck is supple. No lymphadenopathy.,Chest: Clear to auscultation bilaterally. No wheeze. No crackles. Good air exchange.,Cardiovascular: Regular rate and rhythm. No murmur. Good pulses bilaterally.,Abdomen: Soft, nontender. Nondistended. Positive bowel sounds. No mass. No organomegaly.,Genitourinary: Tanner I female genitalia. Femoral pulses equal bilaterally. No rash.,Extremities: Full range of motion. No cyanosis, clubbing or edema. Negative Ortolani and Barlow maneuver.,Back: Straight. No scoliosis.,Integument: Warm, dry and pink without lesions.,Neurological: Alert. Good muscle tone and strength. Cranial nerves II through XII are grossly intact.,ASSESSMENT AND PLAN:,1. Well 1-year-old white female.,2. Anticipatory guidance. Reviewed growth, diet development and safety issues as well as immunizations. Will receive Pediarix and HIB today. Discussed risks and benefits as well as possible side effects and symptomatic treatment. Will also obtain a screening CBC and lead level today via fingerstick and call the family with results as they become available. Gave 1-year well child checkup handout to Mom and Dad.,3. Follow up for the 15-month well child check or as needed for acute care.

pediatrics - neonatal, well child check, denver ii, child check, checkup, check, child,

A well-child check with concern of some spitting up quite a bit.

Pediatrics - Neonatal

Well-Child Check - 5

SUBJECTIVE:, The patient presents with Mom for a first visit to our office for a well-child check with concern of some spitting up quite a bit. Mom wants to make sure that this is normal. The patient is nursing well every two to three hours. She does have some spitting up on occasion. It has happened two or three times with some curdled appearance x 1. No projectile in nature, nonbilious. Normal voiding and stooling pattern. Growth and Development: Denver II normal, passing all developmental milestones per age. See Denver II form in the chart.,PAST MEDICAL HISTORY:, Mom reports uncomplicated pregnancy with prenatal care provided by Dr. XYZ in Wichita, Kansas. Delivery after induction secondary to postdate at St. Joseph Hospital. Infant delivered by SVD with birth weight of 6 pounds 13 ounce. Length of 19 inches. Did well after delivery and dismissed to home with Mom. Received hepatitis B #1 prior to dismissal. No other hospitalizations. No surgeries. No known medical allergies. No medications. Mom has tried Mylicon drops on occasion.,FAMILY HISTORY: , Significant for cardiovascular disease, hypertension, diabetes mellitus and thyroid problems in maternal and paternal grandparents. Healthy Mother, Father. There is also history of breast, colon and ovarian cancer on the maternal side of the family, her grandmother who is present at visit today. There is history of asthma in the patient's father.,SOCIAL HISTORY:, The patient lives at home with 23-year-old mother, who is a homemaker and 24-year-old father, John, who is a supervisor at Excel. The family lives in Bentley, Kansas. No smoking in the home. Family does have one pet cat.,REVIEW OF SYSTEMS:, As per HPI, otherwise, negative.,OBJECTIVE:, Weight: 7 pounds 12 ounces. Height: 21 inches. Head circumference: 35 cm. Temperature: 97.2 degrees.,General: Well-developed, well-nourished, cooperative, alert, interactive 2-week-old white female in no acute distress.,HEENT: Atraumatic, normocephalic. Anterior fontanel is soft and flat. Pupils are equal, round and reactive. Sclerae clear. Red reflexes present bilaterally. TMs are clear bilaterally. Oropharynx: Mucous membranes are moist and pink.,Neck: Supple, no lymphadenopathy.,Chest: Clear to auscultation bilaterally. No wheeze or crackles. Good air exchange.,Cardiovascular: Regular rate and rhythm. No murmur. Good pulses bilaterally.,Abdomen: Soft, nontender, nondistended. Positive bowel sounds. No mass nor organomegaly.,Genitourinary: Tanner I female genitalia. Femoral pulses are equal bilaterally. No rash.,Extremities: Full range of motion. No cyanosis, clubbing or edema. Negative Ortolani or Barlow maneuver.,Back: Straight. No scoliosis.,Integument: Warm, dry and pink without lesions.,Neurologic: Alert. Good muscle tone and strength.,ASSESSMENT/PLAN:,1. Well 2-week-old white female.,2. Anticipatory guidelines for growth, diet, development, safety issues as well as immunizations and visitation schedule. Gave 2-week well-child check handout and American Academy of Pediatrics book Birth to 5 years to Mom and family.,3. Call the office or on-call physician if the patient has fever, feeding problems or breathing problems. Otherwise plan to recheck at 1-month of age.

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A 9-month well-child check.

Pediatrics - Neonatal

Well-Child Check - 2

SUBJECTIVE:, This 9-month-old Hispanic male comes in today for a 9-month well-child check. They are visiting from Texas until the end of April 2004. Mom says he has been doing well since last seen. He is up-to-date on his immunizations per her report. She notes that he has developed some bumps on his chest that have been there for about a week. Two weeks ago he was diagnosed with left otitis media and was treated with antibiotics. Mom says he has been doing fine since then. She has no concerns about him.,PAST MEDICAL HISTORY:, Significant for term vaginal delivery without complications.,MEDICATIONS: , None.,ALLERGIES:, None.,SOCIAL HISTORY:, Lives with parents. There is no smoking in the household.,REVIEW OF SYSTEMS:, Developmentally is appropriate. No fevers. No other rashes. No cough or congestion. No vomiting or diarrhea. Eating normally.,OBJECTIVE:, His weight is 16 pounds 9 ounces. Height is 26-1/4 inches. Head circumference is 44.75 cm. Pulse is 124. Respirations are 26. Temperature is 98.1 degrees. Generally, this is a well-developed, well-nourished, 9-month-old male, who is active, alert, and playful in no acute distress.,HEENT: Normocephalic, atraumatic. Anterior fontanel is soft and flat. Tympanic membranes are clear bilaterally. Conjunctivae are clear. Pupils equal, round and reactive to light. Nares without turbinate edema. Oropharynx is nonerythematous.,NECK: Supple, without lymphadenopathy, thyromegaly, carotid bruit, or JVD.,CHEST: Clear to auscultation bilaterally.,CARDIOVASCULAR: Regular rate and rhythm, without murmur.,ABDOMEN: Soft, nontender, nondistended, normoactive bowel sounds. No masses or organomegaly to palpation.,GU: Normal male external genitalia. Uncircumcised penis. Bilaterally descended testes. Femoral pulses 2/4.,EXTREMITIES: Moves all four extremities equally. Minimal tibial torsion.,SKIN: Without abnormalities other than five small molluscum contagiosum with umbilical herniation noted on chest.,ASSESSMENT/PLAN:,1. Well-child check. Is doing well. Will recommend a followup well-child check at 1 year of age and immunizations at that time. Discussed safety issues, including poisons, choking hazards, pet safety, appropriate nutrition with Mom. She is given a parenting guide handout.,2. Molluscum contagiosum. Described the viral etiology of these. Told her they are self limited, and we will continue to monitor at this time.,3. Left otitis media, resolved. Continue to monitor. We will plan on following up in three months if they are still in the area, or p.r.n.

pediatrics - neonatal, well-child check, otitis media, molluscum contagiosum, immunizations, developed, atraumatic, child,

Bilateral tympanostomy with myringotomy tube placement. The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy.

