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Well-child check sports physical - Well child asthma with good control, allergic rhinitis.

Pediatrics - Neonatal

Sports Physical - 2

CHIEF COMPLAINT:, Well-child check sports physical.,HISTORY OF PRESENT ILLNESS:, This is a 14-1/2-year-old white male known to have asthma and allergic rhinitis. He is here with his mother for a well-child check. Mother states he has been doing well with regard to his asthma and allergies. He is currently on immunotherapy and also takes Advair 500/50 mg, Flonase, Claritin and albuterol inhaler as needed. His last exacerbation was 04/04. He has been very competitive in his sports this spring and summer and has had no issues since that time. He eats well from all food groups. He has very good calcium intake. He will be attending Maize High School in the ninth grade. He has same-sex and opposite-sex friends. He has had a girlfriend in the past. He denies any sexual activity. No use of alcohol, cigarettes or other drugs. His bowel movements are without problems. His immunizations are up to date. His last tetanus booster was in 07/03.,CURRENT MEDICATIONS:, As above.,ALLERGIES: , He has no known medication allergies.,REVIEW OF SYSTEMS:,Constitutional: He has had no fever.,HEENT: No vision problems. No eye redness, itching or drainage. No earache. No sore throat or congestion.,Cardiovascular: No chest pain.,Respiratory: No cough, shortness of breath or wheezing.,GI: No stomachache, vomiting or diarrhea.,GU: No dysuria, urgency or frequency.,Hematological: No excessive bruising or bleeding. He did have a minor concussion in 06/04 while playing baseball.,PHYSICAL EXAMINATION:,General: He is alert and in no distress.,Vital signs: He is afebrile. His weight is at the 75th percentile. His height is about the 80th percentile.,HEENT: Normocephalic. Atraumatic. Pupils are equal, round and reactive to light. TMs are clear bilaterally. Nares patent. Nasal mucosa is mildly edematous and pink. No secretions. Oropharynx is clear.,Neck: Supple.,Lungs: Good air exchange bilaterally.,Heart: Regular. No murmur.,Abdomen: Soft. Positive bowel sounds. No masses. No hepatosplenomegaly.,GU: Male. Testes descended bilaterally. Tanner IV. No hernia appreciated.,Extremities: Symmetrical. Femoral pulses 2+ bilaterally. Full range of motion of all extremities.,Back: No scoliosis.,Neurological: Grossly intact.,Skin: Normal turgor. Minor sunburn on upper back.,Neurological: Grossly intact.,ASSESSMENT:,1. Well child.,2. Asthma with good control.,3. Allergic rhinitis, stable.,PLAN:, Hearing and vision assessment today are both within normal limits. Will check an H&H today. Continue all medications as directed. Prescription written for albuterol inhaler, #2, one for home and one for school to be used for rescue. Anticipatory guidance for age. He is to return to the office in one year or sooner if needed.

A 7-year-old white male started to complain of pain in his fingers, elbows, and neck. This patient may have had reactive arthritis.

Pediatrics - Neonatal

Pediatric Rheumatology Consult

HISTORY: ,We had the pleasure of seeing the patient today in our Pediatric Rheumatology Clinic. He was sent here with a chief complaint of joint pain in several joints for few months. This is a 7-year-old white male who has no history of systemic disease, who until 2 months ago, was doing well and 2 months ago, he started to complain of pain in his fingers, elbows, and neck. At this moment, this is better and is almost gone, but for several months, he was having pain to the point that he would cry at some point. He is not a complainer according to his mom and he is a very active kid. There is no history of previous illness to this or had gastrointestinal problems. He has problems with allergies, especially seasonal allergies and he takes Claritin for it. Other than that, he has not had any other problem. Denies any swelling except for that doctor mentioned swelling on his elbow. There is no history of rash, no stomach pain, no diarrhea, no fevers, no weight loss, no ulcers in his mouth except for canker sores. No lymphadenopathy, no eye problems, and no urinary problems.,MEDICATIONS: , His medications consist only of Motrin only as needed and Claritin currently for seasonal allergies and rhinitis.,ALLERGIES: , He has no allergies to any drugs.,BIRTH HISTORY: ,Pregnancy and delivery with no complications. He has no history of hospitalizations or surgeries.,FAMILY HISTORY: , Positive for arthritis in his grandmother. No history of pediatric arthritis. There is history of psoriasis in his dad.,SOCIAL HISTORY: , He lives with mom, dad, brother, sister, and everybody is healthy. They live in Easton. They have 4 dogs, 3 cats, 3 mules and no deer. At school, he is in second grade and he is doing PE without any limitation.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Temperature is 98.7, pulse is 96, respiratory rate is 24, height is 118.1 cm, weight is 22.1 kg, and blood pressure is 61/44.,GENERAL: He is alert, active, in no distress, very cooperative.,HEENT: He has no facial rash. No lymphadenopathy. Oral mucosa is clear. No tonsillitis. His ear canals are clear and pupils are reactive to light and accommodation.,CHEST: Clear to auscultation.,HEART: Regular rhythm and no murmur.,ABDOMEN: Soft, nontender with no visceromegaly.,MUSCULOSKELETAL: Shows no limitation in any of his joints or active swelling today. He has no tenderness either in any of his joints. Muscle strength is 5/5 in proximal muscles.,LABORATORY DATA:, Includes an arthritis panel. It has normal uric acid, sedimentation rate of 2, rheumatoid factor of 6, and antinuclear antibody that is negative and C-reactive protein that is 7.1. His mother stated that this was done while he was having symptoms.,ASSESSMENT AND PLAN: , This patient may have had reactive arthritis. He is seen frequently and the patient has family history of psoriatic arthritis or psoriasis. I do not see any problems at this moment on his laboratories or on his physical examination. This may have been related to recent episode of viral infection or infection of some sort. Mother was oriented about the finding and my recommendation is to observe him and if there is any recurrence of the symptoms or persistence of swelling or limitation in any of his joints, I will be glad to see him back.,If you have any question on further assessment and plan, please do no hesitate to contact us.

pediatrics - neonatal, rheumatology, pediatric, reactive arthritis, psoriatic arthritis, psoriasis, joints, swelling, arthritis,

Prematurity, 34 weeks' gestation, now 5 days old, group B streptococcus exposure, but no sepsis, physiologic jaundice, and feeding problem.

Pediatrics - Neonatal

Prematurity - Discharge Summary

ADMITTING DIAGNOSES,1. Prematurity.,2. Appropriate for gestational age.,3. Maternal group B streptococcus positive culture.,DISCHARGE DIAGNOSES,1. Prematurity, 34 weeks' gestation, now 5 days old.,2. Group B streptococcus exposure, but no sepsis.,3. Physiologic jaundice.,4. Feeding problem.,HISTORY OF ILLNESS: ,This is a 4-pound female infant born to a 26-year-old gravida 1, now para 1-0-0-1 lady with an EDC of November 19, 2003. Group B streptococcus culture was positive on September 29, 2003, and betamethasone was given 1 dose prior to delivery. Mother also received 1 dose of penicillin approximately 1-1/2 hours prior to delivery. The infant delivered vaginally, had a double nuchal cord and required CPAP and free flow oxygen. Her Apgars were 8 at 1 minute and 9 at 5 minutes. At the end of delivery, it was noted there was a partial placental abruptio.,HOSPITAL COURSE: ,The infant has had a basically uncomplicated hospital course. She did not require oxygen. She did have antibiotics, ampicillin and gentamicin for approximately 48 hours to cover for possible group B streptococcus. The culture was negative and the antibiotics were stopped at 48 hours.,The infant was noted to have physiologic jaundice and her highest bilirubin was 7.1. She was treated for approximately 24 hours with phototherapy and the bilirubin on October 15, 2003 was 3.4.,FEEDING: , The infant has had some difficulty with feeding, but at the time of discharge, she is taking approximately 30 mL every feeding and is taking Formula or breast milk, that is, ___ 24 calories per ounce.,PHYSICAL EXAMINATION:, ,VITAL SIGNS: At discharge, reveals a well-developed infant whose temperature is 98.3, pulse 156, respirations 35, her weight is 1779 g (1% below her birthweight).,HEENT: Head is normocephalic. Eyes are without conjunctival injection. Red reflex is elicited bilaterally. TMs not well visualized. Nose and throat are patent without palatal defect.,NECK: Supple without clavicular fracture.,LUNGS: Clear to auscultation.,HEART: Regular rate without murmur, click or gallop present.,EXTREMITIES: Pulses are 2/4 for brachial and femoral. Extremities without evidence of hip defects.,ABDOMEN: Soft, bowel sounds present. No masses or organomegaly.,GENITALIA: Normal female, but the clitoris is not covered by the labia majora.,NEUROLOGICAL: The infant has good Moro, grasp, and suck reflexes.,INSTRUCTIONS FOR CONTINUING CARE,The infant will be discharged home. She will have home health visits one time per week for 3 weeks, and she will be seen in followup at San Juan Pediatrics the week of October 20, 2003. She is to continue feeding with either breast milk or Formula, that is, ___ to 24 calories per ounce.,CONDITION: , Her condition at discharge is good.

A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever.

Pediatrics - Neonatal

Reactive Airway Disease

CHIEF COMPLAINT AND IDENTIFICATION:, A is a 23-month-old girl, who has a history of reactive airway disease who is being treated on an outpatient basis for pneumonia who presents with cough and fever.,HISTORY OF PRESENT ILLNESS: , The patient is to known to have reactive airway disease and uses Pulmicort daily and albuterol up to 4 times a day via nebulization.,She has no hospitalizations.,The patient has had a 1 week or so history of cough. She was seen by the primary care provider and given amoxicillin for yellow nasal discharge according to mom. She has been taking 1 teaspoon every 6 hours. She originally was having some low-grade fever with a maximum of 100.4 degrees Fahrenheit; however, on the day prior to admission, she had a 104.4 degrees Fahrenheit temperature, and was having posttussive emesis. She is using her nebulizer, but the child was in respiratory distress, and this was not alleviated by the nebulizer, so she was brought to Children's Hospital Central California.,At Children's Hospital, the patient was originally treated as an asthmatic and was receiving nebulized treatments; however, a chest x-ray did show right-sided pneumonia, and the patient was hypoxemic after resolution of her respiratory distress, so the Hospitalist Service was contacted regarding admission. The patient was seen and admitted through the emergency room.,REVIEW OF SYSTEMS: , Negative except that indicated in the history of present illness. All systems were checked.,PAST MEDICAL HISTORY: , As stated in the history of present illness, no hospitalizations, no surgeries.,IMMUNIZATIONS: , The patient is up-to-date on her shots. She has a schedule for her 2-year-old shot soon.,ALLERGIES: , No known drug allergies.,DEVELOPMENT HISTORY: , Developmentally, she is within normal limits.,FAMILY HISTORY:, Her maternal uncles have asthma. There are multiple family members on the maternal side that have diabetes mellitus, otherwise the family history is negative for other chronic medical conditions.,SOCIAL HISTORY: , Her sister has a runny nose, but no other sick contacts. The family lives in Delano. She lives with her mom and sister. The dad is involved, but the parents are separated. There is no smoking exposure.,PHYSICAL EXAMINATION:, ,GENERAL: The child was in no acute distress.,VITAL SIGNS: Temperature 99.8 degrees Fahrenheit, heart rate 144, respiratory rate 28. Oxygen saturations 98% on continuous. Off of oxygen shows 85% laying down on room air. The T-max in the ER was 101.3 degrees Fahrenheit.,SKIN: Clear.,HEENT: Pupils were equal, round, react to light. No conjunctival injection or discharge. Tympanic membranes were clear. No nasal discharge. Oropharynx moist and clear.,NECK: Supple without lymphadenopathy, thyromegaly, or masses.,CHEST: Clear to auscultation bilaterally; no tachypnea, wheezing, or retractions.,CARDIOVASCULAR: Regular rate and rhythm. No murmurs noted. Well perfused peripherally.,ABDOMEN: Bowel sounds are present. The abdomen is soft. There is no hepatosplenomegaly, no masses, nontender to palpation.,GENITOURINARY: No inguinal lymphadenopathy. Tanner stage I female.,EXTREMITIES: Symmetric in length. No joint effusions. She moves all extremities well.,BACK: Straight. No spinous defects.,NEUROLOGIC: The patient has a normal neurologic exam. She is sitting up solo in bed, gets on her knees, stands up, is playful, smiles, is interactive. She has no focal neurologic deficits.,LABORATORY DATA: , Chest x-ray by my reading shows a right lower lobe infiltrate. Metabolic panel: Sodium 139, potassium 3.5, chloride 106, total CO2 22, BUN and creatinine are 5 and 0.3 respectively, glucose 84, CRP 4.3. White blood cell count 13.7, hemoglobin and hematocrit 9.6 and 29.9 respectively, and platelets 294,000. Differential of the white count 34% lymphocytes, 55% neutrophils.,ASSESSMENT AND PLAN: , This is a 22-month-old girl, who has an infiltrate on the x-ray, hypoxemia, and presented in respiratory distress. I believe, she has bacterial pneumonia, which is partially treated by her amoxicillin, which is a failure of her outpatient treatment. She will be placed on the pneumonia pathway and started on cefuroxime to broaden her coverage. She is being admitted for hypoxemia. I hope that this will resolve overnight, and she will be discharged in the morning. I will start her home medications of Pulmicort twice daily and albuterol on a p.r.n. basis; however, at this point, she has no wheezing, so no systemic steroids will be instituted.,Further interventions will depend on the clinical course.

A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture. Adenoid hyperplasia bilateral.

Pediatrics - Neonatal

Otitis Media - H&P

CHIEF COMPLAINT:, This 3-year-old female presents today for evaluation of chronic ear infections bilateral.,ASSOCIATED SIGNS AND SYMPTOMS FOR OTITIS MEDIA: , Associated signs and symptoms include: cough, fever, irritability and speech and language delay. Duration (ENT): Duration of symptom: 12 rounds of antibiotics for otitis media. Quality of ear problems: Quality of the pain is throbbing.,ALLERGIES: , No known medical allergies.,MEDICATIONS:, None currently.,PMH:, Past medical history is unremarkable.,PSH: , No previous surgeries.,SOCIAL HISTORY:, Parent admits child is in a large daycare.,FAMILY HISTORY:, Parent admits a family history of Alzheimer's disease associated with paternal grandmother.,ROS:, Unremarkable with exception of chief complaint.,PHYSICAL EXAM:, Temp: 99.6 Weight: 38 lbs.,Patient is a 3-year-old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus.,The child is accompanied by her mother who communicates well in English.,Head & Face: Inspection of head and face shows no abnormalities. Examination of salivary glands shows no abnormalities. Facial strength is normal.,Eyes: Pupil exam reveals PERRLA.,ENT: Otoscopic examination reveals otitis media bilateral.,Hearing exam using tuning fork shows hearing to be diminished bilateral.,Inspection of left ear reveals drainage of a small amount.,Inspection of nasal mucosa, septum and turbinates reveals no abnormalities.,Frontal and maxillary sinuses all transilluminate well bilaterally.,Inspection of lips, teeth, gums, and palate reveals no gingival hypertrophy, no pyorrhea, healthy gums, healthy teeth and no abnormalities.,Inspection of the tongue reveals normal color, good motility and midline position.,Examination of oropharynx reveals no abnormalities.,Examination of nasopharynx reveals adenoid hypertrophy.,Neck: Neck exam reveals no abnormalities.,Lymphatic: No neck or supraclavicular lymphadenopathy noted.,Respiratory: Chest inspection reveals chest configuration non-hyperinflated and symmetric expansion. Auscultation of lungs reveal clear lung fields and no rubs noted.,Cardiovascular: Heart auscultation reveals no murmurs, gallop, rubs or clicks.,Neurological/Psychiatric: Testing of cranial nerves reveals no deficits. Mood and affect normal and appropriate to situation.,TEST RESULTS:, Audiometry test shows conductive hearing loss at 30 decibels and flat tympanogram.,IMPRESSION: , OM, suppurative without spontaneous rupture. Adenoid hyperplasia bilateral.,PLAN:, Patient scheduled for myringotomy and tubes, with adenoidectomy, using general anesthesia, as outpatient and scheduled for 08/07/2003. Surgery will be performed at Children's Hospital. Pre-operative consent form read and signed by parent. Common risks and side effects of the procedure and anesthesia were mentioned. Parent questions elicited and answered satisfactorily regarding planned procedure. ,EDUCATIONAL MATERIAL PROVIDED: , Hospital preregistration, middle ear infection and myringtomy and tubes surgery.,PRESCRIPTIONS:, Augmentin Dosage: 400 mg-57 mg/5 ml powder for reconstitution Sig: One PO Q8h Dispense: 1 Refills: 0 Allow Generic: No

9-month-old male product of a twin gestation complicated by some very mild prematurity having problems with wheezing, cough and shortness of breath over the last several months.

Pediatrics - Neonatal

Pediatric - Letter

Sample Address,RE: Sample Patient,Dear Doctor:,We had the pleasure of seeing Abc and his mother in the clinic today. As you certainly know, he is now a 9-month-old male product of a twin gestation complicated by some very mild prematurity. He has been having problems with wheezing, cough and shortness of breath over the last several months. You and your partners have treated him aggressively with inhaled steroids and bronchodilator. Despite this, however; he has had persistent problems with a cough and has been more recently started on both a short burst of prednisolone as well as a more prolonged alternating day course. ,Although there is no smoke exposure there is a significant family history with both Abc's father and uncle having problems with asthma as well as his older sister. The parents now maintain separate households and there has been a question about the consistency of his medication administration at his father's house. ,On exam today, Abc had some scattered rhonchi which cleared with coughing but was otherwise healthy. ,We spent the majority of our 45-minute just reviewing basic principles of asthma management and I believe that Abc's mother is fairly well versed in this. I think the most important thing to realize is that Abc probably does have fairly severe childhood asthma and fortunately has avoided hospitalization. ,I think it would be prudent to continue his alternate day steroids until he is completely symptom free on the days off steroids but it would be reasonable to continue to wean him down to as low as 1.5 milligrams (0.5 milliliters on alternate days). I have encouraged his mother to contact our office so that we can answer questions if necessary by phone.,Thanks so much for allowing us to be involved in his care. ,Sincerely,

pediatrics - neonatal, gestation, bronchodilator, childhood, childhood asthma, cough, father, healthy, letter, mother, pediatric, prematurity, shortness of breath, sister, wheezing, wheezing cough, asthma,

He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally.