Pediatrics - Neonatal

Tympanostomy & Myringotomy Tube Placement

PREOPERATIVE DIAGNOSES:,1. Chronic otitis media with effusion.,2. Conductive hearing loss.,POSTOPERATIVE DIAGNOSES:,1. Chronic otitis media with effusion.,2. Conductive hearing loss.,PROCEDURE PERFORMED: , Bilateral tympanostomy with myringotomy tube placement _______ split tube 1.0 mm.,ANESTHESIA: ,Total IV general mask airway.,ESTIMATED BLOOD LOSS: ,None.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:, The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy. After risks, complications, consequences, and questions were addressed with the family, a written consent was obtained for the procedure.,PROCEDURE:, The patient was brought to the operative suite by Anesthesia. The patient was placed on the operating table in supine position. After this, the patient was then placed under general mask airway and the patient's head was then turned to the left.,The Zeiss operative microscope and medium-sized ear speculum were placed and the cerumen from the external auditory canals were removed with a cerumen loop to #5 suction. After this, the tympanic membrane is then brought into direct visualization with no signs of any gross retracted pockets or cholesteatoma. A myringotomy incision was then made within the posterior inferior quadrant and the middle ear was then suctioned with a #5 suction demonstrating dry contents. A _____ split tube 1.0 mm was then placed in the myringotomy incision utilizing a alligator forcep. Cortisporin Otic drops were placed followed by cotton balls. Attention was then drawn to the left ear with the head turned to the right and the medium sized ear speculum placed. The external auditory canal was removed off of its cerumen with a #5 suction which led to the direct visualization of the tympanic membrane. The tympanic membrane appeared with no signs of retraction pockets, cholesteatoma or air fluid levels. A myringotomy incision was then made within the posterior inferior quadrant with a myringotomy blade after which a _________ split tube 1.0 mm was then placed with an alligator forcep. After this, the patient had Cortisporin Otic drops followed by cotton balls placed. The patient was then turned back to Anesthesia and transferred to recovery room in stable condition and tolerated the procedure very well. The patient will be followed up approximately in one week and was sent home with a prescription for Ciloxan ear drops to be used as directed and with instructions not to get any water in the ears.

pediatrics - neonatal, chronic otitis media with effusion, conductive hearing loss, bilateral tympanostomy, myringotomy tube placement, cortisporin otic drops, otitis media, tympanostomy, tympanic, membrane, otitis, media, effusion, conductive, hearing, ear, tube, myringotomy

Viral upper respiratory infection (URI) with sinus and eustachian congestion. Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.

Pediatrics - Neonatal

URI & Eustachian Congestion

HISTORY OF PRESENT ILLNESS: , Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. She has had a dry cough and a fever as high as 100, but this has not been since the first day. She denies any vomiting or diarrhea. She did try some Tylenol Cough and Cold followed by Tylenol Cough and Cold Severe, but she does not think that this has helped.,FAMILY HISTORY: , The patient's younger sister has recently had respiratory infection complicated by pneumonia and otitis media.,REVIEW OF SYSTEMS:, The patient does note some pressure in her sinuses. She denies any skin rash.,SOCIAL HISTORY:, Patient lives with her mother, who is here with her.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS: Temp is 38.1, pulse is elevated at 101, other vital signs are all within normal limits. Room air oximetry is 100%.,GENERAL: Patient is a healthy-appearing, white female, adolescent who is sitting on the stretcher, and appears only mildly ill.,HEENT: Head is normocephalic, atraumatic. Pharynx shows no erythema, tonsillar edema, or exudate. Both TMs are easily visualized and are clear with good light reflex and no erythema. Sinuses do show some mild tenderness to percussion.,NECK: No meningismus or enlarged anterior/posterior cervical lymph nodes.,HEART: Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS: Clear without rales, rhonchi, or wheezes.,SKIN: No rash.,ASSESSMENT:, Viral upper respiratory infection (URI) with sinus and eustachian congestion.,PLAN:, I did educate the patient about her problem and urged her to switch to Advil Cold & Sinus for the next three to five days for better control of her sinus and eustachian discomfort. I did urge her to use Afrin nasal spray for the next three to five days to further decongest her sinuses. If she is unimproved in five days, follow up with her PCP for re-exam.

pediatrics - neonatal, upper respiratory infection, eustachian congestion, erythema, uri, nasal, cough, eustachian, respiratory, sinus, congestion, infection, tonsillar

Thyroid mass diagnosed as papillary carcinoma. The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.