Pediatrics - Neonatal

Pediatric Urology Letter

XYZ, M.D. ,Suite 123, ABC Avenue ,City, STATE 12345 ,RE: XXXX, XXXX ,MR#: 0000000,Dear Dr. XYZ: ,XXXX was seen in followup in the Pediatric Urology Clinic. I appreciate you speaking with me while he was in clinic. He continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. ,When I examined him, he seems to indicate that his pain is essentially in the lower abdomen in the suprapubic region; however, on actual physical examination, he seems to complain of pain through his entire right side. His parents have brought up the question of whether this could be gastrointestinal in origin and that is certainly an appropriate consideration. They also feel that since he has been on Detrol, his pain levels have been somewhat worse, and so, I have given them the option of stopping the Detrol initially. I think he should stay on MiraLax for management of his bowels. I would also suggest that he be referred to Pediatric Gastroenterology for evaluation. If they do not find any abnormalities from a gastrointestinal perspective, then the next step would be to endoscope his bladder and then make sure that he does not have any evidence of bladder anatomic abnormalities that is leading to this pain. ,Thank you for following XXXX along with us in Pediatric Urology Clinic. If you have any questions, please feel free to contact me. ,Sincerely yours,

pediatrics - neonatal, differential function, diuretic renal scan, abdominal pain, renal scan, pediatric urology,

Increasing oxygen requirement. Baby boy has significant pulmonary hypertension.

Pediatrics - Neonatal

Pulmonary Hypertension - Pediatric Consult

INDICATION FOR CONSULTATION: , Increasing oxygen requirement.,HISTORY: , Baby boy, XYZ, is a 29-3/7-week gestation infant. His mother had premature rupture of membranes on 12/20/08. She then presented to the Labor and Delivery with symptoms of flu. The baby was then induced and delivered. The mother had a history of premature babies in the past. This baby was doing well, and then, we had a significant increasing oxygen requirement from room air up to 85%. He is now on 60% FiO2.,PHYSICAL FINDINGS,GENERAL: He appears to be pink, well perfused, and slightly jaundiced.,VITAL SIGNS: Pulse 156, 56 respiratory rate, 92% sat, and 59/28 mmHg blood pressure.,SKIN: He was pink.,He was on the high-frequency ventilator with good wiggle.,His echocardiogram showed normal structural anatomy. He has evidence for significant pulmonary hypertension. A large ductus arteriosus was seen with bidirectional shunt. A foramen ovale shunt was also noted with bidirectional shunt. The shunting for both the ductus and the foramen ovale was equal left to right and right to left.,IMPRESSION: , My impression is that baby boy, XYZ, has significant pulmonary hypertension. The best therapy for this is to continue oxygen. If clinically worsens, he may require nitric oxide. Certainly, Indocin should not be used at this time. He needs to have lower pulmonary artery pressures for that to be considered.,Thank you very much for allowing me to be involved in baby XYZ's care.

pediatrics - neonatal, high-frequency ventilator, structural anatomy, foramen ovale, oxygen requirement, hypertension, pulmonary

Ligation (clip interruption) of patent ductus arteriosus. This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.

Pediatrics - Neonatal

Patent Ductus Arteriosus Ligation

TITLE OF OPERATION: , Ligation (clip interruption) of patent ductus arteriosus.,INDICATION FOR SURGERY: , This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch. She has now been put forward for operative intervention.,PREOP DIAGNOSIS: ,1. Patent ductus arteriosus.,2. Severe prematurity.,3. Operative weight less than 4 kg (600 grams).,COMPLICATIONS: , None.,FINDINGS: , Large patent ductus arteriosus with evidence of pulmonary over circulation. After completion of the procedure, left recurrent laryngeal nerve visualized and preserved. Substantial rise in diastolic blood pressure.,DETAILS OF THE PROCEDURE: , After obtaining information consent, the patient was positioned in the neonatal intensive care unit, cribbed in the right lateral decubitus, and general endotracheal anesthesia was induced. The left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed. Dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma. The lung was quite edematous and was retracted anteriorly exposing the area of the isthmus. The pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion. It was then test occluded and then interrupted with a medium titanium clip. There was preserved pulsatile flow in the descending aorta. The left recurrent laryngeal nerve was identified and preserved. With excellent hemostasis, the intercostal space was closed with 4-0 Vicryl sutures and the muscular planes were reapproximated with 5-0 Caprosyn running suture in two layers. The skin was closed with a running 6-0 Caprosyn suture. A sterile dressing was placed. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was returned to the supine position in which palpable bilateral femoral pulses were noted.,I was the surgical attending present in the neonatal intensive care unit and in-charge of the surgical procedure throughout the entire length of the case.

pediatrics - neonatal, clip interruption, ligation, patent ductus arteriosus, premature baby, intercostal space, arteriosus, interruption, pulmonary, circulation

Template for History and Physical for a newborn.

Pediatrics - Neonatal

Normal Newborn H&P Template

HISTORY OF PRESENT ILLNESS: , This is a ** week gestational age ** delivered by ** at ** on **. Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound. ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear. The baby was vertex presentation. The baby was dried, stimulated, and bulb suctioned. Apgar scores of ** at one minute and ** at five minutes.,PAST MEDICAL HISTORY,MATERNAL HISTORY:, The mother is a **-year-old, G**, P** female with blood type **. She is rubella immune, hepatitis surface antigen negative, RPR nonreactive, HIV negative. Mother was group B strep **. Mother's past medical history is **.,PRENATAL CARE: , Mother began prenatal care in the ** trimester and had at least ** documented prenatal visits. She did not smoke, drink alcohol, or use illicit drugs during pregnancy.,SURGICAL HISTORY: , **,MEDICATIONS:, Medications taken during this pregnancy were **.,ALLERGIES: , **,FAMILY HISTORY: , **,SOCIAL HISTORY: , **,PHYSICAL EXAMINATION,VITAL SIGNS: Temperature **, heart rate **, respiratory rate **. Dextrose stick **. Ballard score by the RN is ** weeks. Birth weight is ** grams, which is the ** percentile for gestational age. Length is ** centimeters which is ** percentile for gestational age. Head circumference is ** centimeters which is ** percentile for gestational age.,GENERAL: **Alert, active, nondysmorphic-appearing infant in no acute distress.,HEENT: Anterior fontanelle open and flat. Positive bilateral red reflexes.,Ears have normal shape and position with no pits or tags. Nares patent. Palate intact. Mucous membranes moist.,NECK: Full range of motion.,CARDIOVASCULAR: Normal precordium, regular rate and rhythm. No murmurs. Normal femoral pulses.,RESPIRATORY; Clear to auscultation bilaterally. No retractions.,ABDOMEN: Soft, nondistended. Normal bowel sounds. No hepatosplenomegaly. Umbilical stump is clean, dry, and intact.,GENITOURINARY: Normal tanner I **. Anus patent.,MUSCULOSKELETAL: Negative Barlow and Ortolani. Clavicles intact. Spine straight. No sacral dimple or hair tuft. Leg lengths grossly symmetric. Five fingers on each hand and five toes on each foot.,SKIN: Warm and pink with brisk capillary refill. No jaundice.,NEUROLOGICAL: Normal tone. Normal root, suck, grasp, and Moro reflexes. Moves all extremities equally.,DIAGNOSTIC STUDIES,LABORATORY DATA:, **,ASSESSMENT: , Full term, appropriate for gestational age **.,PLAN:,1. Routine newborn care.,2. Anticipatory guidance.,3. Hepatitis B immunization prior to discharge.,

Fever, otitis media, and possible sepsis.

Pediatrics - Neonatal

Otitis Media - Discharge Summary

ADMITTING DIAGNOSES:,1. Fever.,2. Otitis media.,3. Possible sepsis.,HISTORY OF PRESENT ILLNESS: ,The patient is a 10-month-old male who was seen in the office 1 day prior to admission. He has had a 2-day history of fever that has gone up to as high as 103.6 degrees F. He has also had intermittent cough, nasal congestion, and rhinorrhea and no history of rashes. He has been taking Tylenol and Advil to help decrease the fevers, but the fever has continued to rise. He was noted to have some increased workup of breathing and parents returned to the office on the day of admission.,PAST MEDICAL HISTORY: , Significant for being born at 33 weeks' gestation with a birth weight of 5 pounds and 1 ounce.,PHYSICAL EXAMINATION: , On exam, he was moderately ill appearing and lethargic. HEENT: Atraumatic, normocephalic. Pupils are equal, round, and reactive to light. Tympanic membranes were red and yellow, and opaque bilaterally. Nares were patent. Oropharynx was slightly moist and pink. Neck was soft and supple without masses. Heart is regular rate and rhythm without murmurs. Lungs showed increased workup of breathing, moderate tachypnea. No rales, rhonchi or wheezes were noted. Abdomen: Soft, nontender, nondistended. Active bowel sounds. Neurologic exam showed good muscle strength, normal tone. Cranial nerves II through XII are grossly intact.,LABORATORY FINDINGS: , He had electrolytes, BUN and creatinine, and glucose all of which were within normal limits. White blood cell count was 8.6 with 61% neutrophils, 21% lymphocytes, 17% monocytes, suggestive of a viral infection. Urinalysis was completely unremarkable. Chest x-ray showed a suboptimal inspiration, but no evidence of an acute process in the chest.,HOSPITAL COURSE: , The patient was admitted to the hospital and allowed a clear liquid diet. Activity is as tolerates. CBC with differential, blood culture, electrolytes, BUN, and creatinine, glucose, UA, and urine culture all were ordered. Chest x-ray was ordered as well with 2 views to evaluate for a possible pneumonia. Pulse oximetry checks were ordered every shift and as needed with O2 ordered per nasal cannula if O2 saturations were less that 94%. Gave D5 and quarter of normal saline at 45 mL per hour, which was just slightly above maintenance rate to help with hydration. He was given ceftriaxone 500 mg IV once daily to treat otitis media and possible sepsis, and I will add Tylenol and ibuprofen as needed for fevers. Overnight, he did have his oxygen saturations drop and went into oxygen overnight. His lungs remained clear, but because of the need for O2, we instituted albuterol aerosols every 6 hours to help maintain good lung function. The nurses were instructed to attempt to wean O2 if possible and advance the diet. He was doing clear liquids well and so I saline locked to help to accommodate improve the mobility with the patient. He did well the following evening with no further oxygen requirement. He continued to spike fevers but last fever was around 13:45 on the previous day. At the time of exam, he had 100% oxygen saturations on room air with temperature of 99.3 degrees F. with clear lungs. He was given additional dose of Rocephin when it was felt that it would be appropriate for him to be discharged that morning.,CONDITION OF THE PATIENT AT DISCHARGE: , He was at 100% oxygen saturations on room air with no further dips at night. He has become afebrile and was having no further increased work of breathing.,DISCHARGE DIAGNOSES:,1. Bilateral otitis media.,2. Fever.,PLAN: ,Recommended discharge. No restrictions in diet or activity. He was continued Omnicef 125 mg/5 mL one teaspoon p.o. once daily and instructed to follow up with Dr. X, his primary doctor, on the following Tuesday. Parents were instructed also to call if new symptoms occurred or he had return if difficulties with breathing or increased lethargy.

pediatrics - neonatal, sepsis, cough, nasal congestion, rhinorrhea, oxygen saturations, otitis media, otitis, breathing, lungs, oropharynx, fever

Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress.

Pediatrics - Neonatal

Normal Newborn Infant Physical Exam

GENERAL: , A well-developed infant in no acute respiratory distress.,VITAL SIGNS: ,Initial temperature was XX, pulse XX, respirations XX. Weight XX grams, length XX cm, head circumference XX cm.,HEENT: ,Head is normocephalic with anterior fontanelle open, soft, and non-bulging. Eyes: Red reflex elicited bilaterally. TMs occluded with vernix and not well visualized. Nose and throat are patent without palatal defect.,NECK: , Supple without clavicular fracture.,LUNGS:, Clear to auscultation.,HEART:, Regular rate without murmur, click, or gallop present. Pulses are 2/4 for brachial and femoral.,ABDOMEN:, Soft with bowel sounds present. No masses or organomegaly.,GENITALIA: , Normal.,EXTREMITIES: , Without evidence of hip defects.,NEUROLOGIC: ,The infant has good Moro, grasp, and suck reflexes.,SKIN: , Warm and dry without evidence of rash.

pediatrics - neonatal, fontanelle, normocephalic, newborn infant, physical exam, acute respiratory, newborn, respiratory, distress, head, infant,

A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.

Pediatrics - Neonatal

New Onset Seizure

REASON FOR CONSULTATION: , New-onset seizure.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old female with a history of known febrile seizures, who was placed on Keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures. Although this has been a very successful treatment in terms of her febrile seizure control, she is now having occasional brief periods of pauses and staring, where she becomes unresponsive, but does not lose her postural tone. The typical spell according to dad last anywhere from 10 to 15 seconds, mom says 3 to 4 minutes, which likely means probably somewhere in the 30- to 40-second period of time. Mom did note that an episode had happened outside of a store recently, was associated with some perioral cyanosis, but there has never been a convulsive activity noted. There have been no recent changes in her Keppra dosing and she is currently only at 20 mg/kg per day, which is overall a low dose for her.,PAST MEDICAL HISTORY: , Born at 36 weeks' gestation by C-section delivery at 8 pounds 3 ounces. She does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue.,PAST SURGICAL HISTORY: , She has undergone no surgical procedures.,FAMILY MEDICAL HISTORY: , There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt. There is no other significant neurological history on the paternal side of the family.,SOCIAL HISTORY: , Currently lives with her mom, dad, and two siblings. She is at home full time and does not attend day care.,REVIEW OF SYSTEMS: ,Clear review of 10 systems are taken and revealed no additional findings other than those mentioned in the history of present illness.,PHYSICAL EXAMINATION:,Vital Signs: Weight was 15.6 kg. She was afebrile. Remainder of her vital signs were stable and within normal ranges for her age as per the medical record.,General: She was awake, alert, and oriented. She was in no acute distress, only slightly flustered when trying to place the EEG leads.,HEENT: Showed normocephalic and atraumatic head. Her conjunctivae were nonicteric and sclerae were clear. Her eye movements were conjugate in nature. Her tongue and mucous membranes were moist.,Neck: Trachea appeared to be in the midline.,Chest: Clear to auscultation bilaterally without crackles, wheezes or rhonchi.,Cardiovascular: Showed a normal sinus rhythm without murmur.,Abdomen: Showed soft, nontender, and nondistended, with good bowel sounds. There was no hepatomegaly or splenomegaly, or other masses noted on examination.,Extremities: Showed IV placement in the right upper extremity with appropriate restraints from the IV. There was no evidence of clubbing, cyanosis or edema throughout. She had no functional deformities in any of her peripheral limbs.,Neurological: From neurological standpoint, her cranial nerves were grossly intact throughout. Her strength was good in the bilateral upper and lower extremities without any distal to proximal variation. Her overall resting tone was normal. Sensory examination was grossly intact to light touch throughout the upper and lower extremities. Reflexes were 1+ in bilateral patella. Toes were downgoing bilaterally. Coordination showed accurate striking ability and good rapid alternating movements. Gait examination was deferred at this time due to EEG lead placement.,ASSESSMENT:, A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.,RECOMMENDATIONS,1. For now, we will go ahead and try to capture EEG as long as she tolerates it; however, if she would require sedation, I would defer the EEG until further adjustments to seizure medications are made and we will see her response to these medications.,2. As per the above, I will increase her Keppra to 300 mg p.o. b.i.d. bringing her to a total daily dose of just under 40 mg/kg per day. If further spells are noted, we may increase upwards again to around 4.5 to 5 mL each day.,3. I do not feel like any specific imaging needs to be done at this time until we see her response to the medication and review her EEG findings. EEG, hopefully, will be able to be reviewed first thing tomorrow morning; however, I would not delay discharge the patient to wait on the EEG results. The patient has been discharged and we will contact the family as an outpatient.,4. The patient will need followup arrangement with me in 5 to 6 weeks' time, so we may recheck and see how she is doing and arrange for further followup then.

The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation. Mother had two previous C-sections.

Pediatrics - Neonatal

Neonatal Discharge Summary

HOSPITAL COURSE:, The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation. Mother had two previous C-sections. Baby was born at 5:57 on 07/30/2006. Mother received ampicillin 2 g 4 hours prior to delivery. Mother came with preterm contractions, with progressive active labor in spite of the terbutaline and magnesium sulfate. Baby was born with Apgar scores of 8 and 9 at delivery. Fluid was cleared. Nuchal cord x1. Prenatal was at ABC Valley. Prenatal labs were O positive, antibody negative, rubella immune, RPR nonreactive. Baby was suctioned on perineum with good support. The baby was admitted to the NICU for prematurity and to rule out sepsis. Baby's cry was good. Color, tone, and __________ mild retractions. CBC, CRP, blood cultures were done. IV fluids of D10 at a rate of 6 mL an hour. Ampicillin and gentamicin were started via protocol. At the time of admission, the patient was stable on room air and has feeding issues. Baby was fed EBM 22 and NeoSure per os. Ampicillin and gentamicin were started per protocol but were discontinue when blood cultures came out negative after 48 hours. The patient continues on feeding issues, will not suck properly, was kept in the NICU, and put on OG tube for a couple of days after which p.o. feeds were advanced. Also, the baby was able to suck properly and was tolerating feeds. The baby was fed EBM 22 and NeoSure was added a day before discharge. At the time of discharge, baby was stable on room air, baby was tolerated p.o. foods and was sucking properly, was taking ad lib feeds and gaining weight.,ADMISSION DIAGNOSES:, Respiratory distress, rule out sepsis and prematurity.,DISCHARGE DIAGNOSES:, Stable, ex-34-week preemie.,Pediatrician after discharge will be Dr. X.,DISCHARGE INSTRUCTIONS: , To follow up with Dr. X in 2 to 3 days, an appointment was made for 08/14/2006. CPR teaching was completed on 08/11/2006 to parents. Formula feeding schedule with breast and NeoSure 2 to 3 ounces per feed. Ad lib feeding on demand.

pediatrics - neonatal, gestation, preemie, prematurity, sepsis, neosure, feeds, born, delivery, perineum, discharge,

Normal child physical exam template.

Pediatrics - Neonatal

Normal Child Exam Template

CHILD PHYSICAL EXAMINATION,VITAL SIGNS: Birth weight is ** grams, length **, occipitofrontal circumference **. Character of cry was lusty.,GENERAL APPEARANCE: Well.,BREATHING: Unlabored.,SKIN: Clear. No cyanosis, pallor, or icterus. Subcutaneous tissue is ample.,HEAD: Normal. Fontanelles are soft and flat. Sutures are opposed.,EYES: Normal with red reflex x2.,EARS: Patent. Normal pinnae, canals, TMs.,NOSE: Patent nares.,MOUTH: No cleft.,THROAT: Clear.,NECK: No masses.,CHEST: Normal clavicles.,LUNGS: Clear bilaterally.,HEART: Regular rate and rhythm without murmur.,ABDOMEN: Soft, flat. No hepatosplenomegaly. The cord is three vessel.,GENITALIA: Normal ** genitalia **with testes descended bilaterally.,ANUS: Patent.,SPINE: Straight and without deformity.,EXTREMITIES: Equal movements.,MUSCLE TONE: Good.,REFLEXES: Moro, grasp, and suck are normal.,HIPS: No click or clunk.

pediatrics - neonatal, child physical examination, physical, genitalia, child,

Skull, complete, five images.

Pediatrics - Neonatal

Multiple Images of Skull (Pediatric)

EXAM:, Skull, complete, five images,HISTORY:, Plagiocephaly.,TECHNIQUE: , Multiple images of the skull were evaluated. There are no priors for comparison.,FINDINGS: , Multiple images of the skull were evaluated and they reveal radiographic visualization of the cranial sutures without evidence of closure. There is no evidence of any craniosynostosis. There is no radiographic evidence of plagiocephaly.,IMPRESSION: , No evidence of craniosynostosis or radiographic characteristics for plagiocephaly.

pediatrics - neonatal, craniosynostosis, plagiocephaly, complete five images, multiple images, radiographic, images, skull,

Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity. The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.

Pediatrics - Neonatal

Neonatal Discharge Summary - 1

ADMITTING DIAGNOSES:, Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity.,HISTORY OF PRESENTING ILLNESS: , The baby is an ex-32 weeks small for gestational age infant with birth weight 1102. Baby was born at ABCD Hospital at 1333 on 07/14/2006. Mother is a 20-year-old gravida 1, para 0 female who received prenatal care. Prenatal course was complicated by low amniotic fluid index and hypertension. She was evaluated for evolving preeclampsia and had a C-section secondary to the nonreassuring fetal status. Baby delivered operatively, Apgar scores were 8 and 9 initially taken to level 2 satellite nursery and arrangements were to transfer to Children's Hospital. Infant was transferred to Children's Hospital for higher level of care, stayed at Children's Hospital for approximately 2 weeks, and was transferred back to ABCD where he stayed until he was discharged on 08/16/2006.,HOSPITAL COURSE: , At the time of transfer to ABCD, these were the following issues.,FEEDING AND NUTRITION: , Baby was on TPN and p.o. feeds had been started and were advanced 1 ml q.6h. Baby was tolerating p.o. feeds of expressed breast milk and baby began to experience some abdominal distention. The p.o. feeds were held and IV D10 water was given. Baby was started on Mylicon drops and glycerin suppositories. Abdominal ultrasound showed gaseous distention without signs of obstruction. OG tube was passed. Baby improved after couple of days when p.o. feedings were restarted. Baby was also given Reglan. At the time of discharge, baby was tolerating p.o. feeds well of BM fortified with 22-cal NeoSure. Feeding amounts at the time of discharge was between 35 to 50 mL per feed and weight was 1797 grams.,RESPIRATIONS: , At the time of admission, baby was not having any apnea spells, no bradycardia or desaturations, was saturating well on room air and continued to do well on room air until the time of discharge.,HYPOGLYCEMIA: , Baby began to experience hypoglycemic episodes on 07/24/2006. Blood glucose level was as low as 46. D10 was given initially as bolus. Baby continued to experience hypoglycemic episodes. Diazoxide was started 5 mg/kg per os every 8 hours and fingersticks were done to monitor blood glucose level. The baby improved with diazoxide, hypoglycemic issues resolved and then began again. Diazoxide was discontinued, but the hypoglycemic issues restarted. The Diazoxide was restarted again. Blood glucose level stabilized and then diazoxide was weaned off until daily dose of 6 mg/kg and then the diazoxide was discontinued. At the time of discharge, blood glucose levels were not being stable for 24 hours.,CARDIOVASCULAR: , Infant was hemodynamically stable on admission from Madera. Infant has a closed PDA. Infant had two cardiac echograms done. The lab showing normal antegrade flow across the right coronary artery as well as the left main and left anterior descending coronary artery, then the circumflex coronary artery.,CNS:, Infant had a head ultrasound done to rule out intracranial abnormalities and intracranial hemorrhage. The ultrasound was negative for intracranial hemorrhage.,INFECTIOUS DISEASE:, The patient had been on antibiotics during the stay at Madera. At the time of admission to the ABCD, the patient was not on any antibiotics and his clinically condition has remained stable.,HEMATOLOGY: , The patient is status post phototherapy at Madera and was started on iron.,OPHTHALMOLOGY: , Exam on 07/17/2006 showed immature retina. The patient is to get followup exam after discharge.,DISCHARGE DIAGNOSIS: , Stable ex-32-weeks preemie.,DISCHARGE INSTRUCTIONS: , The patient has been educated on CPR measures. Followup appointment has been made at Kid's Care. Calcium challenge has been done. The patient's parents are comfortable with feeding. The patient has been discharged on NeoSure and expressed breast milk.,

pediatrics - neonatal, delivered, preeclampsia, immaturity, intrauterine, prenatal, coronary artery, blood glucose, discharge, baby, coronary, intracranial, hypoglycemia, hypoglycemic, infant,

Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.

Pediatrics - Neonatal

Mastoiditis - Discharge Summary

DISCHARGE DIAGNOSES: ,1. Suspected mastoiditis ruled out.,2. Right acute otitis media.,3. Severe ear pain resolving.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis. The child has had very severe ear pain and blood draining from the right ear. The child had a temperature maximum of 101.4 in the ER. The patient was admitted and started on IV Unasyn, which he tolerated well and required Morphine and Vicodin for pain control. In the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased. The patient was evaluated by Dr. X from the ENT while in house. After reviewing the CT scan, it was felt that the CT scan was not consistent with mastoiditis. The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge. At the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved. The patient is also able to take p.o. well.,DISCHARGE PHYSICAL EXAMINATION:,GENERAL: The patient is alert, in no respiratory distress.,VITAL SIGNS: His temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.,HEENT: Right ear shows no redness. The area behind his ear is nontender. There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.,NECK: Supple.,CHEST: Clear breath sounds.,CARDIAC: Normal S1, S2 without murmur.,ABDOMEN: Soft. There is no hepatosplenomegaly or tenderness.,SKIN: Warm and well perfused.,DISCHARGE WEIGHT: , 38.7 kg.,DISCHARGE CONDITION: , Good.,DISCHARGE DIET:, Regular as tolerated.,DISCHARGE MEDICATIONS: ,1. Ciprodex Otic Solution in the right ear twice daily.,2. Augmentin 500 mg three times daily x10 days.,FOLLOW UP: ,1. Dr. Y in one week (ENT).,2. The primary care physician in 2 to 3 days.,TIME SPENT: , Approximate discharge time is 28 minutes.

Mediastinal exploration and delayed primary chest closure. The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification.

Pediatrics - Neonatal

Mediastinal Exploration

TITLE OF OPERATION:, Mediastinal exploration and delayed primary chest closure.,INDICATION FOR SURGERY:, The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification. The patient experienced an unexplained cardiac arrest at the completion of the procedure, which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass. The patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago. She did not meet the criteria for delayed primary chest closure.,PREOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,POSTOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,ANESTHESIA:, General endotracheal.,COMPLICATIONS:, None.,FINDINGS: , No evidence of intramediastinal purulence or hematoma. At completion of the procedure no major changes in hemodynamic performance.,DETAILS OF THE PROCEDURE: , After obtaining informed consent, the patient was brought to the room, placed on the operating room table in supine position. Following the administration of general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed. The chest was then prepped and draped in the usual sterile fashion and previously placed segmental AlloDerm was removed. The mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned. Through a separate incision and another 15-French Blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the RV-PA connection as well as inferior most aspect of the ventriculotomy. The pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires. The subcutaneous tissue and skin were closed in layers. There was no evidence of significant increase in central venous pressure or desaturation. The patient tolerated the procedure well. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was transferred to the Pediatric Intensive Care Unit shortly thereafter in critical but stable condition.,I was the surgical attending present in the operating room in charge of the surgical procedure throughout the entire length of the case.

pediatrics - neonatal, mediastinal exploration, delayed primary chest closure, extracorporeal membrane oxygenation, stage i norwood procedure, sano modification, chest closure, infant, mediastinal, exploration, closure, endotracheal, chest

This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.

Pediatrics - Neonatal

Kawasaki Disease - Discharge Summary

ADMITTING DIAGNOSIS: , Kawasaki disease.,DISCHARGE DIAGNOSIS:, Kawasaki disease, resolving.,HOSPITAL COURSE:, This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR. When he was sent to the hospital, he had a fever of 102. Subsequently, the patient was evaluated and based on the criteria, he was started on high dose of aspirin and IVIG. Echocardiogram was also done, which was negative. IVIG was done x1, and between 12 hours of IVIG, he spiked fever again; it was repeated twice, and then after second IVIG, he did not spike any more fever. Today, his fever and his rash have completely resolved. He does not have any conjunctivitis and no redness of mucous membranes. He is more calm and quite and taking good p.o.; so with a very close followup and a cardiac followup, he will be sent home.,DISCHARGE ACTIVITIES:, Ad-lib.,DISCHARGE DIET: , PO ad-lib.,DISCHARGE MEDICATIONS: , Aspirin high dose 340 mg q.6h. for 1 day and then aspirin low dose 40 mg q.d. for 14 days and then Prevacid also to prevent his GI from aspirin 15 mg p.o. once a day. He will be followed by his primary doctor in 2 to 3 days. Cardiology for echo followup in 4 to 6 weeks and instructed not to give any vaccine in less than 11 months because of IVIG, all the live virus vaccine, and if he gets any rashes, any fevers, should go to primary care doctor as soon as possible.

pediatrics - neonatal, mucous membranes, conjunctivitis, ad lib, kawasaki disease, vaccine, fever, aspirin

The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.

Pediatrics - Neonatal

Neuroblastoma - Consult

REASON FOR VISIT:, The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected. It was felt to be stage 2. It was not N-Myc amplified and had favorable Shimada histology. In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology. He is now being treated with chemotherapy per protocol P9641 and not on study. He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin. He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle. In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving. He is not acted ill or had any fevers. He has had somewhat diminished appetite, but it seems to be improving now. He is peeing and pooping normally and has not had any diarrhea. He did not have any appreciated nausea or vomiting. He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above. Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:, Reviewed as above and otherwise unchanged.,FAMILY HISTORY:, Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce. The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS: ,1. Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2. G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3. Fluconazole 37.5 mg daily.,4. Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm. Vital Signs: Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg. Eyes: Conjunctivae are clear, nonicteric. Pupils are equally round and reactive to light. Extraocular muscle movements appear intact with no strabismus. Ears: TMs are clear bilaterally. Oral Mucosa: No thrush is appreciated. No mucosal ulcerations or erythema. Chest: Port-a-Cath is nonerythematous and nontender to VP access port. Respiratory: Good aeration, clear to auscultation bilaterally. Cardiovascular: Regular rate, normal S1 and S2, no murmurs appreciated. Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses. Skin: No rashes. Neurologic: The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974. Medical tests none. Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES: ,1. Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2. History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3. Immunosuppression.,4. Mucosal candidiasis.,5. Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:, None.,PLANS: ,1. Neuroblastoma. The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy. I will plan for restaging with CT of the abdomen prior to the cycle.,2. Immunosuppression. The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday. Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3. Mucosal candidiasis. We will continue fluconazole for thrush. I am pleased that the clinical evidence of disease appears to have resolved. For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time. We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient. This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF. His ANC is nicely recovered. He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07. He continues on fluconazole for recent history of thrush. Plans are otherwise documented above.

This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease.

Pediatrics - Neonatal

Neonatal Consult

INFORMANT:, Dad on phone. Transferred from ABCD Memorial Hospital, rule out sepsis.,HISTORY: ,This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease. The patient had a fever of 100.1 on 09/13/2006 taken rectally, and mom being a nurse, took the baby to the hospital and he was admitted for rule out sepsis. All the sepsis workup was done, CBC, UA, LP, and CMP, and since a murmur was noted 2/5, he also had an echo done. The patient was put on ampicillin and cefotaxime. Echo results came back and they showed patent foramen ovale/ASD with primary pulmonary stenosis and then considering severe congenital heart disease, he was transferred here on vancomycin, ampicillin, and cefotaxime. The patient was n.p.o. when he came in. He was on 3/4 L of oxygen. According to the note, it conveyed that he had some subcostal retractions. On arriving here, baby looks very healthy. He has no subcostal retractions. He is not requiring any oxygen and he is positive for urine and stool. The stool is although green in color, and in the morning today, he spiked a fever of 100.1, but right now he is afebrile. ED called that case is a direct admit.,REVIEW OF SYSTEMS: ,The patient supposedly had fever, some weight loss, poor appetite. The day he had fever, no rash, no ear pain, no congestion, no rhinorrhea, no throat pain, no neck pain, no visual changes, no conjunctivitis, no cough, no dyspnea, no vomiting, no diarrhea, and no dysuria. According to mom, baby felt floppy on the day of fever and he also used to have stools every day 4 to 6 which is yellowish-to-green in color, but today the stool we noticed was green in color. He usually has urine 4 to 5 a day, but the day he had fever, his urine also was low. Mom gave baby some Pedialyte.,PAST MEDICAL HISTORY:, None.,HOSPITALIZATIONS:, Recent transfer from ABCD for the rule out sepsis and heart disease.,BIRTH HISTORY: ,Born on 08/23/2006 at Memorial Hospital, NSVD, no complications. Hospital stay 24 hours. Breast-fed, no formula, no jaundice, 7 pounds 8 ounces.,FAMILY HISTORY:, None.,SURGICAL HISTORY: , None.,SOCIAL HISTORY: ,Lives with mom and dad. Dad is a service manager at GMC; 4-year-old son, who is healthy; and 2 cats, 2 dogs, 3 chickens, 1 frog. They usually visit to a ranch, but not recently. No sick contact and no travel.,MEDICATIONS: , Has been on vancomycin, cefotaxime, and ampicillin.,ALLERGIES:, No allergies.,DIET:, Breast feeds q.2h.,IMMUNIZATIONS: , No immunizations.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 99, pulse 158, respiratory rate 68, blood pressure 87/48, oxygen 100% on room air.,MEASUREMENTS: Weight 3.725 kg.,GENERAL: Alert and comfortable and sleeping.,SKIN: No rash.,HEENT: Intact extraocular movements. PERRLA. No nasal discharge. No nasal cannula, but no oxygen is flowing active, and anterior fontanelle is flat.,NECK: Soft, nontender, supple.,CHEST: CTAP.,GI: Bowel sounds present. Nontender, nondistended.,GU: Bilaterally descended testes.,BACK: Straight.,NEUROLOGIC: Nonfocal.,EXTREMITIES: No edema. Bilateral pedal pulses present and upper arm pulses are also present.,LABORATORY DATA:, As drawn on 09/13/2006 at ABCD showed WBC 4.2, hemoglobin 11.8, hematocrit 34.7, platelets 480,000. Sodium 140, potassium 4.9, chloride 105, bicarbonate 28, BUN 7, creatinine 0.4, glucose 80, CRP 0.5. Neutrophils 90, bands 7, lymphocytes 27, monocytes 12, and eosinophils 4. Chest x-ray done on 09/13/2006 read as mild left upper lobe infiltrate, but as seen here, and discussed with Dr. X, we did not see any infiltrate and CBG was normal. UA and LP results are pending. Also pending are cultures for blood, LP, and urine.,ASSESSMENT AND PLAN: , This is a 3-week-old Caucasian baby boy admitted for rule out sepsis and congenital heart disease.,INFECTIOUS DISEASE/PULMONARY: , Afebrile with so far 20-hour blood cultures, LP and urine cultures are negative. We will get all the results from ABCD and until then we will continue to rule out sepsis protocol and put the patient on ampicillin and cefotaxime. The patient could be having fever due to mild gastroenteritis or urinary tract infection, so to rule out all these things we have to wait for all the results.,CVS: , He had a grade 2/5 murmur status post echo, which showed a patent foramen ovale, as well as primary pulmonary stenosis. These are the normal findings in a newborn as discussed with Dr. Y, so we will just observe the patient. He does not need any further workup.,GASTROINTESTINAL:

A 1-month-26-day-old with failure-to-thrive. was only at her birth weight, and was noted to have murmur.