Pediatrics - Neonatal

Thyroid Mass Consult

REASON FOR CONSULTATION: , Thyroid mass diagnosed as papillary carcinoma.,HISTORY OF PRESENT ILLNESS: ,The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now been proven to be papillary carcinoma on fine needle aspiration biopsy. The patient's parents relayed that they first noted a relatively small but noticeable mass in the middle portion of her thyroid gland about 2004. An ultrasound examination had reportedly been done in the past and the mass is being observed. When it began to enlarge recently, she was referred to the Pediatric Endocrinology Department and had an evaluation there. The patient was referred for fine needle aspiration and the reports recently returned a diagnosis of papillary thyroid carcinoma. The patient has not had any hoarseness, difficulty swallowing, or any symptoms of endocrine dysfunction. She has no weight changes consistent with either hyper or hypothyroidism. There is no family history of thyroid cancer in her family. She has no notable discomfort with this lesion. There have been no skin changes. Historically, she does not have a history of any prior head and neck radiation or treatment of any unusual endocrinopathy.,PAST MEDICAL HISTORY:, Essentially unremarkable. The patient has never been hospitalized in the past for any major illnesses. She has had no prior surgical procedures.,IMMUNIZATIONS: , Current and up to date.,ALLERGIES: , She has no known drug allergies.,CURRENT MEDICATIONS: ,Currently taking no routine medications. She describes her pain level currently as zero.,FAMILY HISTORY: , There is no significant family history, although the patient's father does note that his mother had a thyroid surgery at some point in life, but it was not known whether this was for cancer, but he suspects it might have been for goiter. This was done in Tijuana. His mom is from central portion of Mexico. There is no family history of multiple endocrine neoplasia syndromes.,SOCIAL HISTORY: ,The patient is a junior at Hoover High School. She lives with her mom in Fresno.,REVIEW OF SYSTEMS: , A careful 12-system review was completely normal except for the problems related to the thyroid mass.,PHYSICAL EXAMINATION:,GENERAL: The patient is a 55.7 kg, nondysmorphic, quiet, and perhaps slightly apprehensive young lady, who was in no acute distress. She was alert and oriented x3 and had an appropriate affect.,HEENT: The head and neck examination is most significant. There is mild amount of facial acne. The patient's head, eyes, ears, nose, and throat appeared to be grossly normal.,NECK: There is a slightly visible midline bulge in the region of the thyroid isthmus. A firm nodule is present there, and there is also some nodularity in the right lobe of the thyroid. This mass is relatively hard, slightly fixed, but not tethered to surrounding tissues, skin, or muscles that I can determine. There are some shotty adenopathy in the area. No supraclavicular nodes were noted.,CHEST: Excursions are symmetric with good air entry.,LUNGS: Clear.,CARDIOVASCULAR: Normal. There is no tachycardia or murmur noted.,ABDOMEN: Benign.,EXTREMITIES: Extremities are anatomically correct with full range of motion.,GENITOURINARY: External genitourinary exam was deferred at this time and can be performed later during anesthesia. This is same as too for her rectal examination.,SKIN: There is no acute rash, purpura, or petechiae.,NEUROLOGIC: Normal and no focal deficits. Her voice is strong and clear. There is no evidence of dysphonia or vocal cord malfunction.,DIAGNOSTIC STUDIES: , I reviewed laboratory data from the Diagnostics Lab, which included a mild abnormality in the AST at 11, which is slightly lower than the normal range. T4 and TSH levels were recorded as normal. Free thyroxine was normal, and the serum pregnancy test was negative. There was no level of thyroglobulin recorded on this. A urinalysis and comprehensive metabolic panel was unremarkable. A chest x-ray was obtained, which I personally reviewed. There is a diffuse pattern of tiny nodules in both lungs typical of miliary metastatic disease that is often seen in patients with metastatic thyroid carcinoma.,IMPRESSION/PLAN: , The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis and is unfortunate in that it generally means a more advanced stage of disease. I spent approximately 30 minutes with the patient and her family today discussing the surgical aspects of the treatment of this disease. During this time, we talked about performing a total thyroidectomy to eradicate as much of the native thyroid tissue and remove the primary source of the cancer in anticipation of radioactive iodine therapy. We talked about sentinel node dissection, and we spent significant amount of time talking about the possibility of hypoparathyroidism if all four of the parathyroid glands were damaged during this operation. We also discussed the recurrent laryngeal and external laryngeal branches of the nerve supplying the vocal cord function and how they cane be damaged during the thyroidectomy as well. I answered as many of the family's questions as they could mount during this stressful time with this recent information supplied to them. I also did talk to them about the chest x-ray pattern, which was complete __________ as the film was just on the day prior to my clinic visit. This will have some impact on the postoperative adjunctive therapy. The radiologist commented about the risk of pulmonary fibrosis and the use of radioactive iodine in this situation, but it seems likely that is going to be necessary to attempt to treat this disease in the patient's case. I did discuss with them the possibility of having to take large doses of calcium and vitamin D in the event of hypoparathyroidism if that does happen, and we also talked about possibly sparing parathyroid tissue and reimplanting it in a muscle belly either in the neck or forearm if that becomes a necessity. All of the family's questions have been answered. This is a very anxious and anxiety provoking time in the family. I have made every effort to get the patient under schedule within the next 48 hours to have this operation done. We are tentatively planning on proceeding this upcoming Friday afternoon with total thyroidectomy.

A two week well-child check.

Pediatrics - Neonatal

Well-Child Check - 3

SUBJECTIVE:, Patient presents with Mom for first visit to the office for two week well-child check. Mom has no concerns stating that patient has been doing well overall since dismissal from the hospital. Nursing every two to three hours with normal voiding and stooling pattern. She does have a little bit of some gas and Mom has been using Mylicon drops which are helpful. She is burping well, hiccuping, sneezing and burping appropriately. Growth and development: Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development. See Denver II form in the chart.,PAST MEDICAL HISTORY:, Mom reports uncomplicated pregnancy and delivery with prenatal care provided by Dr. Hoing. Delivery at Newton Medical Center at 39 weeks, 5 days gestation. Birth weight was 3160 g. Length 49.5 cm. Head circumference 33 cm. Infant was delivered to 22-year-old A-positive mom who is G1 P0, now P1. Infant did well after delivery and was dismissed to home with Mom the following day. No other hospitalizations. No surgeries.,ALLERGIES: , None.,MEDICATIONS:, Gas drops p.r.n.,FAMILY HISTORY: , Significant for cardiovascular problems and hypertension as well as diabetes mellitus on the maternal side of the family. History of cancer and asthma on the paternal side of the family. Mom unsure of what type of cancer.,SOCIAL HISTORY:, Patient lives at home with 22-year-old mother Aubrey Mizel and her parents Bud and Sue Mizel in Newton, Kansas. Father of the baby, Shivanka Silva age 30, is a full-time student at WSU in Wichita, Kansas and does help with care of the newborn. There is no smoking in the home. Family does have one pet dog in home.,REVIEW OF SYSTEMS:, As per HPI; otherwise negative.,OBJECTIVE:,Vital Signs: Weight 7 pounds, 1-1/5 ounces. Height 21 inches. Head circumference 35.8 cm. Temperature 97.7.,General: Well-developed, well-nourished, cooperative, alert and interactive 2-week-old female in no acute distress.,HEENT: Atraumatic, normocephalic. Anterior fontanel soft and flat. Pupils equal, round and reactive. Sclerae clear. Red reflex present bilaterally. TMs clear bilaterally. Oropharynx: Mucous membranes moist and pink.,Neck: Supple, no lymphadenopathy.,Chest: Clear to auscultation bilaterally. No wheeze or crackles. Good air exchange.,Cardiovascular: Regular rate and rhythm. No murmur. Good pulses bilaterally.,Abdomen: Soft, nontender. Nondistended. Positive bowel sounds. No masses or organomegaly. Healing umbilicus.,GU: Tanner I female genitalia. Femoral pulses equal bilaterally. No rash.,Extremities: Full range of motion. No cyanosis, clubbing or edema. Negative Ortolani and Barlow maneuver.,Back: Straight. No scoliosis. Some increased pigment over the sacrum.,Integument: Warm, dry and pink without lesions.,Neurological: Alert. Good muscle tone and strength.,ASSESSMENT/PLAN:,1. Well 2-week-old mixed race Caucasian and Middle Eastern descent female.,2. Anticipatory guidance for growth and diet development and safety issues as well as immunizations and visitation schedule. Gave two week well-child check handout to Mom. Plan follow up for the one month well-child check or as needed for acute care. Mom will call for feeding problems, breathing problems or fever. Otherwise, plan to see at one month.

Well child - Left lacrimal duct stenosis

Pediatrics - Neonatal

Well-Child Check - 1

CHIEF COMPLAINT:, Well-child check.,HISTORY OF PRESENT ILLNESS:, This is a 12-month-old female here with her mother for a well-child check. Mother states she has been doing well. She is concerned about drainage from her left eye. Mother states she was diagnosed with a blocked tear duct on that side shortly after birth, and normally she has crusted secretions every morning. She states it is worse when the child gets a cold. She has been using massaging when she can remember to do so. The patient is drinking whole milk without problems. She is using solid foods three times a day. She sleeps well without problems. Her bowel movements are regular without problems. She does not attend daycare.,DEVELOPMENTAL ASSESSMENT:, Social: She can feed herself with fingers. She is comforted by parent’s touch. She is able to separate and explore. Fine motor: She scribbles. She has a pincer grasp. She can drink from a cup. Language: She says dada. She says one to two other words and she indicates her wants. Gross motor: She can stand alone. She cruises. She walks alone. She stoops and recovers.,PHYSICAL EXAMINATION:,General: She is alert, in no distress.,Vital signs: Weight: 25th percentile. Height: 25th percentile. Head circumference: 50th percentile.,HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Left eye with watery secretions and crusted lashes. Conjunctiva is clear. TMs are clear bilaterally. Nares are patent. Mild nasal congestion present. Oropharynx is clear.,Neck: Supple.,Lungs: Clear to auscultation.,Heart: Regular. No murmur.,Abdomen: Soft. Positive bowel sounds. No masses. No hepatosplenomegaly.,GU: Female external genitalia.,Extremities: Symmetrical. Femoral pulses are 2+ bilaterally. Full range of motion of all extremities.,Neurologic: Grossly intact.,Skin: Normal turgor.,Testing: Hearing and vision assessments grossly normal.,ASSESSMENT:,1. Well child.,2. Left lacrimal duct stenosis.,PLAN:, MMR #1 and Varivax #1 today. VIS statements given to Mother after discussion. Evaluation and treatment as needed with Dr. XYZ with respect to the blocked tear duct. Anticipatory guidance for age. She is to return to the office in three months.

pediatrics - neonatal, well-child check, drainage, eye, lacrimal duct stenosis, lacrimal duct, mmr, varivax, vis statements, tear duct, lacrimal, percentile, mother, child,

The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis.

Pediatrics - Neonatal

Supraventricular Tachycardia - Consult

HISTORY: , The patient is a 4-month-old who presented today with supraventricular tachycardia and persistent cyanosis. The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised. Parents; however, did note the patient to be quite dusky since the time of her birth; however, were reassured by the pediatrician that this was normal. The patient demonstrates good interval weight gain and only today presented to an outside hospital with significant duskiness, some irritability, and rapid heart rate. Parents do state that she does appear to breathe rapidly, tires somewhat with the feeding with increased respiratory effort and diaphoresis. The patient is exclusively breast fed and feeding approximately 2 hours. Upon arrival at Children's Hospital, the patient was found to be in a narrow complex tachycardia with the rate in excess of 258 beats per minute with a successful cardioversion to sinus rhythm with adenosine. The electrocardiogram following the cardioversion had demonstrated normal sinus rhythm with a right atrial enlargement, northwest axis, and poor R-wave progression, possible right ventricular hypertrophy.,FAMILY HISTORY:, Family history is remarkable for an older sibling found to have a small ventricular septal defect that is spontaneously closed.,REVIEW OF SYSTEMS: , A complete review of systems including neurologic, respiratory, gastrointestinal, genitourinary are otherwise negative.,PHYSICAL EXAMINATION:,GENERAL: Physical examination that showed a sedated, acyanotic infant who is in no acute distress.,VITAL SIGNS: Heart rate of 170, respiratory rate of 65, saturation, it is nasal cannula oxygen of 74% with a prostaglandin infusion at 0.5 mcg/kg/minute.,HEENT: Normocephalic with no bruit detected. She had symmetric shallow breath sounds clear to auscultation. She had full symmetrical pulses.,HEART: There is normoactive precordium without a thrill. There is normal S1, single loud S2, and a 2/6 continuous shunt type of murmur could be appreciated at the left upper sternal border.,ABDOMEN: Soft. Liver edge is palpated at 3 cm below the costal margin and no masses or bruits detected.,X-RAYS:, Review of the chest x-ray demonstrated a normal situs, normal heart size, and adequate pulmonary vascular markings. There is a prominent thymus. An echocardiogram demonstrated significant cyanotic congenital heart disease consisting of normal situs, a left superior vena cava draining into the left atrium, a criss-cross heart with atrioventricular discordance of the right atrium draining through the mitral valve into the left-sided morphologic left ventricle. The left atrium drained through the tricuspid valve into a right-sided morphologic right ventricle. There is a large inlet ventricular septal defect as pulmonary atresia. The aorta was malopposed arising from the right ventricle in the anterior position with the left aortic arch. There was a small vertical ductus as a sole source of pulmonary artery blood flow. The central pulmonary arteries appeared confluent although small measuring 3 mm in the diameter. Biventricular function is well maintained.,FINAL IMPRESSION: , The patient has significant cyanotic congenital heart disease physiologically with a single ventricle physiology and ductal-dependent pulmonary blood flow and the incidental supraventricular tachycardia now in the sinus rhythm with adequate ventricular function. The saturations are now also adequate on prostaglandin E1.,RECOMMENDATION: , My recommendation is that the patient be continued on prostaglandin E1. The patient's case was presented to the cardiothoracic surgical consultant, Dr. X. The patient will require further echocardiographic study in the morning to further delineate the pulmonary artery anatomy and confirm the central confluence. A consideration will be made for diagnostic cardiac catheterization to fully delineate the pulmonary artery anatomy prior to surgical intervention. The patient will require some form of systemic to pulmonary shunt, modified pelvic shunt or central shunt as a durable source of pulmonary blood flow. Further surgical repair was continued on the size and location of the ventricular septal defect over the course of the time for consideration of possible Rastelli procedure. The current recommendation is for proceeding with a central shunt and followed then by bilateral bidirectional Glenn shunt with then consideration for a septation when the patient is 1 to 2 years of age. These findings and recommendations were reviewed with the parents via a Spanish interpreter.

pediatrics - neonatal, congenital heart disease, cyanotic, ductal-dependent, pulmonary blood flow, ventricular septal defect, blood flow, supraventricular tachycardia, tachycardia, ventricular, supraventricular, shunt, heart, pulmonary,

Healthy checkups and sports physical - 12 years old - Healthy Tanner III male, developing normally.