Pediatrics - Neonatal

Infant Not Gaining Weight

CHIEF COMPLAINT:, Not gaining weight.,HISTORY OF PRESENT ILLNESS:, The patient is a 1-month-26-day-old African-American female in her normal state of health until today when she was taken to her primary care physician's office to establish care and to follow up on her feeds. The patient appeared to have failure-to-thrive. was only at her birth weight but when eating one may be possibly gaining 2 ounces every 3-4 hours, and was noted to have a murmur. At this point, the Hospitalist Service was contacted for admission. The patient was directly admitted to Children's Hospital Explore Ward.,In the explore ward, she was noted to be in mild respiratory distress and has some signs and symptoms of heart failure and had a prominent murmur, so an echo was done at bedside, which did show a moderately-sized patent ductus arteriosus and very small VSD and some mild signs and symptoms of congestive heart failure. The patient was also seen by Dr. X of Cardiology Service and a plan was then obtained.,PAST MEDICAL/BIRTH HISTORY: , The patient was born at term repeat C-section to a 27-year-old G3, P2 African-American female. Pregnancy was not complicated by hypertension, diabetes, drugs, alcohol abuse or smoking. Birthweight was 7 pounds 4 ounces at Community Hospital. The mother did have a repeat C-section. There is no rupture of membranes or group B strep status. The prenatal care began in the second month of pregnancy and was otherwise uncomplicated. Mother denies any sexual transmitted diseases or other significant illness. The patient was discharged home on day of life #3 without any complications.,ALLERGIES:, No known drug allergies.,DIET: , The patient only takes Enfamil 20 calories, 1-3 ounces per history every 3-4 hours.,ELIMINATION: , The patient urinates 3-4 times a day and has a bowel movement 3-4 times a day.,FAMILY HISTORY/SOCIAL HISTORY: , The patient lives with the mother. She has 2 older male siblings. All were reported good health. Family history is negative for any congenital heart disease, syndromes, hypertension, sickle cell anemia or sickle cell trait and no significant positive PPD contacts and history of second-hand smoke exposures.,REVIEW OF SYSTEMS: ,GENERAL: The patient has been reported to have normal activity and normal cry with no significant weight loss per mom's report, but conversely no significant weight gain. Mother does not report that she sweats whenever she eats or has any episodes of cyanosis. ,HEENT: Denies any significant nasal congestion or cough. ,RESPIRATORY: Denies any difficulty breathing or wheezing. ,CARDIOVASCULAR: As per above. GI: No history of any persistent vomiting or diarrhea. ,GU: Denies any decreased urinary output. ,MUSCULOSKELETAL: Negative. ,NEUROLOGICAL: Negative. ,SKIN: Negative.,All other systems reviewed are negative.,PHYSICAL EXAMINATION:,GENERAL: The patient is examined in her room, our next floor. She is crying very vigorously, especially when I examined but she is consolable.,VITAL SIGNS: Temperature currently is 96.3, heart rate 137, respirations 36, blood pressure 105/61 while crying.,HEENT: Normocephalic. The patient has a possible right temporoparietal bossing noted and slightly irregular shaped trapezoidal-shaped head. The anterior fontanelle is soft and flat. Pupils are equal, reactive to light and accommodation, but there is some mild hypertelorism. There is also some mild posterior rotation of the ears. Oropharynx, mucous membranes are pink and moist. There is a slightly high arched palate.,NECK: Significant for possible mild reddening of the neck.,LUNGS: Significant for perihilar crackles. Mild tachypnea is noted. O2 saturations are currently 97% on room air. There is mild intercostal retraction.,CARDIOVASCULAR: Heart has regular rate and rhythm. Peripheral pulses are only 1+. Capillary refills less than 3-4 seconds.,EXTREMITIES: Slightly cool to touch. There is 2-3/6 systolic murmur along the left sternal border. Does radiate to the axilla and to the back.,ABDOMEN: Soft, slightly distended, but nontender. The liver edge is palpable 4 cm below right costal margin. The spleen tip is also palpable.,GU: Normal female external genitalia is noted.,MUSCULOSKELETAL: The patient has poor fat deposits in her extremities. Strength is only 2/4. She had normal number of fingers and toes.,SKIN: Significant for slight mottling. There are very poor subcutaneous fat deposits in her skin.,LABORATORY DATA: , The i-STAT only shows sodium 135, potassium on a heel stick was 6.3, hemoglobin and hematocrit are 14 and 41, and white count was 1.4. CBG on i-STAT showed the pH of 7.34 with CO2 of 55, O2 sat of 51, CO2 of 29 with the base excess of 4. Chest x-ray shows bilateral infiltrates and significant cardiomegaly consistent with congenital heart disease and mild congestive heart failure.,ASSESSMENT: , This is an almost 2-month-old presents with:,1. Failure-to-thrive.,2. Significant murmur and patent ductus arteriosus.,3. Congestive heart failure.,PLAN: ,At present, we are going to admit and monitor closely tonight. We will get a chest x-ray and start Lasix at 1 mg/kg twice daily. We will also get a CBC and check a blood culture and further workup as necessary.

Left communicating hydrocele. Left inguinal hernia and hydrocele repair. The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele.

Pediatrics - Neonatal

Inguinal Hernia & Hydrocele Repair

PREOPERATIVE DIAGNOSIS: ,Left communicating hydrocele.,POSTOPERATIVE DIAGNOSIS: , Left communicating hydrocele.,ANESTHESIA: , General.,PROCEDURE: ,Left inguinal hernia and hydrocele repair.,INDICATIONS: , The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele. The fluid size tends to fluctuate with time but has been relatively persistent for the past year. I met with the patient's mom and also spoke with his father by phone in the past couple of months and explained the diagnosis of patent processus vaginalis for communicating hydrocele and talked to them about the surgical treatment and options. All their questions have been answered and the patient is fit for operation today.,OPERATIVE FINDINGS: ,The patient had a very thin patent processus vaginalis leading to a rather sizeable hydrocele sac in the left hemiscrotum. We probably drained around 10 to 15 mL of fluid from the hydrocele sac. The processus vaginalis was clearly seen back to the peritoneal reflection where a high ligation was successfully performed. There were no other abnormalities noted in the inguinal scrotal region.,DESCRIPTION OF OPERATION: , The patient came to the operating room and had an uneventful induction of inhalation anesthetic. A peripheral IV was placed, and we conducted a surgical time-out to reiterate all of The patient's important identifying information and to confirm that we were indeed going to perform a left inguinal hernia and hydrocele repair. After preparation and draping was done with chlorhexidine based prep solution, a local infiltration block as well as an ilioinguinal and iliohypogastric nerve block was performed with 0.25% Marcaine with dilute epinephrine. A curvilinear incision was made low in the left inguinal area along one of prominent skin folds. Soft tissue dissection was carried down through Scarpa's layer to the external oblique fascia, which was then opened to expose the underlying spermatic cord structures. The processus vaginalis was dissected free from the spermatic cord structures, and the distal hydrocele sac was widely opened and drained of its fluid contents. The processus vaginalis was cleared back to peritoneal reflection at the deep inguinal ring and a high ligation was performed there using both the transfixing and a mass ligature of 3-0 Vicryl. After the excess hydrocele and processus vaginalis tissue was excised, the spermatic cord structures were replaced and the external oblique and Scarpa's layers were closed with interrupted 3-0 Vicryl sutures. Subcuticular 5-0 Monocryl and Steri-Strips were used for the final skin closure. The patient tolerated the operation well. He was awakened and taken to the recovery room in good condition. Blood loss was minimal. No specimen was submitted.,

pediatrics - neonatal, hydrocele, hydrocele repair, hernia, inguinal, fluid collection, tunica vaginalis, peritesticular space, hydrocele sac, spermatic cord, cord structures, inguinal hernia, communicating hydrocele, fluid, vaginalis

A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.

Pediatrics - Neonatal

Infantile Spasms

CHIEF COMPLAINT:, Arm and leg jerking.,HISTORY OF PRESENT ILLNESS: ,The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then. Mom denies any apnea, perioral cyanosis, or color changes. These movements are without any back arching. They mainly occur during sleep, so mom is unaware of any eye rolling. Mom is able to wake the patient up during this periods and stop the patient's extremity movements.,Otherwise, this patient has been active, breast-feeding well, although she falls asleep at the breast. She is currently taking in 15 to 20 minutes of breast milk every 2 to 3 hours. She is having increased diapers up to 8 wet and 6 to 7 dirty-yellow stools per day.,REVIEW OF SYSTEMS:, Negative fever, negative fussiness, tracks with her eyes, some sneezing and hiccups. This patient has developed some upper airway congestion in the past day. She has not had any vomiting or diarrhea. Per mom, she does not spit up, and mom is also unable to notice any relationship between these movements and feeds. This patient has not had any rashes. Mom was notified by the nurses at birth that her temperature may be low of approximately 97.5 degrees Fahrenheit. Otherwise, the above history of present illness and other review of systems negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pound 11 ounce baby, ex-41-weeker born via vaginal delivery without vacuum assist or forceps. There were no complications during pregnancy such as diabetes or hypertension. Prenatal care started at approximately 3 weeks, and mom maintained all visits. She also denies any smoking, alcohol, or drug use during the pregnancy. Mom was GBS status positive, but denies any other infections such as urinary tract infections. She did not have any fever during labor and received inadequate intrapartum antibiotics prophylaxis. After delivery, this patient did not receive antibiotics secondary to "borderline labs." She was jaundiced after birth and received photo treatments. Her discharge bilirubin level was approximately 11. Mom and child stayed in the hospital for approximately 3-1/2 days.,Mom denies any history of sexually transmitted disease in her or dad. She specifically denies any blistering, herpetic genital lesions. She does have a history though of human papillomavirus warts (vaginal), removed 20 years ago.,PAST SURGICAL HISTORY:, Negative.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , None.,SOCIAL HISTORY: , At home live mom, dad, and 18-, 16-, 14-, 12-year-old brothers, and a 3-year-old sister. All the residents at home are sick currently with cold, cough, runny nose, except for mom. At home also live 2 dogs and 2 outside cats. Mom denies any recent travel history, especially during the recent holidays and no smoke exposures.,FAMILY HISTORY:, Dad is with a stepdaughter with seizures starting at 14 years old, on medications currently. The patient's 16-year-old brother has incessant nonsustained ventricular tachycardia. The maternal grandmother is notable for hypertension and diabetes. There are no other children in the family who see a specialist or no child death less than 1 year of age.,PHYSICAL EXAMINATION:

4-day-old with hyperbilirubinemia and heart murmur.

Pediatrics - Neonatal

Hyperbilirubinemia - 4-day-old

HISTORY: , The patient is a 4-day-old being transferred here because of hyperbilirubinemia and some hypoxia. Mother states that she took the child to the clinic this morning since the child looked yellow and was noted to have a bilirubin of 23 mg%. The patient was then sent to Hospital where she had some labs drawn and was noted to be hypoxic, but her oxygen came up with minimal supplemental oxygen. She was also noted to have periodic breathing. The patient is breast and bottle-fed and has been feeding well. There has been no diarrhea or vomiting. Voiding well. Bowels have been regular.,According to the report from referring facility, because the patient had periodic breathing and was hypoxic, it was thought the patient was septic and she was given a dose of IM ampicillin.,The patient was born at 37 weeks' gestation to gravida 3, para 3 female by repeat C-section. Birth weight was 8 pounds 6 ounces and the mother's antenatal other than was normal except for placenta previa. The patient's mother apparently went into labor and then underwent a cesarean section.,FAMILY HISTORY: , Positive for asthma and diabetes and there is no exposure to second-hand smoke.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: The patient has a temperature of 36.8 rectally, pulse of 148 per minute, respirations 50 per minute, oxygen saturation is 96 on room air, but did go down to 90 and the patient was given 1 liter by nasal cannula.,GENERAL: The patient is icteric, well hydrated. Does have periodic breathing. Color is pink and also icterus is noted, scleral and skin.,HEENT: Normal.,NECK: Supple.,CHEST: Clear.,HEART: Regular with a soft 3/6 murmur. Femorals are well palpable. Cap refill is immediate,ABDOMEN: Soft, small, umbilical hernia is noted, which is reducible.,EXTERNAL GENITALIA: Those of a female child.,SKIN: Color icteric. Nonspecific rash on the body, which is sparse. The patient does have a cephalhematoma hematoma about 6 cm over the left occipitoparietal area.,EXTREMITIES: The patient moves all extremities well. Has a normal tone and a good suck.,EMERGENCY DEPARTMENT COURSE: , It was indicated to the parents that I would be repeating labs and also catheterize urine specimen. Parents were made aware of the fact that child did have a murmur. I spoke to Dr. X, who suggested doing an EKG, which was normal and since the patient will be admitted for hyperbilirubinemia, an echo could be done in the morning. The case was discussed with Dr. Y and he will be admitting this child for hyperbilirubinemia.,CBC done showed a white count of 15,700, hemoglobin 18 gm%, hematocrit 50.6%, platelets 245,000, 10 bands, 44 segs, 34 lymphs, and 8 monos. Chemistries done showed sodium of 142 mEq/L, potassium 4.5 mEq/L, chloride 104 mEq/L, CO2 28 mmol/L, glucose 75 mg%, BUN 8 mg%, creatinine 0.7 mg%, and calcium 8.0 mg%. Total bilirubin was 25.4 mg, all of which was unconjugated. CRP was 0.3 mg%. Blood culture was drawn. Catheterized urine specimen was normal. Parents were kept abreast of what was going on all the time and the need for admission. Phototherapy was instituted in the ER almost after the baby got to the emergency room.,IMPRESSION:, Hyperbilirubinemia and heart murmur.,DIFFERENTIAL DIAGNOSES: , Considered breast milk, jaundice, ABO incompatibility, galactosemia, and ventricular septal defect.

pediatrics - neonatal, hypoxia, periodic breathing, heart murmur, urine specimen, yellow, bilirubin, heart, murmur, hyperbilirubinemia,

Gastrostomy, a 6-week-old with feeding disorder and Down syndrome.

Pediatrics - Neonatal

Gastrostomy

PREOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,POSTOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,OPERATION PERFORMED: , Gastrostomy.,ANESTHESIA: , General.,INDICATIONS: ,This 6-week-old female infant had been transferred to Children's Hospital because of Down syndrome and congenital heart disease. She has not been able to feed well and in fact has to now be NG tube fed. Her swallowing mechanism does not appear to be very functional, and therefore, it was felt that in order to aid in her home care that she would be better served with a gastrostomy.,OPERATIVE PROCEDURE: ,After the induction of general anesthetic, the abdomen was prepped and draped in usual manner. Transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection. The muscle was divided and the peritoneal cavity entered. The greater curvature of the stomach was grasped with a Babcock clamp and brought into the operative field. The site for gastrostomy was selected and a pursestring suture of #4-0 Nurolon placed in the gastric wall. A 14-French 0.8 cm Mic-Key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube. Following this, the stomach was returned to the abdominal cavity and the posterior fascia was closed using a #4-0 Nurolon affixing the stomach to the posterior fascia. The anterior fascia was then closed with #3-0 Vicryl, subcutaneous tissue with the same, and the skin closed with #5-0 subcuticular Monocryl. The balloon was inflated to the full 5 mL. A sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition.,

pediatrics - neonatal, feeding disorder, down syndrome, congenital heart disease, mic-key tubeless, nurolon, subcutaneous tissue, fascia, syndrome, stomach, gastrostomy

Followup of laparoscopic fundoplication and gastrostomy. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access.

Pediatrics - Neonatal

Fundoplication & Gastrostomy Followup

REASON FOR VISIT: , Followup of laparoscopic fundoplication and gastrostomy.,HISTORY OF PRESENT ILLNESS: , The patient is a delightful baby girl, who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access and to protect her airway at a time when it is either going to heal enough to improve and allow decannulation or eventually prove that she will need laryngotracheoplasty. Dr. X is following The patient for this and currently plans are to perform a repeat endoscopic exam every couple of months to assist the status of her airway caliber.,The patient had a laparoscopic fundoplication and gastrostomy on 10/05/2007. She has done well since that time. She has had some episodes of retching intermittently and these seemed to be unpredictable. She also had some diarrhea and poor feeding tolerance about a week ago but that has also resolved. The patient currently takes about 1 ounce to 1.5 ounce of her feedings by mouth and the rest is given by G-tube. She seems otherwise happy and is not having an excessive amount of stools. Her parents have not noted any significant problems with the gastrostomy site.,The patient's exam today is excellent. Her belly is soft and nontender. All of her laparoscopic trocar sites are healing with a normal amount of induration, but there is no evidence of hernia or infection. We removed The patient's gastrostomy button today and showed her parents how to reinsert one without difficulty. The site of the gastrostomy is excellent. There is not even a hint of granulation tissue or erythema, and I am very happy with the overall appearance.,IMPRESSION: , The patient is doing exceptionally well status post laparoscope fundoplication and gastrostomy. Hopefully, the exquisite control of acid reflux by fundoplication will help her airway heal, and if she does well, allow decannulation in the future. If she does require laryngotracheoplasty, the protection from acid reflux will be important to healing of that procedure as well.,PLAN: ,The patient will follow up as needed for problems related to gastrostomy. We will see her when she comes in the hospital for endoscopic exams and possibly laryngotracheoplasty in the future.

pediatrics - neonatal, decannulation, enteral feeding, feeding access, laparoscopic fundoplication, gastrostomy, airway, laryngotracheoplasty, laparoscopic, fundoplication,

Head injury, anxiety, and hypertensive emergency.