Pediatrics - Neonatal

Sports Physical - 3

SUBJECTIVE:, This is a 12-year-old male who comes in for healthy checkups and sports physical. No major concerns today. He is little bit congested at times. He has been told he is allergic to grasses. They have done over-the-counter Claritin and that seems to help but he is always sniffling mother reports. He has also got some dryness on his face as far as the skin and was wondering what cream he could put on.,PAST MEDICAL HISTORY:, Otherwise, reviewed. Very healthy.,CURRENT MEDICATIONS:, Claritin p.r.n.,ALLERGIES TO MEDICINES:, None.,FAMILY SOCIAL HISTORY:, Everyone else is healthy at home currently.,DIETARY:, He is on whole milk and does a variety of foods. Growth chart is reviewed with mother. Voids and stools well.,DEVELOPMENTAL:, He is in seventh grade and going out for cross-country and track. He is supposed to be wearing glasses, is not today. We did not test his vision because he recently saw the eye doctor though we did discuss the need for him to wear glasses with mother. His hearing was normal today and no concerns with speech.,PHYSICAL EXAMINATION:,General: A well-developed, well-nourished male in no acute distress.,Dermatologic: Without rash or lesion.,HEENT: Head normocephalic and atraumatic. Eyes: Pupils equal, round and reactive to light. Extraocular movements intact. Red reflexes are present bilaterally. Optic discs are sharp with normal vasculature. Ears: Tympanic membranes are gray, translucent with normal light reflex. Nares are very congested. Turbinates swollen and boggy.,Neck: Supple without masses.,Chest: Clear to auscultation and percussion, easy respirations. No accessory muscle use.,Cardiovascular: Regular rate and rhythm without murmurs, rubs, heaves or gallops.,Back: Symmetric with no scoliosis or kyphosis noted. Normal flexibility. Femoral pulses 2+ and symmetric.,Abdomen: Soft, nontender, nondistended without hepatosplenomegaly.,GU Exam: Normal Tanner III male. Testes descended bilaterally. No abnormal rash, discharge, or scars.,Extremities: Pink and warm. Moves all extremities well with normal function and strength in the arms and legs. Normal balance, station, and gait. Normal speech.,Neurologic: Nonfocal with normal speech, station, gait, and balance.,ASSESSMENT:, Healthy Tanner III male, developing normally.,PLAN:,1. Diet, growth, safety, drugs, violence, and social competence all discussed.,2. Immunizations reviewed.,3. We will place him on Clarinex 5 mg once daily, some Rhinocort-AQ nasal spray one spray each nostril once daily and otherwise discussed the importance of him wearing glasses.,4. Return to clinic p.r.n. and at two to three years for a physical, otherwise return p.r.n.

Single frontal view of the chest. Respiratory distress. The patient has a history of malrotation.

Pediatrics - Neonatal

Single Frontal View - Chest - Pediatric

EXAM:, Single frontal view of the chest.,HISTORY:, Respiratory distress. The patient has a history of malrotation. The patient is back for a re-anastomosis of the bowel with no acute distress.,TECHNIQUE:, Single frontal view of the chest was evaluated and correlated with the prior film dated MM/DD/YY.,FINDINGS:, A single frontal view of the chest was evaluated. It reveals interval placement of an ET tube and an NG tube. ET tube is midway between the patient's thoracic inlet and carina. NG tube courses with the distal tip in the left upper quadrant beneath the left hemidiaphragm. There is no evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions. The mediastinum seen was slightly prominent; however, this may be secondary to thymus and/or technique. There is a slight increase seen with regards to the central pulmonary vessels. Again, this may represent a minimal amount of pulmonary vascular congestion. There is paucity of bowel gas seen in the upper abdomen. The osseous thorax appears to be grossly intact and symmetrical. Slightly low lung volumes, however, this may be secondary to the film being taken on the expiratory phase of respiration.,IMPRESSION:,1. No evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions.,2. Slight prominence to the mediastinum which may be secondary to thymus and/or technique.,3. Slight prominence of some of the central pulmonary vasculature which may represent a minimal amount of vascular congestion.

pediatrics - neonatal, malrotation, consolidation, pneumothoraces, single frontal view, respiratory distress, vascular congestion, frontal view, effusions, mediastinum, vascular, congestion, respiratory, anastomosis, pulmonary, single, frontal, chest

Sports physical with normal growth and development.

Pediatrics - Neonatal

Sports Physical - 1

HISTORY: , This child is seen for a sports physical.,NUTRITIONAL HISTORY:, She takes meats, vegetables, and fruits. Eats well. Has may be 1 to 2 cups a day of milk. Her calcium intake could be better. She does not drink that much pop but she likes koolaid. Her stools are normal. Brushes her teeth. Sees a dentist.,DEVELOPMENTAL HISTORY: , She did well in school last year. Hearing and vision, no problems. She wears corrective lenses. She will be in 8th grade and involved in volleyball, basketball, and she will be moving to Texas. She did go to Burton this last year. She also plays clarinet, and will be involved also in cheerleading. She likes to swim in the summer time. Her menarche was January 2004. It occurs every 7 weeks. No particular problems at this time.,OTHER ACTIVITIES: ,TV time about 2 to 3 hours a day. She does not use drugs, alcohol, or smoke, and denies sexual activity.,MEDICATIONS:, Advair 250/50 b.i.d., Flonase b.i.d., Allegra q.d. 120 mg, Xopenex and albuterol p.r.n.,ALLERGIES:, No known drug allergies.,OBJECTIVE:,Vital Signs: Blood pressure: 98/60. Temperature: 96.6 tympanic. Weight: 107 pounds, which places her at approximately the 60th percentile for weight and the height is about 80th percentile at 64-1/2 inches. Her body mass index is 18.1, which is 40th percentile. Pulse: 68.,HEENT: Normocephalic. Fundi benign. Pupils are equal and reactive to light and accommodation. Conjunctivae were non-injected. Her pupils were equal, and reactive to light and accommodation. No strabismus. She wears glasses. Her vision was 20/20 in both eyes. TMs are bilaterally clear. Nonerythematous. Hearing in the ears, she was able to pass 40 decibel to 30 decibel. With the right ear, she has some problems, but the left ear she passed. Throat was clear. Nonerythematous. Good dentition.,Neck: Supple. Thyroid normal sized. No increased lymphadenopathy in the submandibular nodes and no axillary nodes.,Respiratory: Clear. No wheezes and no crackles. No tachypnea and no retractions.,Cardiovascular: Regular rate and rhythm. S1 and S2 normal. No murmur.,Abdomen: Soft. No organomegaly and no masses. No hepatosplenomegaly.,GU: Normal female genitalia. Tanner stage III in breast and pubic hair development and she was given a breast exam. Negative for any masses.,Skin: Without rash.,Extremities: Deep tendon reflexes 2+/4+ bilaterally and equal.,Neurological: Romberg negative.,Back: No scoliosis.,She had good circumduction at the shoulder joints and duck walk is normal.,ASSESSMENT:, Sports physical with normal growth and development.,PLAN:, If problems continue, she will need to have her hearing rechecked. Hopefully in the school, there will be a screening mat. She received her first hepatitis A vaccine and she needs to have a booster in 6 to 12 months. We reviewed her immunizations for tetanus and her last acellular DPT was 11/25/1996. When she goes to Texas, Mom has an appointment already to see an allergist but she needs to find a primary care physician and we will ask for record release. We talked about her menarche. Recommended the exam of the breast regularly. Talked about other anticipatory guidance including sunscreen, use of seat belts, and drugs, alcohol, and smoking, and sexual activity and avoidance at her age and to continue on her present medications. She also has had problems with her ankles in the past. She had no limitation here, but we gave her some ankle strengthening exercise handouts while she was in the office.

Consult and Spinal fluid evaluation in a 15-day-old

Pediatrics - Neonatal

Spinal fluid evaluation

HISTORY: ,This 15-day-old female presents to Children's Hospital and transferred from Hospital Emergency Department for further evaluation. Information is obtained in discussion with the mother and the grandmother in review of previous medical records. This patient had the onset on the day of presentation of a jelly-like red-brown stool started on Tuesday morning. Then, the patient was noted to vomit after feeds. The patient was evaluated at Hospital with further evaluation with laboratory data showing a white blood cell count elevated at 22.2; hemoglobin 14.1; sodium 138; potassium 7.2, possibly hemolyzed; chloride 107; CO2 23; BUN 17; creatinine 1.2; and glucose of 50, which was repeated and found to be stable in that range. The patient underwent a barium enema, which was read by the radiologist as negative. The patient was transferred to Children's Hospital for further evaluation after being given doses of ampicillin, cefotaxime, and Rocephin.,PAST MEDICAL HISTORY: , Further, the patient was born in Hospital. Birth weight was 6 pounds 4 ounces. There was maternal hypertension. Mother denies group B strep or herpes. Otherwise, no past medical history.,IMMUNIZATIONS: , None today.,MEDICATIONS: , Thrush medicine identified as nystatin.,ALLERGIES: , Denied.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY: ,Here with mother and grandmother, lives at home. There is no smoking at home.,FAMILY HISTORY: , None noted exposures.,REVIEW OF SYSTEMS: ,The patient is fed Enfamil, bottle-fed. Has had decreased feeding, has had vomiting, has had diarrhea, otherwise negative on the 10 plus systems reviewed.,PHYSICAL EXAMINATION:,VITAL SIGNS/GENERAL: On physical examination, the initial temperature 97.5, pulse 140, respirations 48 on this 2 kg 15-day-old female who is small, well-developed female, age appropriate.,HEENT: Head is atraumatic and normocephalic with a soft and flat anterior fontanelle. Pupils are equal, round, and reactive to light. Grossly conjugate. Bilateral red reflex appreciated bilaterally. Clear TMs, nose, and oropharynx. There is a kind of abundant thrush and white patches on the tongue.,NECK: Supple, full, painless, and nontender range of motion.,CHEST: Clear to auscultation, equal, and stable.,HEART: Regular without rubs or murmurs, and femoral pulses are appreciated bilaterally.,ABDOMEN: Soft and nontender. No hepatosplenomegaly or masses.,GENITALIA: Female genitalia is present on a visual examination.,SKIN: No significant bruising, lesions, or rash.,EXTREMITIES: Moves all extremities, and nontender. No deformity.,NEUROLOGICALLY: Eyes open, moves all extremities, grossly age appropriate.,MEDICAL DECISION MAKING: , The differential entertained on this patient includes upper respiratory infection, gastroenteritis, urinary tract infection, dehydration, acidosis, and viral syndrome. The patient is evaluated in the emergency department laboratory data, which shows a white blood cell count of 13.1, hemoglobin 14.0, platelets 267,000, 7 stabs, 68 segs, 15 lymphs, and 9 monos. Serum electrolytes not normal. Sodium 138, potassium 5.0, chloride 107, CO2 acidotic at 18, glucose normal at 88, and BUN markedly elevated at 22 as is the creatinine of 1.4. AST and ALT were elevated as well at 412 and 180 respectively. A cath urinalysis showing no signs of infection. Spinal fluid evaluation, please see procedure note below. White count 0, red count 2060. Gram stain negative.,PROCEDURE NOTE: , After discussion of the risks, benefits, and indications, and obtaining informed consent with the family and their agreement to proceed, this patient was placed in the left lateral position and using aseptic Betadine preparation, sterile draping, and sterile technique pursued throughout, this patient's L4- L5 interspace was anesthetized with the 1% lidocaine solution following the above sterile preparation, entered with a 22-gauge styletted spinal needle of approximately 0.5 mL clear CSF, they were very slow to obtain. The fluid was obtained, the needle was removed, and sterile bandage was placed. The fluid was sent to laboratory for further evaluation (aunt and grandmother) were present throughout the period of time during this procedure and the procedure was tolerated well. An i-STAT initially obtained showed somewhat of an acidosis with a base excess of -12. A repeat i-STAT after a bolus of normal saline and a second bolus of normal saline, her maintenance rate of D5 half showed a base excess of -11, which is slowly improving, but not very fast. Based on the above having this patient consulted to the Hospitalist Service at 2326 hours of request, this patient was consulted to PICU with the plan that the patient need to have continued IV fluids. Showing signs of dehydration, a third bolus of normal saline was provided, twice maintenance D5 half was continued. The patient was admitted to the Hospitalist Service for continued IV fluids. The patient maintains to have clear lungs, has been feeding well here in the department, took virtually a whole small bottle of the appropriate formula. She has not had any vomiting, is burping. The patient is admitted for continued close observation and rehydration due to the working diagnoses of gastroenteritis, metabolic acidosis, and dehydration. Critical care time on this patient is less than 30 minutes, exclusive, otherwise time has been spent evaluating this patient according to this patient's care and admission to the Hospitalist Service.

Repair of total anomalous pulmonary venous connection, ligation of patent ductus arteriosus, repair secundum type atrial septal defect (autologous pericardial patch), subtotal thymectomy, and insertion of peritoneal dialysis catheter.