Pediatrics - Neonatal

Head Injury

CHIEF COMPLAINT:, Head injury.,HISTORY: , This 16-year-old female presents to Children's Hospital via paramedic ambulance with a complaint at approximately 6 p.m. while she was at band practice using her flag device. She struck herself in the head with the flag. There was no loss of consciousness. She did feel dizzy. She complained of a headache. She was able to walk. She continued to participate in her flag practice. She got dizzier. She sat down for a while and walked and during the second period of walking, she had some episodes of diplopia, felt that she might faint and was assisted to the ground and was transported via paramedic ambulance to Children's Hospital for further evaluation.,PAST MEDICAL HISTORY: , Hypertension.,ALLERGIES:, DENIED TO ME; HOWEVER, IT IS NOTED BEFORE SEVERAL ACCORDING TO MEDITECH.,CURRENT MEDICATIONS: , Enalapril.,PAST SURGICAL HISTORY: , She had some kind of an abdominal obstruction as an infant.,SOCIAL HISTORY: , She is here with mother and father who lives at home. There is no smoking at home. There is second-hand smoke exposure.,FAMILY HISTORY: ,No noted family history of infectious disease exposure.,IMMUNIZATIONS:, She is up-to-date on her shots, otherwise negative.,REVIEW OF SYSTEMS: ,On the 10-plus systems reviewed with the section of those noted on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS: Her temperature 100 degrees, pulse 86, respirations 20, and her initial blood pressure 166/116, and a weight of 55.8 kg.,GENERAL: She is supine awake, alert, cooperative, and active child.,HEENT: Head atraumatic, normocephalic. Pupils equal, round, reactive to light. Extraocular motions intact and conjugate. Clear TMs, nose and oropharynx. Moist oral mucosa without noted lesions.,NECK: Supple, full painless nontender range motion.,CHEST: Clear to auscultation, equal, stable to palpation.,HEART: Regular without rubs or murmurs.,ABDOMEN: No abdominal bruits are heard.,EXTREMITIES: Equal femoral pulses are appreciated. Equal radial and dorsalis pedis pulses are appreciated. He moves all extremities without difficulty. Nontender. No deformity. No swelling.,SKIN: There was no significant bruising, lesions or rash about her abdomen. No significant bruising, lesions or rash.,NEUROLOGIC: Symmetric face and extremity motion. Ambulates without difficulty. She is awake, alert, and appropriate.,MEDICAL DECISION MAKING:, The differential entertained includes head injury, anxiety, and hypertensive emergency. She is evaluated in the emergency department with serial blood pressure examinations, which are noted to return to a more baseline state for her 130s/90s. Her laboratory data shows a mildly elevated creatinine of 1.3. Urine is within normal. Urinalysis showing no signs of infection. Head CT read by staff has no significant intracranial pathology. No mass shift, bleed or fracture per Dr. X. A 12-lead EKG reviewed preliminarily by myself noting normal sinus rhythm, normal axis rates of 90. No significant ST-T wave changes. No significant change from previous 09/2007 EKG. Her headache has resolved. She is feeling better. I spoke with Dr. X at 0206 hours consulting Nephrology regarding this patient's presentation with the plan for home. Follow up with her regular doctor. Blood pressures have normalized for her. She should return to emergency department on concern. They are to call the family to Nephrology Clinic next week for optimization of her blood pressure control with a working diagnosis of head injury, hypertension, and syncope.

Pediatric Gastroenterology - History of gagging.

Pediatrics - Neonatal

Gagging - 3-year-old

HISTORY OF PRESENT ILLNESS: , This is a 3-year-old female patient, who was admitted today with a history of gagging. She was doing well until about 2 days ago, when she developed gagging. No vomiting. No fever. She has history of constipation. She normally passes stool every two days after giving an enema. No rectal bleeding. She was brought to the Hospital with some loose stool. She was found to be dehydrated. She was given IV fluid bolus, but then she started bleeding from G-tube site. There was some fresh blood coming out of the G-tube site. She was transferred to PICU. She is hypertensive. Intensivist Dr. X requested me to come and look at her, and do upper endoscopy to find the site of bleeding.,PAST MEDICAL HISTORY: , PEHO syndrome, infantile spasm, right above knee amputation, developmental delay, G-tube fundoplication.,PAST SURGICAL HISTORY: , G-tube fundoplication on 05/25/2007. Right above knee amputation.,ALLERGIES:, None.,DIET: , She is NPO now, but at home she is on PediaSure 4 ounces 3 times a day through G-tube, 12 ounces of water per day.,MEDICATIONS: , Albuterol, Pulmicort, MiraLax 17 g once a week, carnitine, phenobarbital, Depakene and Reglan.,FAMILY HISTORY:, Positive for cancer.,PAST LABORATORY EVALUATION: , On 12/27/2007; WBC 9.3, hemoglobin 7.6, hematocrit 22.1, platelet 132,000. KUB showed large stool with dilated small and large bowel loops. Sodium 140, potassium 4.4, chloride 89, CO2 21, BUN 61, creatinine 2, AST 92 increased, ALT 62 increased, albumin 5.3, total bilirubin 0.1. Earlier this morning, she had hemoglobin of 14.5, hematocrit 41.3, platelets 491,000. PT 58 increased, INR 6.6 increased, PTT 75.9 increased.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Temperature 99 degrees Fahrenheit, pulse 142 per minute, respirations 34 per minute, weight 8.6 kg.,GENERAL: She is intubated.,HEENT: Atraumatic. She is intubated.,LUNGS: Good air entry bilaterally. No rales or wheezing.,ABDOMEN: Distended. Decreased bowel sounds.,GENITALIA: Grossly normal female.,CNS: She is sedated.,IMPRESSION: , A 3-year-old female patient with history of passage of blood through G-tube site with coagulopathy. She has a history of G-tube fundoplication, developmental delay, PEHO syndrome, which is progressive encephalopathy optic atrophy.,PLAN: ,Plan is to give vitamin K, FFP, blood transfusion. Consider upper endoscopy. Procedure and informed consent discussed with the family.

pediatrics - neonatal, g-tube, peho syndrome, tube site, gagging, constipation, endoscopy, peho, hemoglobin, hematocrit, intubated, bleeding, blood, fundoplication, tube,

Questionable foreign body, right nose. Belly and back pain. Mild constipation.

Pediatrics - Neonatal

Foreign Body - Right Nose

CHIEF COMPLAINT:, Questionable foreign body, right nose. Belly and back pain. ,SUBJECTIVE: , Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain. This does not seem to be slowing him down. They have not noticed any change in his urine or bowels. They have not noted him to have any fevers or chills or any other illness. They state he is otherwise acting normally. He is eating and drinking well. He has not had any other acute complaints, although they have noted a foul odor coming from his nose. Apparently, he was seen here a few weeks ago for a foreign body in the right nose, which was apparently a piece of cotton; this was removed and placed on antibiotics. His nose got better and then started to become malodorous again. Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there. Otherwise, he has not had any runny nose, earache, no sore throat. He has not had any cough, congestion. He has been acting normally. Eating and drinking okay. No other significant complaints. He has not had any pain with bowel movement or urination, nor have they noted him to be more frequently urinating, then again he is still on a diaper.,PAST MEDICAL HISTORY: , Otherwise negative.,ALLERGIES: , No allergies.,MEDICATIONS: , No medications other than recent amoxicillin.,SOCIAL HISTORY: , Parents do smoke around the house.,PHYSICAL EXAMINATION: , VITAL SIGNS: Stable. He is afebrile.,GENERAL: This is a well-nourished, well-developed 2-year-old little boy, who is appearing very healthy, normal for his stated age, pleasant, cooperative, in no acute distress, looks very healthy, afebrile and nontoxic in appearance.,HEENT: TMs, canals are normal. Left naris normal. Right naris, there is some foul odor as well as questionable purulent drainage. Examination of the nose, there was a foreign body noted, which was the appearance of a cotton ball in the right nose, that was obviously infected and malodorous. This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual. There was some erythema. No other purulent drainage noted. There was some bloody drainage. This was suctioned and all mucous membranes were visualized and are negative.,NECK: Without lymphadenopathy. No other findings.,HEART: Regular rate and rhythm.,LUNGS: Clear to auscultation.,ABDOMEN: His abdomen is entirely benign, soft, nontender, nondistended. Bowel sounds active. No organomegaly or mass noted.,BACK: Without any findings. Diaper area normal.,GU: No rash or infections. Skin is intact.,ED COURSE: , He also had a P-Bag placed, but did not have any urine. Therefore, a straight catheter was done, which was done with ease without complication and there was no leukocytes noted within the urine. There was a little bit of blood from catheterization but otherwise normal urine. X-ray noted some stool within the vault. Child is acting normally. He is jumping up and down on the bed without any significant findings.,ASSESSMENT:,1. Infected foreign body, right naris.,2. Mild constipation.,PLAN:, As far as the abdominal pain is concerned, they are to observe for any changes. Return if worse, follow up with the primary care physician. The right nose, I will place the child on amoxicillin 125 per 5 mL, 1 teaspoon t.i.d. Return as needed and observe for more foreign bodies. I suspect, the child had placed this cotton ball in his nose again after the first episode.

Irritable baby, 6-week-old, with fever for approximately 24 hours.

Pediatrics - Neonatal

H&P - Infant with fever

CHIEF COMPLAINT:, Irritable baby with fever for approximately 24 hours.,HISTORY OF PRESENT ILLNESS:, This 6-week-old infant was doing well until about 48 hours prior to admission, developed irritability, fussiness, a little bit of vomiting, and then fever up to 103-degrees. The child was brought into the emergency room and a complete septic workup was done, and the child is being treated in a rule out sepsis protocol.,PAST MEDICAL HISTORY:, This child was born by term pregnancy, spontaneous vaginal delivery, to a mother who was a teenager. He is bottle fed and he has had his hepatitis B vaccine. He lives in a home where there are smokers. This is his first illness.,PAST SURGICAL HISTORY:, He has had no previous surgeries.,MEDICATION (S):, He takes no medications on a regular basis.,REVIEW OF SYSTEMS:, Positive for those things mentioned already in the past medical history and history of present illness.,FAMILY HISTORY:, The family history is noncontributory.,SOCIAL HISTORY:, This child lives with his mother and father, both are teenagers, unmarried, who are not well educated. Grandmother is a heavy smoker.,PHYSICAL EXAMINATION:,VITAL SIGNS: The vital signs are stable, the patient is febrile at 101-degrees.,HEAD, EYES, EARS, NOSE, AND THROAT/GENERAL: The anterior fontanelle is not bulging. The rest of the examination is within normal limits. The neck is supple, no nuchal rigidity noted, though this child is irritable and fussy, and whines and cries where ever you make touch him. He has an irritable disposition no matter what you do to him, and whines even while at rest.,HEART: The heart rate is rapid, but there was no murmur noted.,LUNGS: The lungs are clear.,ABDOMEN: The abdomen is without mass, distention, or visceromegaly.,GENITOURINARY/RECTAL: Examination within normal limits.,EXTREMITIES: The extremities are normal. No Kernig's or Brudzinski sign.,NEUROLOGIC: Cranial nerves II through XII are intact, no focal deficits. As I mentioned before, the child is extremely irritable, fussy, and has a great deal of general inconsolability.,SKIN: The child, in addition, has a skin pattern of cutis marmorata, which I think is a bit more exaggerated since the child is febrile and has some peripheral vasodilatation.,CLINICAL IMPRESSION (S):, Likely viral syndrome, viral meningitis, flu syndrome.,PLAN:, Continue the septic workup protocol, supportive care with IV fluids, and Tylenol as needed for fever, and continue the antibiotics until spinal fluid cultures and blood cultures are negative for 48 hours. In addition, I believe that the rapid heart rate is a sinus tachycardia, and is related to the child's illness, irritability, and his fever. In addition, there were no intracranial bruits noted.

Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency.

Pediatrics - Neonatal

Goldenhar Syndrome - Discharge Summary

ADMITTING DIAGNOSES,1. Vomiting, probably secondary to gastroenteritis.,2. Goldenhar syndrome.,3. Severe gastroesophageal reflux.,4. Past history of aspiration and aspiration pneumonia.,DISCHARGE DIAGNOSES,1. Gastroenteritis versus bowel obstruction.,2. Gastroesophageal reflux.,3. Goldenhar syndrome.,4. Anemia, probably iron deficiency.,HISTORY OF PRESENT ILLNESS:, This is a 10-week-old female infant who has Goldenhar syndrome and has a gastrostomy tube in place and a J-tube in place. She was noted to have vomiting approximately 18 to 24 hours prior to admission and was seen in the emergency department and then admitted.,Because of her Goldenhar syndrome and previous problems with aspiration, she is not fed my mouth, but does have a G-tube. However, she has not been tolerating feedings through this prior to admission.,PHYSICAL EXAMINATION:,GENERAL: At transfer to UNM on October 13, 2003 reveals a dysmorphic infant who is small and slightly cachectic. Her left side of the face is deformed with microglia present, micrognathia present, and a moderate amount of torticollis.,VITAL SIGNS: Presently, her temperature is 98, pulse 152, respirations 36, weight is 3.98 kg, pulse oximetry on room air is 95%.,HEENT: Head is with anterior fontanelle open. Eyes: Red reflex elicited bilaterally. Left ear is without an external ear canal and the right is not well visualized at this time. Nose is presently without any discharge, and throat is nonerythematous. NECK: Neck with torticollis exhibited.,LUNGS: Presently are clear to auscultation.,HEART: Regular rate without murmur, click or gallop present. ABDOMEN: Moderately distended, but soft. Bowel sounds are decreased, and there is a G-tube and a J-tube in place. The skin surrounding the G-tube is moderately erythematous, but without any discharges present. J-tube is with a dressing in place and well evaluated.,EXTREMITIES: Grossly normal. Hip defects are not checked at this time.,GENITALIA: Normal female.,NEUROLOGIC: The infant does have a suck reflex, feeding grasp-reflex, and a feeding Moro reflex.,SKIN: Warm and dry and there is a macular area to the left ___ that is approximately 1 cm in length.,LABORATORY DATA: , WBC count on October 12, 2003 is 12,600 with 16 segs, 6 bands, 54 lymphocytes, 13% of which are noted to be reactive. Hemoglobin is 10.4, hematocrit 30.8, and she has abnormal red blood cell morphology. RDW is 13.1 and MCV is 91. Sodium level is 138, potassium 5.4, chloride 103, CO2 23, BUN 7, creatinine 0.4, glucose 84, calcium 9.9, and at this dictation, the report on the abdominal flat plate is pending.,HOSPITAL COURSE: ,The child was placed at bowel rest initially and then re-tried on full strength formula, but she did not tolerate. She was again placed on bowel rest and her medications, Pepcid and Reglan, were given in an attempt to increase bowel motility. Feedings were re-attempted with Pedialyte through the J-tube and these did not result in production of any stool and the child then began having vomiting again. The vomitus was noted to be bilious in nature and with particulate matter present.,After consultation with Dr. X, it was determined the child probably needed further evaluation, and she had both of her drains placed to gravity and was kept n.p.o. Her fluids have been D5 and 0.25 normal saline with 20 mEq/L of potassium chloride, which has run at her maintenance of 16 mL/h.,CONSULTATIONS: , With Dr. X and Dr. Y and the child is now ready for transport for continued diagnosis and treatment. Her condition at discharge is stable.

13 years old complaining about severe ear pain - Chronic otitis media.

Pediatrics - Neonatal

Ear pain - Pediatric Consult

PRESENTATION: , Patient, 13 years old, comes to your office with his mother complaining about severe ear pain. He awoke during the night with severe ear pain, and mom states that this is the third time this year he has had earaches.,HISTORY OF PRESENT ILLNESS: ,Patient reports that he felt good after taking antibiotics with each earache episode and has recently started on the wrestling team. Mom reports that patient has been afebrile with each of the earache episodes, and he has not had upper respiratory symptoms. Patient denies any head trauma associated with wrestling practice.,BIRTH AND DEVELOPMENTAL HISTORY:, Patient's mother reports a normal pregnancy with no complications, having received prenatal care from 12 weeks. Vaginal delivery was uneventful with a normal perinatal course. Patient sat alone at 6 months, crawled at 9 months, and walked at 13 months. His verbal and motor developmental milestones were as expected.,FAMILY/SOCIAL HISTORY: , Patient lives with both parents and two siblings (brother - age 11 years, sister - age 15 years). He reports enjoying school, remains active in scouts, and is very excited about being on the wresting team. Mom reports that he has several friends, but she is concerned about the time required for the wrestling team. Patient is in 8th grade this year and an A/B student. Both siblings are healthy. His Dad has hypertension and has frequent heartburn symptoms that he treats with over-the-counter (OTC) medications. Mom is healthy and has asthma.,PAST MEDICAL HISTORY: ,Patient has been seen in the clinic yearly for well child exams. He has had no major illnesses or hospitalizations. He had one emergency room visit 2 years ago for a knee laceration. Patient has been healthy except for the past year when he had two episodes of otitis media not associated with respiratory infections. He received antibiotic therapy (amoxicillin) for the otitis media and both episodes resolved without problems. Patient's Mom states that he takes no prescribed medications or OTC medications, but he admits that he has been taking his dad's OTC Pepcid AE sometimes when he gets heartburn. Upon further examination, he reports taking Pepcid when he eats pizza or Mexican food. He does complain of sore throats sometimes and often feels burning in his throat when he goes to sleep at night after a late evening snack.,NUTRITIONAL HISTORY: , Patient eats cereal bars or pop tarts with milk for breakfast most days. He takes his lunch (usually a sandwich and chips or yogurt and fruit) for lunch. Mom or his sister cooks supper in the evening. The family goes out to eat once or twice a week and he only gets "fast food" once or twice a week according to his Mom. He says he eats "a lot" especially after a wrestling meet.,PHYSICAL EXAM:,Height/weight: Patient weighs 109 pounds (60th percentile) and is 69 inches tall (93rd percentile). He is following the growth pattern he established in infancy.,Vital signs: BP 110/60, T 99.2, HR 70, R 16.,General: Alert, cooperative but a bit shy.,Neuro: DTRs symmetric, 2+, negative Romberg, able to perform simple calculations without difficulty, short-term memory intact. He responds appropriately to verbal and visual cues, and movements are smooth and coordinated.,HEENT: Normocephalic, PEERLA, red reflex present, optic disk and ocular vessels normal. TMs deep red, dull, landmarks obscured, full bilaterally. Post auricular and submandibular nodes on left are palpable and slightly tender.,Lungs: CTA, breath sounds equal bilaterally, excursion and chest configuration normal.,Cardiac: S1, S2 split, no murmurs, pulses equal bilaterally.,Abdomen: Soft, rounded, reports no epigastric tenderness but states that heartburn begins in epigastric area and rises to throat. Bowel sounds active in all quadrants. No hepatosplenomegaly or tenderness. No CVA tenderness.,Musculoskeletal: Full range of motion, all extremities. Spine straight, able to perform jumping jacks and duck walk without difficulty.,Genital: Normal male, Tanner stage 4. Rectal exam - small amount of soft stool, no fissures or masses.,LABS: ,Stool negative for blood and H. pylori antigen. Normal CBC and urinalysis. A barium swallow and upper GI was scheduled for the following week. It showed marked GE reflux.,ASSESSMENT: , The differential diagnoses for patient included (a) chronic otitis media/treatment failure, (b) peptic ulcer disease/gastritis, (c) gastro esophageal reflux disease (GERD) or carbonated beverage syndrome, (d) trauma.,CHRONIC OTITIS MEDIA. , Chronic otitis media due to a penicillin resistant organism would be the obvious diagnosis in this case. It is rare for an adolescent to have otitis media with no precipitating factor (such as being on a swim team or otherwise exposed to unusual organisms or in an unusual environment). It is certainly unusual for him to have three episodes in 1 year.,PEPTIC ULCER DISEASE., There were no symptoms of peptic ulcer disease, a negative H. pylori screen and lack of pain made this diagnosis less likely. Trauma. Trauma was a possibility, particularly since adolescent males frequently minimize symptoms especially if they might limit participation in a sport but patient maintained that he had not had an event where he struck his head or neck and that he always wore his helmet with ear padding.,GERD., The history of "heartburn" relieved by his father's medication was striking. The positive study supported the diagnosis of GERD, which was severe and chronic enough to cause irritation of the mucosal surfaces exposed to the gastric juices and edema, inflammation in the inner ears.,PLAN:, Patient and his Mom agreed to a trial of omeprazole 20 mg at bedtime for 2 weeks. Patient was to keep a diary of any episodes of heartburn, including what foods seemed to aggravate it. The clinician asked him to avoid using any antacid products in the meantime to gage the effectiveness of the medication. He was also given a prescription for 10 days of Augmentin99 and a follow-up appointment for 2 weeks. At his follow-up appointment he reported one episode after he ate a whole large pizza after wrestling practice but said it went away pretty quickly after he took his medication. A 6-month follow up appointment was scheduled.

Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure.

Pediatrics - Neonatal

Circumcision - Infant

PROCEDURE: , Circumcision.,PRE-PROCEDURE DIAGNOSIS: , Normal male phallus.,POST-PROCEDURE DIAGNOSIS: , Normal male phallus.,ANESTHESIA: ,1% lidocaine without epinephrine.,INDICATIONS: , The risks and benefits of the procedure were discussed with the parents. The risks are infection, hemorrhage, and meatal stenosis. The benefits are ease of care and cleanliness and fewer urinary tract infections. The parents understand this and have signed a permit.,FINDINGS: , The infant is without evidence of hypospadias or chordee prior to the procedure.,TECHNIQUE: ,The infant was given a dorsal penile block with 1% lidocaine without epinephrine using a tuberculin syringe and 0.5 cc of lidocaine was delivered subcutaneously at 10:30 and at 1:30 o'clock at the dorsal base of the penis.,The infant was prepped then with Betadine and draped with a sterile towel in the usual manner. Clamps were placed at 10 o'clock and 2 o'clock and the adhesions between the glans and mucosa were instrumentally lysed. Dorsal hemostasis was established and a dorsal slit was made. The foreskin was fully retracted and remaining adhesions between the glans and mucosa were manually lysed. The infant was fitted with a XX-cm Plastibell. The foreskin was retracted around the Plastibell and circumferential hemostasis was established. The excess foreskin was removed with scissors and the infant tolerated the procedure well with a minimum amount of blood loss. Instructions for continuing care are to watch for any evidence of hemorrhage or urination and the parents are instructed in the care of the circumcised penis.

pediatrics - neonatal, dorsal slit, hypospadias, chordee, epinephrine, hemorrhage, penis, adhesions, circumcision, phallus, lidocaine, foreskin, infant

The patient is 14 months old, comes in with a chief complaint of difficulty breathing.

Pediatrics - Neonatal

Difficulty Breathing - ER Visit

HISTORY:, The patient is 14 months old, comes in with a chief complaint of difficulty breathing. Difficulty breathing began last night. He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home. They were home for about an hour when he began to get worse and they drove here to Children's Hospital. He has a history of reactive airway disease. He has been seen here twice in the last month on 10/04/2007 and 10/20/2007, both times with some wheezing. He was diagnosed with pneumonia back on 06/12/2007 here in the Emergency Department but was not admitted at that time. He has been on albuterol off and on over that period. He has had fever overnight. No vomiting, no diarrhea. Increased work of breathing with retractions and audible wheezes noted and thus brought to the Emergency Department. Normal urine output. No rashes have been seen.,PAST MEDICAL HISTORY: , As noted above. No hospitalizations, surgeries, allergies.,MEDICATIONS: , Xopenex.,IMMUNIZATIONS:, Up-to-date.,BIRTH HISTORY:, The child was full term, no complications, home with mom. No surgeries.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No smokers or pets in the home. No ill contacts, no travel, no change in living condition.,REVIEW OF SYSTEMS: , Ten are asked, all are negative, except as noted above.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.,GENERAL: The child is awake, alert, in moderate respiratory distress.,HEENT: Pupils equal, round, reactive to light. Extraocular movements are intact. The TMs are clear. The nares show some dry secretions. Audible congestion and wheezing is noted. Mucous membranes are dry. Throat is clear. No oral lesions noted.,NECK: Supple without lymphadenopathy or masses. Trachea is midline.,LUNGS: Show inspiratory and expiratory wheezes in all fields. Audible wheezes are noted. There are intercostal and subcostal retractions and suprasternal muscle use is noted.,HEART: Shows tachycardia. Regular rhythm. Normal S1, S2. No murmur.,ABDOMEN: Soft, nontender. Positive bowel sounds. No guarding. No rebound. No hepatosplenomegaly.,EXTREMITIES: Capillary refill is brisk. Good distal pulses.,NEUROLOGIC: Cranial nerves II through XII intact. Moves all 4 extremities equally and normally.,HOSPITAL COURSE: , The child has an IV placed. I felt the child was dehydrated on examination. We gave 20 mL/kg bolus of normal saline over one hour. The child was given Solu-Medrol 2 mg/kg IV. He was initially started on unit dose albuterol and Atrovent but high-dose albuterol for continuous nebulization was ordered.,A portable chest x-ray was done showing significant peribronchial thickening bilaterally. Normal heart size. No evidence of pneumothorax. No evidence of focal pneumonia. After 3 unit dose of albuterol/Atrovent breathing treatments, there was much better air exchange bilaterally but still with inspiratory/expiratory wheezes and high-dose continuous albuterol was started at that time. The child was monitored closely while on high-dose albuterol and slowly showed improvement resulting in only expiratory wheezes after one hour. The child's pulse ox on breathing treatments with 100% oxygen was 100%. Respiratory rate remained about 40 to 44 breaths per minute indicating tachypnea. The child's color improved with oxygen therapy, and the capillary refill was always less than 2 seconds.,The child has failed outpatient therapy at this time. After 90 minutes of continuous albuterol treatment, the child still has expiratory wheezes throughout. After I removed the oxygen, the pulse ox was down at 91% indicating hypoxia. The child has a normal level of alertness; however, has not had any vomiting here. I spoke with Dr. X, on call for hospitalist service. She has come down and evaluated the patient. We both feel that since this child had two ER visits this last month, one previous ER visit within the last 5 hours, we should admit the child for continued albuterol treatments, IV steroids, and asthma teaching for the family. The child is admitted in a stable condition.,DIFFERENTIAL DIAGNOSES: ,Ruled out pneumothorax, pneumonia, bronchiolitis, croup.,TIME SPENT: ,Critical care time outside billable procedures was 45 minutes with this patient.,IMPRESSION: ,Status asthmaticus, hypoxia.,PLAN: ,Admitted to Pediatrics.

A 3-year-old abrupt onset of cough and increased work of breathing.

Pediatrics - Neonatal

Discharge Summary - Respiratory Distress

ADMITTING DIAGNOSES:,1. Respiratory distress.,2. Reactive airways disease.,DISCHARGE DIAGNOSES:,1. Respiratory distress.,2. Reactive airways disease.,3. Pneumonia.,HISTORY OF PRESENT ILLNESS: , The patient is a 3-year-old boy previously healthy who has never had a history of asthma or reactive airways disease who presented with a 36-hour presentation of URI symptoms, then had an abrupt onset of cough and increased work of breathing. Child was brought to Children's Hospital and received nebulized treatments in the ER and the Hospitalist Service was contacted regarding admission. The patient was seen and admitted through the emergency room.,He was placed on the hospitalist system and was started on continuous nebulized albuterol secondary to his respiratory distress. He also received inhaled as well as systemic corticosteroids. An x-ray was without infiltrate on initial review by the hospitalist, but there was a right upper lobe infiltrate versus atelectasis per the official radiology reading. The patient was not started on any antibiotics and his fever resolved. However, the CRP was relatively elevated at 6.7. The CBC was normal with a white count of 9.6; however, the bands were 84%. Given these results, which she is to treat the pneumonia as bacterial and discharge the child with amoxicillin and Zithromax.,He was taken off of continuous and he was not on room air all night. In the morning, he still had some bilateral wheezing, but no tachypnea.,DISCHARGE PHYSICAL EXAMINATION: , ,GENERAL: No acute distress, running around the room.,HEENT: Oropharynx moist and clear.,NECK: Supple without lymphadenopathy, thyromegaly or masses.,CHEST: Bilateral basilar wheezing. No distress.,CARDIOVASCULAR: Regular rate and rhythm. No murmurs noted. Well perfused peripherally.,ABDOMEN: Bowel sounds present. The abdomen is soft. There is no hepatosplenomegaly, no masses. Nontender to palpation.,GENITOURINARY: Deferred.,EXTREMITIES: Warm and well perfused.,DISCHARGE INSTRUCTIONS:, As follows:,1. Activity, regular.,2. Diet is regular.,3. Follow up with Dr. X in 2 days.,DISCHARGE MEDICATIONS:,1. Xopenex MDI 2 puffs every 4 hours for 2 days and then as needed for cough or wheeze.,2. QVAR 40, 2 puffs twice daily until otherwise instructed by the primary care provider.,3. Amoxicillin 550 mg p.o. twice daily for 10 days.,4. Zithromax 150 mg p.o. on day 1, then 75 mg p.o. daily for 4 more days.,Total time for this discharge 37 minutes.

A 2-month-old female with 1-week history of congestion and fever x2 days.

Pediatrics - Neonatal

Congestion & Fever - 2-month-old

CHIEF COMPLAINT:, A 2-month-old female with 1-week history of congestion and fever x2 days.,HISTORY OF PRESENT ILLNESS:, The patient is a previously healthy 2-month-old female, who has had a cough and congestion for the past week. The mother has also reported irregular breathing, which she describes as being rapid breathing associated with retractions. The mother states that the cough is at times paroxysmal and associated with posttussive emesis. The patient has had short respiratory pauses following the coughing events. The patient's temperature has ranged between 102 and 104. She has had a decreased oral intake and decreased wet diapers. The brother is also sick with URI symptoms, and the patient has had no diarrhea. The mother reports that she has begun to regurgitate after her feedings. She did not do this previously.,MEDICATIONS: , None.,SMOKING EXPOSURE: , None.,IMMUNIZATIONS: , None.,DIET: ,Similac 4 ounces every 2 to 3 hours.,ALLERGIES:, No known drug allergies.,PAST MEDICAL HISTORY: ,The patient delivered at term. Birth weight was 6 pounds 1 ounce. Postnatal complications: Neonatal Jaundice. The patient remained in the hospital for 3 days. The in utero ultrasounds were reported to be normal.,PRIOR HOSPITALIZATIONS: , None.,FAMILY/SOCIAL HISTORY: , Family history is positive for asthma and diabetes. There is also positive family history of renal disease on the father's side of the family.,DEVELOPMENT: , Normal. The patient tests normal on the newborn hearing screen.,REVIEW OF SYSTEMS: GENERAL: , The patient has had fever, there have been no chills. SKIN: No rashes. HEENT: Mild congestion x1 week. Cough, at times paroxysmal, no cyanosis. The patient turns red in the face during coughing episodes, posttussive emesis. CARDIOVASCULAR: No cyanosis. GI: Posttussive emesis, decreased oral intake. GU: Decreased urinary output. ORTHO: No current issues. NEUROLOGIC: No change in mental status. ENDOCRINE: There is no history of weight loss. DEVELOPMENT: No loss of developmental milestones.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Weight is 4.8 kg, temperature 100.4, heart rate is 140, respiratory rate 30, and saturations 100%.,GENERAL: This is a well-appearing infant in no acute distress.,HEENT: Shows anterior fontanelle to be open and flat. Pupils are equal and reactive to light with red reflex. Nares are patent. Oral mucosa is moist. Posterior pharynx is clear. Hard palate is intact. Normal gingiva.,HEART: Regular rate and rhythm without murmur.,LUNGS: A few faint rales. No retractions. No stridor. No wheezing on examination. Mild tachypnea.,EXTREMITIES: Warm, good perfusion. No hip clicks.,NEUROLOGIC: The patient is alert. Normal tone throughout. Deep tendon reflexes are 2+/4. No clonus.,SKIN: Normal.,LABORATORY DATA:, CBC shows a white count of 12.4, hemoglobin 10.1, platelet count 611,000; 38 segs 3 bands, 42 lymphocytes, and 10 monocytes. Electrolytes were within normal limits. C-reactive protein 0.3. Chest x-ray shows no acute disease with the exception of a small density located in the retrocardiac area on the posterior view. UA shows 10 to 25 bacteria.,ASSESSMENT/PLAN: ,This is a 2-month-old, who presents with fever, paroxysmal cough and episodes of respiratory distress. The patient is currently stable in the emergency room. We will admit the patient to the pediatric floor. We will send out pertussis PCR. We will also follow results of urine culture and that the urine dip shows 10 to 25 bacteria. The patient will be followed up for signs of sepsis, apnea, urinary tract infection, and pneumonia. We will wait for a radiology reading on the chest x-ray to determine if the density seen on the lateral film is a normal variant or represents pathology.

Congestion, tactile temperature.

Pediatrics - Neonatal

Congestion - 21-day-old

CHIEF COMPLAINT:, Congestion, tactile temperature.,HISTORY OF PRESENT ILLNESS: , The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions). One day ago, mom also noticed a tactile temperature and gave the patient Tylenol.,Baby also has had some decreased p.o. intake. His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion. He sleeps well, but has been more tired and has been fussy over the past 2 days. The parents noticed no improvement with albuterol treatments given in the ER. His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours. Mom denies any diarrhea. His bowel movements are yellow colored and soft in nature.,The parents also noticed no rashes, just his normal neonatal acne. The parents also deny any vomiting, apnea.,EMERGENCY ROOM COURSE: , In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count. This tap was reported as clear, then turning bloody in nature. The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture. This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status. Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.,REVIEW OF SYSTEMS: , See above history of present illness. Mom's nipples are currently cracked and bleeding. Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area. He is status post a circumcision. Otherwise, review of systems is negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section. Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family). GBS status was negative. Mom smoked up to the last 5 months of the pregnancy. Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions. Mom and baby were both discharged out of the hospital last 48 hours. This patient has received no hospitalizations so far.,PAST SURGICAL HISTORY:, Circumcision.,ALLERGIES: , No known drug allergies.,MEDICATIONS:, Tylenol.,IMMUNIZATIONS:, None of the family members this year have received a flu vaccine.,SOCIAL HISTORY:, At home lives mom, dad, a 2-1/2-year-old brother, and a 5-1/2-year-old maternal stepbrother. Both brothers at home are sick with cold symptoms including diarrhea and vomiting. The brother (2-1/2-year-old) was seen in the ER tonight with this patient and discharged home with an albuterol prescription. A nephew of the mom with an ear infection. Mom also states that she herself was sick with the flu soon after delivery. There has been recent travel exposure to dad's family over the Christmas holidays. At this time, there is also exposure to indoor cats and dogs. This patient also has positive smoking exposure coming from mom.,FAMILY HISTORY: , Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker. There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.,PHYSICAL EXAMINATION: ,VITALS: Temperature max is 99, heart rate was 133 to 177, blood pressure is 114/43 (while moving), respiratory rate was 28 to 56 with O2 saturations 97 to 100% on room air. Weight was 4.1 kg.,GENERAL: Not in acute distress, sneezing, positive congestion with breaths taken.,HEENT: Normocephalic, atraumatic head. Anterior fontanelle was soft, open, and flat. Bilateral red reflexes were positive. Oropharynx is clear with palate intact, negative rhinorrhea.,CARDIOVASCULAR: Heart was regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the upper left sternal border, vibratory in nature. Capillary refill was less than 3 seconds.,LUNGS: Positive upper airway congestion, transmitted sounds; negative retractions, nasal flaring, or wheezes.,ABDOMEN: Bowel sounds are positive, nontender, soft, negative hepatosplenomegaly. Umbilical site was with scant dried yellow discharge.,GU: Tanner stage 1 male, circumcised. There was mild hyperemia to the penis with some mild yellow dried discharge.,HIPS: Negative Barlow or Ortolani maneuvers.,SKIN: Positive facial erythema toxicum.,LABORATORY DATA: , CBC drawn showed a white blood cell count of 14.5 with a differential of 25 segmental cells, 5% bands, 54% lymphocytes. The hemoglobin was 14.4, hematocrit was 40. The platelet count was elevated at 698,000. A CRP was less than 0.3.,A hemolyzed BMP sample showed a sodium of 139, potassium of 5.6, chloride 105, bicarb of 21, and BUN of 4, creatinine 0.4, and a glucose of 66.,A cath urinalysis was negative.,A CSF sample showed 0 white blood cells, 3200 red blood cells (again this was a bloody tap per ER personnel), CSF glucose was 41, CSF protein was 89. A Gram stain showed rare white blood cells, many red blood cells, no organisms.,ASSESSMENT: , A 21-day-old with:,1. Rule out sepsis.,2. Possible upper respiratory infection.,Given the patient's multiple sick contacts, he is possibly with a viral upper respiratory infection causing his upper airway congestion plus probable fever. The bacterial considerations although to consider in this child include group B streptococcus, E. coli, and Listeria. We should also consider herpes simplex virus, although these 3200 red blood cells from his CSF could be due to his bloody tap in the ER. Also, there is not a predominant lymphocytosis of his CSF sample (there is 0 white blood cell count in the cell count).,Also to consider in this child is RSV. The patient though has more congested, nasal breathing more than respiratory distress, for example retractions, desaturations, or accessory muscle use. Also, there is negative apnea in this patient.,PLAN: ,1. We will place this patient on the rule out sepsis pathway including IV antibiotics, ampicillin and gentamicin for at least 48 hours.,2. We will follow up with his blood, urine, and CSF cultures.