Pediatrics - Neonatal

Septal Defect Repair

TITLE OF OPERATION:,1. Repair of total anomalous pulmonary venous connection.,2. Ligation of patent ductus arteriosus.,3. Repair secundum type atrial septal defect (autologous pericardial patch).,4. Subtotal thymectomy.,5. Insertion of peritoneal dialysis catheter.,INDICATION FOR SURGERY: , This neonatal was diagnosed postnatally with total anomalous pulmonary venous connection. Following initial stabilization, she was transferred to the Hospital for complete correction.,PREOP DIAGNOSIS: ,1. Total anomalous pulmonary venous connection.,2. Atrial septal defect.,3. Patent ductus arteriosus.,4. Operative weight less than 4 kilograms (3.2 kilograms).,COMPLICATIONS: , None.,CROSS-CLAMP TIME: , 63 minutes.,CARDIOPULMONARY BYPASS TIME MONITOR:, 35 minutes, profound hypothermic circulatory arrest time (4 plus 19) equals 23 minutes. Low flow perfusion 32 minutes.,FINDINGS:, Horizontal pulmonary venous confluence with right upper and middle with two veins entering the confluence on the right and multiple entry sites for left-sided veins. Large patulous anastomosis between posterior aspect of the left atrium and anterior aspect of the pulmonary venous confluence. Nonobstructed ascending vein ligated. Patent ductus arteriosus diminutive left atrium with posterior atrial septal defect with deficient inferior margin. At completion of the procedure, right ventricular pressure approximating one-half of systemic, normal sinus rhythm, good biventricular function by visual inspection.,PROCEDURE: , After the informed consent, the patient was brought to the operating room and placed on the operating room table in supine position. Upon induction of general endotracheal anesthesia and placement of indwelling arterial and venous monitoring lines. The patient was prepped and draped in the usual sterile fashion from chin to groins. A median sternotomy incision was performed. Dissection was carried through the deeper planes until the sternum was scored and divided with an oscillating saw. A subtotal thymectomy was performed. Systemic heparinization was achieved and the pericardium was entered and fashioned until cradle. A small portion of the anterior pericardium was procured and fixed in glutaraldehyde for patch closure of segment of the atrial septal defect during the procedure. Pursestrings were deployed on the ascending aorta on the right. Atrial appendage. The aorta was then cannulated with an 8-French aorta cannula and the right atrium with an 18-French Polystan right-angle cannula. With an ACT greater than 400, greater pulmonary bypass was commenced with excellent cardiac decompression and the patent ductus arteriosus was ligated with a 2-0 silk tie. Systemic cooling was started and the head was packed and iced and systemic steroids were administered. During cooling, traction suture was placed in the apex of the left ventricle. After 25 minutes of cooling, the aorta was cross-clamped and the heart arrested by administration of 30 cubic centimeter/kilogram of cold-blood cardioplegia delivered directly within the aortic root following the aorta cross-clamping. Following successful cardioplegic arrest, a period of low flow perfusion was started and a 10-French catheter was inserted into the right atrial appendage substituting the 18-French Polystan venous cannula. The heart was then rotated to the right side and the venous confluence was exposed. It was incised and enlarged and a corresponding incision in the dorsal and posterior aspect of the left atrium was performed. The two openings were then anastomosed in an end-to-side fashion with several interlocking sutures to avoid pursestring effect with a running 7-0 PDS suture. Following completion of the anastomosis, the heart was returned into the chest and the patient's blood volume was drained into the reservoir. A right atriotomy was then performed during the period of circulatory arrest. The atrial septal defect was very difficult to expose, but it was sealed with an autologous pericardial patch was secured in place with a running 6-0 Prolene suture. The usual deairing maneuvers were carried out and lining was administered and the right atriotomy was closed in two layers with a running 6-0 Prolene sutures. The venous cannula was reinserted. Cardiopulmonary bypass restarted and the aorta cross-clamp was released. The patient returned to normal sinus rhythm spontaneously and started regaining satisfactory hemodynamics which, following a prolonged period of rewarming, allow for us to wean her from cardiopulmonary bypass successfully and moderate inotropic support and sinus rhythm. Modified ultrafiltration was carried out and two sets of atrial and ventricular pacing wires were placed as well as the peritoneal dialysis catheter and two 15-French Blake drains. Venous decannulation was followed by aortic decannulation and administration of protamine sulfate. All cannulation sites were oversewn with 6-0 Prolene sutures and the anastomotic sites noticed to be hemostatic. With good hemodynamics and hemostasis, the sternum was then smeared with vancomycin, placing closure with stainless steel wires. The subcutaneous tissues were closed in layers with the reabsorbable monofilament sutures. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was transferred in very stable condition to the pediatric intensive care unit .,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case. Given the magnitude of the operation, the unavailability of an appropriate level, cardiac surgical resident, Mrs. X (attending pediatric cardiac surgery at the Hospital) participated during the cross-clamp time of the procedure in quality of first assistant.

pediatrics - neonatal, total anomalous pulmonary venous connection, patent ductus arteriosus, ligation, secundum type atrial septal defect, atrial septal defect, subtotal thymectomy, peritoneal dialysis catheter, cross clamp, cardiopulmonary bypass, pulmonary venous, atrial septal, septal defect, anomalous, venous, atrial, arteriosus, patent, ductus, septal, aorta, pulmonary,

Pediatric Gastroenterology - Rectal Bleeding Consult.

Pediatrics - Neonatal

Rectal Bleeding - 1-year-old

HISTORY OF PRESENT ILLNESS:, This is a 1-year-old male patient who was admitted on 12/23/2007 with a history of rectal bleeding. He was doing well until about 2 days prior to admission and when he passes hard stools, there was bright red blood in the stool. He had one more episode that day of stool; the stool was hard with blood in it. Then, he had one episode of rectal bleeding yesterday and again one stool today, which was soft and consistent with dark red blood in it. No history of fever, no diarrhea, no history of easy bruising. Excessive bleeding from minor cut. He has been slightly fussy.,PAST MEDICAL HISTORY: ,Nothing significant.,PREGNANCY DELIVERY AND NURSERY COURSE: , He was born full term without complications.,PAST SURGICAL HISTORY: , None.,SIGNIFICANT ILLNESS AND REVIEW OF SYSTEMS: , Negative for heart disease, lung disease, history of cancer, blood pressure problems, or bleeding problems.,DIET:, Regular table food, 24 ounces of regular milk. He is n.p.o. now.,TRAVEL HISTORY: , Negative.,IMMUNIZATION: , Up-to-date.,ALLERGIES: , None.,MEDICATIONS: , None, but he is on IV Zantac now.,SOCIAL HISTORY: , He lives with parents and siblings.,FAMILY HISTORY:, Nothing significant.,LABORATORY EVALUATION: , On 12/24/2007, WBC 8.4, hemoglobin 7.6, hematocrit 23.2 and platelets 314,000. Sodium 135, potassium 4.7, chloride 110, CO2 20, BUN 6 and creatinine 0.3. Albumin 3.3. AST 56 and ALT 26. CRP less than 0.3. Stool rate is still negative.,DIAGNOSTIC DATA: , CT scan of the abdomen was read as normal.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Temperature 99.5 degrees Fahrenheit, pulse 142 per minute and respirations 28 per minute. Weight 9.6 kilogram.,GENERAL: He is alert and active child in no apparent distress.,HEENT: Atraumatic and normocephalic. Pupils are equal, round and reactive to light. Extraocular movements, conjunctivae and sclerae fair. Nasal mucosa pink and moist. Pharynx is clear.,NECK: Supple without thyromegaly or masses.,LUNGS: Good air entry bilaterally. No rales or wheezing.,ABDOMEN: Soft and nondistended. Bowel sounds positive. No mass palpable.,GENITALIA: Normal male.,RECTAL: Deferred, but there was no perianal lesion.,MUSCULOSKELETAL: Full range of movement. No edema. No cyanosis.,CNS: Alert, active and playful.,IMPRESSION: , A 1-year-old male patient with history of rectal bleeding. Possibilities include Meckel's diverticulum, polyp, infection and vascular malformation.,PLAN:, To proceed with Meckel scan today. If Meckel scan is negative, we will consider upper endoscopy and colonoscopy. We will start colon clean out if Meckel scan is negative. We will send his stool for C. diff toxin, culture, blood for RAST test for cow milk, soy, wheat and egg. Monitor hemoglobin.

Frontal and lateral views of the hip and pelvis.