Newborn circumcision. The penile foreskin was removed using Gomco.

Pediatrics - Neonatal

Circumcision - Newborn

PROCEDURE: , Newborn circumcision.,INDICATIONS: , Parental preference.,ANESTHESIA:, Dorsal penile nerve block.,DESCRIPTION OF PROCEDURE:, The baby was prepared and draped in a sterile manner. Lidocaine 1% 4 mL without epinephrine was instilled into the base of the penis at 2 o'clock and 10 o'clock. The penile foreskin was removed using a XXX Gomco. Hemostasis was achieved with minimal blood loss. There was no sign of infection. The baby tolerated the procedure well. Vaseline was applied to the penis, and the baby was diapered by nursing staff.

pediatrics - neonatal, nerve block, newborn circumcision, foreskin, gomco, penis, circumcision, newborn, penile

Circumcision. The child appeared to tolerate the procedure well. Care instructions were given to the parents.

Pediatrics - Neonatal

Circumcision - Child

PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,The child was placed in a Circumstraint board and restrained in the usual fashion. The area of the penis and scrotum were prepared with povidone iodine solution. The area was draped with sterile drapes, and the remainder of the procedure was done with sterile procedure. A dorsal penile block was done using 2 injections of 0.3 cc each, 1% plain lidocaine. A dorsal slit was made, and the prepuce was dissected away from the glans penis. A ** Gomco clamp was properly placed for 5 minutes. During this time, the foreskin was sharply excised using a #10 blade. With removal of the clamp, there was a good cosmetic outcome and no bleeding. The child appeared to tolerate the procedure well. Care instructions were given to the parents.

pediatrics - neonatal, circumstraint, dorsal slit, gomco clamp, circumcision, childNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

A 5-month-old infant with cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot.

Pediatrics - Neonatal

Congestion & Cough - 5-month-Old

CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS: ,The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot. She had no difficulty breathing and her cough was described as dry and hacky. At that time, physical exam showed a right TM, which was red. Left TM was okay. She was fairly congested but looked happy and playful. She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear. Mom returned to clinic again today because she got much worse overnight. She was having difficulty breathing. She was much more congested and her appetite had decreased significantly today. She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,ALLERGIES: , She has no known drug allergies.,MEDICATIONS: ,None except the Amoxil and Aldex started on Monday.,PAST MEDICAL HISTORY: ,Negative.,SOCIAL HISTORY: , She lives with mom, sister, and her grandparent.,BIRTH HISTORY: , She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces. No complications. Prevented, she passed her hearing screen at birth.,IMMUNIZATIONS: , Also up-to-date.,PAST SURGICAL HISTORY: , Negative.,FAMILY HISTORY: ,Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS: Her respiratory rate was approximately 60 to 65.,GENERAL: She was very congested and she looked miserable. She had no retractions at this time.,HEENT: Her right TM was still red and irritated with no light reflex. Her nasal discharge was thick and whitish yellow. Her throat was clear. Her extraocular muscles were intact.,NECK: Supple. Full range of motion.,CARDIOVASCULAR EXAM: She was tachycardic without murmur.,LUNGS: Revealed diffuse expiratory wheezing.,ABDOMEN: Soft, nontender, and nondistended.,EXTREMITIES: Showed no clubbing, cyanosis or edema.,LABORATORY DATA: ,Her chem panel was normal. RSV screen is positive. Chest x-ray and CBC are currently pending.,IMPRESSION AND PLAN: ,RSV bronchiolitis with otitis media. Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed.

A 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth.

Pediatrics - Neonatal

Chronic Otitis Media

CHIEF COMPLAINT:, Chronic otitis media.,HISTORY OF PRESENT ILLNESS:, This is a 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. There is also associated chronic nasal congestion. There had been no bouts of spontaneous tympanic membrane perforation, but there had been elevations of temperature up to 102 during the acute infection. He is being admitted at this time for myringotomy and tube insertion under general facemask anesthesia.,ALLERGIES:, None.,MEDICATIONS:, None.,FAMILY HISTORY:, Noncontributory.,MEDICAL HISTORY: , Mild reflux.,PREVIOUS SURGERIES:, None.,SOCIAL HISTORY: , The patient is not in daycare. There are no pets in the home. There is no secondhand tobacco exposure.,PHYSICAL EXAMINATION: , Examination of ears reveals retracted poorly mobile tympanic membranes on the right side with a middle ear effusion present. Left ear is still little bit black. Nose, moderate inferior turbinate hypertrophy. No polyps or purulence. Oral cavity, oropharynx 2+ tonsils. No exudates. Neck, no nodes, masses or thyromegaly. Lungs are clear to A&P. Cardiac exam, regular rate and rhythm. No murmurs. Abdomen is soft and nontender. Positive bowel sounds.,IMPRESSION: , Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, and wax accumulation.,PLAN:, The patient will be admitted to the operating room for myringotomy and tube insertion under general facemask anesthesia.

pediatrics - neonatal, chronic nasal congestion, tympanic membrane perforation, chronic otitis media, tube insertion, facemask anesthesia, otitis media, otitis, media,

Lumbar osteomyelitis and need for durable central intravenous access. Placement of left subclavian 4-French Broviac catheter.

Pediatrics - Neonatal

Broviac Catheter Placement

PREOPERATIVE DIAGNOSES:,1. Lumbar osteomyelitis.,2. Need for durable central intravenous access.,POSTOPERATIVE DIAGNOSES:,1. Lumbar osteomyelitis.,2. Need for durable central intravenous access.,ANESTHESIA:, General.,PROCEDURE:, Placement of left subclavian 4-French Broviac catheter.,INDICATIONS: ,The patient is a toddler admitted with a limp and back pain, who was eventually found on bone scan and septic workup to have probable osteomyelitis of the lumbar spine at disk areas. The patient needs prolonged IV antibiotic therapy, but attempt at a PICC line failed. She has exhausted most of her easy peripheral IV access routes and referral was made to the Pediatric Surgery Service for Broviac placement. I met with the patient's mom. With the help of a Spanish interpreter, I explained the technique for Broviac placement. We discussed the surgical risks and alternatives, most of which have been exhausted. All their questions have been answered, and the patient is fit for operation today.,DESCRIPTION OF OPERATION: ,The patient came to the operating room and had an uneventful induction of general anesthesia. We conducted a surgical time-out to reiterate all of the patient's important identifying information and to confirm that we were here to place the Broviac catheter. Preparation and draping of her skin was performed with chlorhexidine based prep solution and then an infraclavicular approach to left subclavian vein was performed. A flexible guidewire was inserted into the central location and then a 4-French Broviac catheter was tunneled through the subcutaneous tissues and exiting on the right anterolateral chest wall well below and lateral to the breast and pectoralis major margins. The catheter was brought to the subclavian insertion site and trimmed so that the tip would lie at the junction of the superior vena cava and right atrium based on fluoroscopic guidelines. The peel-away sheath was passed over the guidewire and then the 4-French catheter was deployed through the peel-away sheath. There was easy blood return and fluoroscopic imaging showed initially the catheter had transited across the mediastinum up the opposite subclavian vein, then it was withdrawn and easily replaced in the superior vena cava. The catheter insertion site was closed with one buried 5-0 Monocryl stitch and the same 5-0 Monocryl was used to tether the catheter at the exit site until fibrous ingrowth of the attached cuff has occurred. Heparinized saline solution was used to flush the line. A sterile occlusive dressing was applied, and the line was prepared for immediate use. The patient was transported to the recovery room in good condition. There were no intraoperative complications, and her blood loss was between 5 and 10 mL during the line placement portion of the procedure.

pediatrics - neonatal, lumbar osteomyelitis, central intravenous access, subclavian, osteomyelitis, broviac catheter, catheter, toddler, intravenous,

Delayed primary chest closure. Open chest status post modified stage 1 Norwood operation. The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.

Pediatrics - Neonatal

Chest Closure

PROCEDURE:, Delayed primary chest closure.,INDICATIONS: , The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation. Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected to leave the chest open to facilitate postoperative management. He is now taken back to the operative room for delayed primary chest closure.,PREOP DX: , Open chest status post modified stage 1 Norwood operation.,POSTOP DX:, Open chest status post modified stage 1 Norwood operation.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,FINDINGS:, No evidence of intramediastinal purulence or hematoma. He tolerated the procedure well.,DETAILS OF PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position. Following general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion. The previously placed AlloDerm membrane was removed. Mediastinal cultures were obtained, and the mediastinum was then profusely irrigated and suctioned. Both cavities were also irrigated and suctioned. The drains were flushed and repositioned. Approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line. The sternum was then smeared with a vancomycin paste. The proximal aspect of the 5 mm RV-PA conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side. The sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches. The skin was closed with interrupted nylon sutures and a sterile dressing was placed. The peritoneal dialysis catheter, atrial and ventricular pacing wires were removed. The patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition.,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.

pediatrics - neonatal, open chest, stage 1 norwood operation, hypoplastic left heart syndrome, delayed primary chest closure, chest closure, norwood operation

Health maintenance exam for 1-year-old female.

Pediatrics - Neonatal

1-year-old Exam - H&P

CHIEF COMPLAINT:, This 1-year-old female presents today for a health maintenance exam. Patient was accompanied by mother.,The child eats 3 meals a day plus 2 snacks and is off the bottle. She sleeps through the night. She takes morning and afternoon naps. Mother is concerned about child's red, matted eye and not walking completely alone yet. Immunizations need to be updated at today's visit.,DEVELOPMENTAL MILESTONES:, 1 year developmental milestones reached: bangs blocks together, drinks from cup, eating finger foods, feeds self, gives toys on request, imitates vocalizations, looks for dropped or hidden objects, points to desired objects, pulls to stand and cruises, releases cube into cup after demonstration, says "mama" and "dada" with meaning, says one or two other words, tries to build tower of 2 cubes and waves bye.,ALLERGIES:, No known medical allergies.,MEDICATIONS:, None.,PMH: , Past medical history is unremarkable.,PSH: , No previous surgeries.,FAMILY HISTORY:, Patient admits a family history of cancer associated with maternal aunt, hypertension associated with paternal grandfather.,SOCIAL HISTORY:, She lives at home with parents. Patient admits being in daycare.,REVIEW OF SYSTEMS:, No change since last visit,PHYSICAL EXAM:, Temp: 97.6 Height: 0 ft. 31 in. Weight: 28 lbs. BMI: 20,Growth Chart Entry: Weight: 28 lbs 0 ozs Height: 0 ft 31 in Head Circumference: 18.50 in Patient is a 1 year-old female who appears in no apparent distress, well developed and well nourished.,Inspection of head and face shows anterior fontanel normal, posterior fontanel normal and head is normocephalic and atraumatic.,Eyes: Fundoscopic exam reveals red reflex is present bilaterally.,Alignment is normal.,Sclera is white bilaterally.,Left inferior palpebral conjunctiva reveals conjunctivitis.,Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.,ENT: Pinna: normal.,Otoscopic examination reveals no abnormalities of external auditory canals and tympanic membranes.,Inspection of nose reveals no abnormalities and nares that are normal.,Nasal mucosa moist, pink, and without mass or exudate with no abnormalities of the septum and turbinates noted.,Inspection of lips, gums, and palate reveals no abnormalities.,Examination of oropharynx reveals no abnormalities and tissues pink and moist.,Neck: Neck exam reveals no masses.,Respiratory: Assessment of respiratory effort reveals even and nonlabored respirations. Auscultation of lungs reveal clear lung fields and no rubs noted.,Cardiovascular: Heart auscultation reveals rate is regular, rhythm is regular and no murmurs, gallop, rubs or clicks. Femoral pulses are 2 /4, bilateral.,Abdomen: Abdomen soft, nontender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities. Palpation of spleen reveals no abnormalities.,Genitourinary: Examination of anus and perineum shows no abnormalities.,Musculoskeletal: Inspection and palpation of bones, joints and muscles is unremarkable.,Muscle tone is normal.,Skin: Skin is not pale, jaundice, or cyanotic. Skin turgor, hydration, and texture is good. Palpation of skin shows no abnormalities.,Neurologic/Psychiatric: Moves all extremities.,TEST & X-RAY RESULTS:, Hb: 12 g/dl.,IMPRESSION:, Routine well child care. Acute conjunctivitis.,PLAN:

1+ year, black female for initial evaluation of a lifelong history of atopic eczema.

Pediatrics - Neonatal

Atopic Eczema

SUBJECTIVE:, This 1+ year, black female, new patient in dermatology, sent in for consult from ABC Practice for initial evaluation of a lifelong history of atopic eczema. The patient’s mom is from Tanzania. The patient has been treated with Elidel cream b.i.d. for six months but apparently this has stopped working now and it seems to make her more dry and plus she has been using some Johnson's Baby Oil on her. The patient is a well-developed baby. Appears stated age. Overall health is good.,FAMILY, SOCIAL, AND ALLERGY HISTORY: , The patient has eczema and a positive atopic family history. No psoriasis. No known drug allergies.,CURRENT MEDICATIONS:, None.,PHYSICAL EXAMINATION:, The patient has eczematous changes today on her face, trunk, and extremities.,IMPRESSION:, Atopic eczema.,TREATMENT:,1. Discussed condition and treatment with Mom.,2. Continue bathing twice a week.,3. Discontinue hot soapy water.,4. Discontinue Elidel for now.,5. Add Aristocort cream 0.25%, Polysporin ointment, Aquaphor b.i.d. and p.r.n. itch. We will see her in one month if not better otherwise on a p.r.n. basis. Send a letter to ABC Practice program.

pediatrics - neonatal, dermatology, elidel cream, johnson's baby oil, polysporin ointment, atopic eczema, eczema, eczematous, hot soapy water, atopic, elidel,

Nerve root decompression at L45 on the left side. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left. Interpretation of radiograph.

Pain Management

Tun-L Catheter Placement

PREOPERATIVE DIAGNOSIS:, Low Back Syndrome - Low back pain with left greater than right lower extremity radiculopathy.,POSTOPERATIVE DIAGNOSIS:, Same.,PROCEDURE:,1. Nerve root decompression at L45 on the left side.,2. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left.,3. Interpretation of radiograph.,ANESTHESIA: , IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None.,INDICATION FOR PROCEDURE: , Severe and excruciating pain in the lumbar spine and lower extremity. MRI shows disc pathology as well as facet arthrosis.,SUMMARY OF PROCEDURE: , The patient was admitted to the operating room, consent was obtained and signed. The patient was taken to the Operating room and was placed in the prone position. Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring. After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral region was prepped and draped in sterile fashion with Betadine and four sterile towels. After the towels were places then sterile drapes were placed on top of that.,After which time the Epimed catheter was then placed, this was done by first repositioning the C-Arm to visualize the lumbar spine and the vertebral bodies were then counted beginning at L5, verifying the sacral hiatus. The skin over the sacral hiatus was then injected with 1% Lidocaine and an #18-gauge needle was used for skin puncture. The #18-gauge needle was inserted off of midline. A #16-gauge RK needle was then placed into the skin puncture and using the paramedian approach and loss-of-resistance technique the needle was placed. Negative aspiration was carefully performed. Omnipaque 240 dye was then injected through the #16-gauge RK needle. The classical run off was noted. A filling defect was noted @ L45 nerve root on the left side. After which time 10 cc of 0.25% Marcaine/Triamcinolone (9/1 mixture) was then infused through the 16 R-K Needle. Some additional lyses of adhesions were visualized as the local anesthetic displaced the Omnipaque 240 dye using this barbotage technique.,An Epimed Tun-L catheter was then inserted through the #16-gauage R-K needle and threaded up to the L45 interspace under continuous fluoroscopic guidance. As the catheter was threaded up under continuous fluoroscopic visualization lyses of adhesions were visualized. The tip of the catheter was noted to be @ L45 level on the left side. After this the #16-gauge RK needle was then removed under fluoroscopic guidance verifying that the tip of the catheter did not migrate from the L45 nerve root region on the left side. After this was successfully done, the catheter was then secured in place; this was done with Neosporin ointment, a Split 2x2, Op site and Hypofix tape. The catheter was then checked with negative aspiration and the Omnipaque 240 dye was then injected. The classical run off was noted in the lumbar region. Some lyses of adhesions were also visualized at this time with barbotage technique. Good dye spread was noted to extend one level above and one level below the L45 nerve root and bilateral spread was noted. Nerve root decompression was visualized as dye spread into the nerve root whereas prior this was a filling defect. After which time negative aspiration was again performed through the Epimed® Tun-L catheter and then 10 cc of solution was then infused through the catheter, this was done over a 10-minute period with initial 3 cc test dose. Approximately 3 minutes elapsed and then the remaining 7 cc were infused (Solution consisting of 8 cc of 0.25% Marcaine, 2 cc of Triamcinolone and 1 cc of Wydase.) The catheter was then capped with a bacterial filter. The patient was noted to have tolerated the procedure well without any complications.,Interpretation of radiograph revealed nerve root adhesions present with lysis of these adhesions as the procedure was performed. A filling defect was seen at the L45 nerve root and this filling defect being significant of fibrosis and adhesions in this region was noted to be lysed with the insertion of the catheter as well as the barbotage procedure. This verified positive nerve root decompression. The tip of the Epimed Tun L catheter was noted to be at L45 level on the left side. Positive myelogram without dural puncture was noted during this procedure; no sub-dural spread of Omnipaque 240 dye was noted. This patient did not report any problems and reported pain reduction.

pain management, low back syndrome, low back pain, nerve root decompression, steroid solution, c-arm, epimed, tun l catheter, nerve root, negative aspiration, omnipaque dye, filling defect, nerve, root, catheter, adhesions, injection, needle,

A 5-month-old boy brought by his parents because of 2 days of cough.