Pediatrics - Neonatal

Slipped Capital Femoral Epiphysis (SCFE)

EXAM: , Two views of the pelvis.,HISTORY:, This is a patient post-surgery, 2-1/2 months. The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.,TECHNIQUE: , Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM/DD/YYYY. Lateral view of the right hip was evaluated.,FINDINGS:, Frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient's most recent priors dated MM/DD/YYYY. Current films reveal stable appearing post-surgical changes. Again demonstrated is a single intramedullary screw across the left femoral neck and head. There are 2 intramedullary screws through the greater trochanter of the right femur. There is a lucency along the previous screw track extending into the right femoral head and neck. There has been interval removal of cutaneous staples and/or surgical clips. These were previously seen along the lateral aspect of the right hip joint.,Deformity related to the previously described slipped capital femoral epiphysis is again seen.,IMPRESSION:,1. Stable-appearing right hip joint status-post pinning.,2. Interval removal of skin staples as described above.

pediatrics - neonatal, scfe, frontal and lateral views, slipped capital femoral epiphysis, lateral views, slipped, capital, epiphysis, frontal, pelvis, femoral, hip

This patient was seen in clinic for a school physical.

Pediatrics - Neonatal

School Physical - 1

SUBJECTIVE:, This patient was seen in clinic for a school physical.,NUTRITIONAL HISTORY:, She eats well, takes meats, vegetables, and fruits, but her calcium intake is limited. She does not drink a whole lot of pop. Her stools are normal. Brushes her teeth, sees a dentist.,Developmental History: Hearing and vision is okay. She did well in school last year. She will be going to move to Texas, will be going to Bowie High School. She will be involved in cheerleading, track, volleyball, and basketball. She will be also playing the clarinet and will be a freshman in that school. Her menarche was 06/30/2004.,PAST MEDICAL HISTORY:, She is still on medications for asthma. She has a problem with her eye lately, this has been bothering her, and she also has had a rash in the left leg. She had been pulling weeds on 06/25/2004 and then developed a rash on 06/27/2004.,Review of her immunizations, her last tetanus shot was 06/17/2003.,MEDICATIONS: ,Advair 100/50 b.i.d., Allegra 60 mg b.i.d., Flonase q.d., Xopenex, Intal, and albuterol p.r.n.,ALLERGIES: , No known drug allergies.,OBJECTIVE:,Vital Signs: Weight: 112 pounds about 40th percentile. Height: 63-1/4 inches, also the 40th percentile. Her body mass index was 19.7, 40th percentile. Temperature: 97.7 tympanic. Pulse: 80. Blood pressure: 96/64.,HEENT: Normocephalic. Fundi benign. Pupils equal and reactive to light and accommodation. No strabismus. Her vision was 20/20 in both eyes and each with contacts. Hearing: She passed that test. Her TMs are bilaterally clear and nonerythematous. Throat was clear. Good mucous membrane moisture and good dentition.,Neck: Supple. Thyroid normal sized. No increased lymphadenopathy in the submandibular nodes and no axillary nodes.,Abdomen: No hepatosplenomegaly.,Respiratory: Clear. No wheezes. No crackles. No tachypnea. No retractions.,Cardiovascular: Regular rate and rhythm. S1 and S2 normal. No murmur.,Abdomen: Soft. No organomegaly and no masses.,GU: Normal female genitalia. Tanner stage 3, breast development and pubic hair development. Examination of the breasts was negative for any masses or abnormalities or discharge from her areola.,Extremities: She has good range of motion of upper and lower extremities. Deep tendon reflexes were 2+/4+ bilaterally and equal. Romberg negative.,Back: No scoliosis. She had good circumduction at shoulder joint and her duck walk was normal.,SKIN: She did have some rash on the anterior left thigh region and also some on the right lower leg that had Kebner phenomenon and maculopapular vesicular eruption. No honey crusting was noted on the skin. She also had some mild rash on the anterior abdominal area near the panty line similar to that rash. It was raised and blanch with pressure, it was slightly erythematous.,ASSESSMENT AND PLAN:,1. Sports physical.,2. The patient received her first hepatitis A vaccine. She will get a booster in 6 to 12 months. Prescription for Atarax 10 mg tablets one to two tablets p.o. q.4-6h. p.r.n. and a prescription for Elocon ointment to be applied topically, except for the face, once a day with a refill. She will be following up with an allergist as soon as she gets to Texas and needs to find a primary care physician. We talked about anticipatory guidance including breast exam, which we have reviewed with her today, seatbelt use, and sunscreen. We talked about avoidance of drugs and alcohol and sexual activity. Continue on her present medications and if her rash is not improved and goes to the neck or the face, she will need to be on PO steroid medication, but presently that was held and moved to treatment with Atarax and Elocon. Also talked about cleaning her clothes and bedding in case she has any poison ivy oil that is harboring on any clothing.

pediatrics - neonatal, school physical, calcium intake, hearing and vision, hepatitis a vaccine, booster, anticipatory guidance, developmental, percentile, physical, school, rash,

Well-child check and school physical.

Pediatrics - Neonatal

School Physical - 2

CHIEF COMPLAINT:, Well-child check and school physical.,HISTORY OF PRESENT ILLNESS:, This is a 9-year-old African-American male here with his mother for a well-child check. Mother has no concerns at the time of the visit. She states he had a pretty good school year. He still has some fine motor issues, especially writing, but he is receiving help with that and math. He continues to eat well. He could do better with milk intake, but Mother states he does eat cheese and yogurt. He brushes his teeth daily. He has regular dental visits every six months. Bowel movements are without problems. He is having some behavior issues, and sometimes he tries to emulate his brother in some of his negative behaviors.,DEVELOPMENTAL ASSESSMENT:, Social: He has a sense of humor. He knows his rules. He does home chores. Fine motor: He is as mentioned before. He can draw a person with six parts. Language: He can tell time. He knows the days of the week. He reads for pleasure. Gross motor: He plays active games. He can ride a bicycle.,REVIEW OF SYSTEMS:, He has had no fever and no vision problems. He had an eye exam recently with Dr. Crum. He has had some headaches which precipitated his vision exam. No earache or sore throat. No cough, shortness of breath or wheezing. No stomachache, vomiting or diarrhea. No dysuria, urgency or frequency. No excessive bleeding or bruising.,MEDICATIONS:, No daily medications.,ALLERGIES:, Cefzil.,IMMUNIZATIONS:, His immunizations are up to date.,PHYSICAL EXAMINATION:,General: He is alert and in no distress, afebrile.,HEENT: Normocephalic, atraumatic. Pupils equal, round and react to light. TMs are clear bilaterally. Nares: Patent. Oropharynx is clear.,Neck: Supple.,Lungs: Clear to auscultation.,Heart: Regular. No murmur.,Abdomen: Soft. Positive bowel sounds. No masses. No hepatosplenomegaly.,GU: Tanner III.,Extremities: Symmetrical. Femoral pulses 2+ bilaterally. Full range of motion of all extremities.,Back: No scoliosis.,Neurological: Grossly intact.,Skin: Normal turgor. No rashes.,Hearing: Grossly normal.,ASSESSMENT:, Well child.,PLAN:, Anticipatory guidance for age. He is to return to the office in one year.