Pediatrics - Neonatal

A 5-month-old boy with cough

CHIEF COMPLAINT:, A 5-month-old boy with cough.,HISTORY OF PRESENT ILLNESS:, A 5-month-old boy brought by his parents because of 2 days of cough. Mother took him when cough started 2 days go to Clinic where they told the mother he has viral infection and gave him Tylenol, but yesterday at night cough got worse and he also started having fever. Mother did not measure it.,REVIEW OF SYSTEMS:, No vomiting. No diarrhea. He had runny nose started with the cough two days ago. No skin rash. No cyanosis. Pulling on his right ear. Feeding, he is bottle-fed 2 ounces every 2 hours. Mother states he urinates like 5 to 6 times a day, stools 1 time a day. He is still feeding good to mom.,IMMUNIZATIONS: , He received first set of shot and due for the second set on 01/17/2008.,BIRTH HISTORY:, He was premature at 33 weeks born at Hospital kept in NICU for 2 weeks for feeding problem as the mother said. Mother had good prenatal care at 4 weeks for more than 12 visits. No complications during pregnancy. Rupture of membranes happened two days before the labor. Mother received the antibiotics, but she is not sure, if she received steroids also or not.,FAMILY HISTORY: , No history of asthma or lung disease.,SOCIAL HISTORY: , Lives with parents and with two siblings, one 18-year-old and the other is 14-year-old in house, in Corrales. They have animals, but outside the house and father smokes outside house. No sick contacts as the mother said.,PAST MEDICAL HISTORY:, No hospitalizations.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , No medications.,History of 2 previous ear infection, last one was in last November treated with ear drops, because there was pus coming from the right ear as the mother said.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Temperature 100.1, heart rate 184, respiratory rate 48. Weight 7 kg.,GENERAL: In no acute distress.,HEAD: Normocephalic and atraumatic. Open, soft, and flat anterior fontanelle.,NECK: Supple.,NOSE: Dry secretions.,EAR: Right ear full of yellowish material most probably pus and necrotic tissue. Tympanic membrane bilaterally visualized.,MOUTH: No pharyngitis. No ulcers. Moist mucous membranes.,CHEST: Bilateral audible breath sound. No wheezes. No palpitation.,HEART: Regular rate and rhythm with no murmur.,ABDOMEN: Soft, nontender, and nondistended.,GENITOURINARY: Tanner I male with descended testes.,EXTREMITIES: Capillary refill less than 2 seconds.,LABS:, White blood cell 8.1, hemoglobin 10.5, hematocrit 30.9, and platelets 380,000. CRP 6, segments 41, and bands 41. RSV positive. Chest x-ray evidenced bronchiolitis with hyperinflation and bronchial wall thickening in the central hilar region. Subsegmental atelectasis in the right upper lobe and left lung base.,ASSESSMENT:, A 5-month-old male with 2 days of cough and 1 day of fever. Chest x-ray shows bronchiolitis with atelectasis, and RSV antigen is positive.,DIAGNOSES: , Respiratory syncytial virus bronchiolitis with right otitis externa.,PLAN: , Plan was to admit to bronchiolitis pathway, and ciprofloxacin for right otitis externa eardrops twice daily.,

Trigger Point Injection. The area over the myofascial spasm was prepped with alcohol utilizing sterile technique.

Pain Management

Trigger Point Injection

OPERATION:,

pain management, myofascial spasm, trigger point injection, trigger, injection, spasm

Mother states he has been wheezing and coughing.

Pediatrics - Neonatal

Asthma in a 5-year-old

CHIEF COMPLAINT: , This 5-year-old male presents to Children's Hospital Emergency Department by the mother with "have asthma." Mother states he has been wheezing and coughing. They saw their primary medical doctor. He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma, prescribed prednisone and an antibiotic. They told to go to the ER if he got worse. He has had some vomiting and some abdominal pain. His peak flows on the morning are normal at 150, but in the morning, they were down to 100 and subsequently decreased to 75 over the course of the day.,PAST MEDICAL HISTORY:, Asthma with his last admission in 07/2007. Also inclusive of frequent pneumonia by report.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , Denied.,MEDICATIONS: ,Advair, Nasonex, Xopenex, Zicam, Zithromax, prednisone, and albuterol.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY: , Lives at home, here in the ED with the mother and there is no smoking in the home.,FAMILY HISTORY: , No noted exposures.,REVIEW OF SYSTEMS: ,Documented on the template. Systems reviewed on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 98.7, pulse 105, respiration is 28, blood pressure 112/65, and weight of 16.5 kg. Oxygen saturation low at 91% on room air.,GENERAL: This is a well-developed male who is cooperative, alert, active with oxygen by facemask.,HEENT: Head is atraumatic and normocephalic. Pupils are equal, round, and reactive to light. Extraocular motions are intact and conjugate. Clear TMs, nose, and oropharynx.,NECK: Supple. Full painless nontender range of motion.,CHEST: Tight wheezing and retractions heard bilaterally.,HEART: Regular without rubs or murmurs.,ABDOMEN: Soft, nontender. No masses. No hepatosplenomegaly.,GENITALIA: Male genitalia is present on a visual examination.,SKIN: No significant bruising, lesions or rash.,EXTREMITIES: Moves all extremities without difficulty, nontender. No deformity.,NEUROLOGIC: Symmetric face, cooperative, and age appropriate.,MEDICAL DECISION MAKING:, The differential entertained on this patient includes reactive airways disease, viral syndrome, and foreign body pneumonia. He is evaluated in the emergency department with continuous high-dose albuterol, Decadron by mouth, pulse oximetry, and close observation. Chest x-ray reveals bronchial thickening, otherwise no definite infiltrate. She is further treated in the emergency department with continued breathing treatments. At 0048 hours, he has continued tight wheezes with saturations 99%, but ED sats are 92% with coughing spells. Based on the above, the hospitalist was consulted and accepts this patient for admission to the hospital with the working diagnosis of respiratory distress and asthma.

Transforaminal Epidural, lumbar - Template. Fluoroscopy was used to identify the boney landmarks of the facet joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1 % lidocaine.

Pain Management

Transforaminal Epidural Steroid Injection - 1

PROCEDURE: ,Transforaminal Epidural, lumbar.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications. I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing. The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE: , Oxygen saturation and vital signs were monitored continuously throughout the procedure. The patient remained awake throughout the procedure in order to interact and give feedback. The X-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in the prone position on the treatment table with a pillow under the lower abdomen to reduce the natural lumbar lordosis. The skin over and surrounding the treatment area was cleaned with betadine. The area was covered with sterile drapes, leaving a small window opening for needle placement. Fluoroscopy was used to identify the boney landmarks of the facet joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1 % lidocaine.,With fluoroscopy, a *** spinal needle was gently guided into the superior-anterior neuroforamin lateral to the mid-pedicular line at ***. Multiple fluoroscopic views were used to ensure proper needle placement. Approximately *** of non-ionic contrast agent was injected into the joint under real time fluoroscopic observation. Correct needle placement was confirmed by production of an appropriate epidurogram and radiculogram without concurrent vascular dye pattern. Finally the treatment solution, consisting of *** was injected.,All injected medications were preservative free. Sterile techniques were used throughout the procedure.,COMPLICATIONS: ,None. No complications.,The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable. The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day. The patient was told to resume all medications. The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week.

pain management, epidural lumbar, facet joints, transforaminal epidural, injection, transforaminal, epidural, lumbar, fluoroscopy, needle,

Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.

Pain Management

Tenosynovectomy & Cortisone Injection

PREOPERATIVE DIAGNOSES,1. EMG-proven left carpal tunnel syndrome.,2. Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3. Dupuytren's nodule in the palm.,POSTOPERATIVE DIAGNOSES,1. EMG-proven left carpal tunnel syndrome.,2. Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3. Dupuytren's nodule in the palm.,PROCEDURE: , Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.,ANESTHESIA: , Local plus IV sedation (MAC).,ESTIMATED BLOOD LOSS: ,Zero.,SPECIMENS: ,None.,DRAINS: , None.,PROCEDURE DETAIL: , Patient brought to the operating room. After induction of IV sedation the left hand was anesthetized suitable for carpal tunnel release; 10 cc of a mixture of 1% Xylocaine and 0.5% Marcaine was injected in the distal forearm and proximal palm suitable for carpal tunnel surgery. Routine prep and drape was employed. Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet and tourniquet inflated to 250 mmHg pressure. Hand was positioned palm up in the lead hand-holder. A short curvilinear incision about the base of the thenar eminence was made. Skin was sharply incised. Sharp dissection was carried down to the transverse carpal ligament and this was carefully incised longitudinally along its ulnar margin. Care was taken to divide the entire length of the transverse retinaculum including its distal insertion into deep palmar fascia in the midpalm. Proximally the antebrachial fascia was released for a distance of 2-3 cm proximal to the wrist crease to insure complete decompression of the median nerve. Retinacular flap was retracted radially to expose the contents of the carpal canal. Median nerve was identified, seen to be locally compressed with moderate erythema and mild narrowing. Locally adherent tenosynovium was present and this was carefully dissected free. Additional tenosynovium was dissected from the flexor tendons, individually stripping and peeling each tendon in sequential order so as to debulk the contents of the carpal canal. Epineurotomy and partial epineurectomy were carried out on the nerve in the area of mild constriction to relieve local external scarring of the epineurium. When this was complete retinacular flap was laid loosely in place over the contents of the carpal canal and skin only was closed with interrupted 5-0 nylon horizontal mattress sutures. A syringe with 3 cc of Kenalog-10 and 3 cc of 1% Xylocaine using a 25 gauge short needle was then selected; 1 cc of this mixture was injected into the third finger A1 and A2 pulley tendon sheaths using standard trigger finger injection technique; 1 cc was injected into the fourth finger A1/A2 pulley tendon sheath using standard tendon sheath injection technique; 1 cc was injected into the Dupuytren's nodule in the midpalm to relieve local discomfort. Routine postoperative hand dressing with well-padded, well-molded volar plaster splint and lightly compressive Ace wrap was applied. Tourniquet was deflated. Good vascular color and capillary refill were seen to return to the tips of all digits. Patient discharged to the ambulatory recovery area and from there discharged home. Discharge medication is Darvocet-N 100, 30 tablets, one to two PO q.4h. p.r.n. Patient asked to begin gentle active flexion, extension and passive nerve glide exercises beginning 24-48 hours after surgery. She was asked to keep the dressings clean, dry and intact and follow up in my office.

pain management, carpal tunnel syndrome, pulley, dupuytren's, tenosynovitis, tenosynovectomy, carpal tunnel release, flexor tenosynovectomy, cortisone injection, dupuytren's nodule, injection, cortisone,

Thoracic epidural steroid injection without fluoroscopy. An 18-gauge Tuohy needle was then placed into the epidural space using loss of resistance technique.

Pain Management

Thoracic epidural steroid injection

PROCEDURE: , Thoracic epidural steroid injection without fluoroscopy.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed. The patient was in the sitting position and the back was prepped with Betadine. Lidocaine 1.5% was used for skin wheal made between __________. An 18-gauge Tuohy needle was then placed into the epidural space using loss of resistance technique with no cerebrospinal fluid or blood noted. After negative aspiration, a mixture of 7 cc preservative free normal saline and 160 mg preservative free Depo-Medrol was injected. Neosporin and band-aid were applied over the puncture site. The patient was discharged to recovery room in stable condition.

pain management, loss of resistance, cerebrospinal fluid, thoracic epidural steroid injection, fluoroscopy, thoracic, steroid, epidural, injection,

Flexible Bronchoscopy (pediatric)

Pediatrics - Neonatal

Bronchoscopy - Pediatric

FLEXIBLE BRONCHOSCOPY,The flexible bronchoscopy is performed under conscious sedation in the Pediatric Intensive Care Unit. I explained to the parents that the possible risks include: irritation of the nasal mucosa, which can be associated with some bleeding; risk of contamination of the lower airways by passage of the scope in the nasopharynx; respiratory depression from sedation; and a very small risk of pneumothorax. A bronchoalveolar lavage may be obtained by injecting normal saline in one of the bronchi and suctioning the fluid back. The sample will then be sent for testing. The flexible bronchoscopy is mainly diagnostic, any therapeutic intervention, if deemed necessary, will be planned and will require a separate procedure.,The parents seem to understand, had the opportunity to ask questions and were satisfied with the information. A booklet containing the description of the procedure and other information was provided.

pediatrics - neonatal, flexible bronchoscopy, pediatric intensive care unit, bleeding, bronchi, bronchoalveolar lavage, bronchoscopy, conscious sedation, nasal mucosa, nasopharynx, pneumothorax, respiratory, pediatric flexible bronchoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

Left L3-L4 transforaminal epidural steroid injection (L3 nerve root) and Left L4-L5 transforaminal epidural steroid injection (L4 nerve root) under fluoroscopic guidance.

Pain Management

Transforaminal Epidural Steroid Injection

PROCEDURE: , Left L3-L4 transforaminal epidural steroid injection (L3 nerve root) and Left L4-L5 transforaminal epidural steroid injection (L4 nerve root) under fluoroscopic guidance.,PATIENT PROFILE: , This is a 44-year-old female. The patient reports greatly increasing pain over the past several weeks. In addition, the patient has associated radicular symptoms of aching, radiating to the L3 dermatome distribution and L4 dermatome distribution. She is status post posterior fusion and lumbar decompression within the past several years. Due to the nature of the patient's persistent pain, epidural steroid injection is recommended. The alternatives, benefits, and risks were discussed with the patient. The patient verbalized understanding of the risks as well as the alternatives and wished to proceed with the procedure. A signed and witnessed informed consent was placed on the chart.,PRE-OP DIAGNOSIS:, Left leg pain, Left leg weakness, Left L3-4 radicular pain, Left L4-5 radicular pain, Lumbar spondylosis.,POST-OP DIAGNOSIS:, Left leg pain, Left leg weakness, Left L3-4 radicular pain, Left, L4-5 radicular pain, Lumbar spondylosis.,ANESTHESIA:, Midazolam 2 mg IV Fentanyl 50 mcg IV.,FINDINGS:,PAIN MANAGEMENT:, The patient reports greatly increasing pain over the past several weeks. The patient now rates pain as 8/10. The reported pain is at L3-4 and L4-5.,DESCRIPTION OF PROCEDURE:, The patient was placed in the prone position on the radiolucent operating table. The lumbar area was prepped and draped in the appropriate sterile fashion. The left L3-L4 level was identified for a transforaminal epidural injection and the overlying skin and subcutaneous tissue were anesthetized. A 22 gauge 3.5 inch B-bevel spinal needle was passed through the skin wheal and advanced in a ventral direction until the tip of the needle was properly placed in the left superior posterior intervertebral foramen as confirmed by AP and lateral fluoroscopic views. No blood was aspirated. There was no CSF flow. Following negative aspiration, 1 mL Isovue-M200 was injected to produce the epidurogram. There was appropriate needle placement and no intravascular or intrathecal flow. 1 mL of a 40 mg/mL solution of Kenalog and 1 mL of 1% Lidocaine was injected.,Attention was then turned to the next injection. The lumbar area was prepped and draped in the appropriate sterile fashion. The left L4-L5 level was identified for a transforaminal epidural injection and a skin wheal was made at the spinal needle entry site. A 22 gauge 3.5 inch spinal needle was passed through the skin wheal and advanced in a ventral direction until the tip of the needle was properly placed in the left superior posterior intervertebral foramen as confirmed by AP and lateral fluoroscopic views. No blood was aspirated. There was no CSF flow. Following negative aspiration 1 mL Isovue-M200 was injected to produce the epidurogram. There was appropriate needle placement and no intravascular or intrathecal flow. 1 mL of a 40 mg/mL solution of Kenalog and 1 mL of 1% Lidocaine was injected. The patient tolerated the procedure well.,DRAINS / DRESSING:, Applied sterile dressing including BAND-AID.,PATIENT TO RECOVERY ROOM: , The patient tolerated the procedure well, and was brought to the recovery room in excellent condition.,COMPLICATIONS: , No immediate complications,DISCHARGE ORDERS:,DISPOSITION: , Discharge patient to home today.,ACTIVITY: , Patient may resume normal activity level in 1 day.,FOLLOW-UP: , Appointment to Surgeon's Office in 2 weeks,CPT4 CODE(S):,64483 LT, Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level.,64484 LT, Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level (List separately in addition to code for primary procedure).,76005, Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint), including neurolytic agent destruction.,ICD9 CODE(S):,724.4 Thoracic or lumbosacral neuritis or radiculitis.,721.3 Lumbosacral spondylosis without myelopathy.

Placement of SynchroMed infusion pump and tunneling of SynchroMed infusion pump catheter. Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.

Pain Management

SynchroMed Pump Placement

PROCEDURES:,1. Placement of SynchroMed infusion pump.,2. Tunneling of SynchroMed infusion pump catheter,3. Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.,DESCRIPTION OF PROCEDURE: , Under general endotracheal anesthesia, the patient was placed in a lateral decubitus position. The patient was prepped and draped in a sterile manner. The intrathecal catheter was placed via a percutaneous approach by the pain management specialist at which point an incision was made adjacent to the needle containing the intrathecal catheter. This incision was carried down through the skin and subcutaneous tissue to the paraspinous muscle fascia which was cleared around the entry point of the intrathecal catheter needle. A pursestring suture of 3-0 Prolene was placed around the needle in the paraspinous muscle. The needle was withdrawn. The pursestring suture was tied to snug the tissues around the catheter and prevent cerebrospinal fluid leak. The catheter demonstrated free flow of cerebrospinal fluid,throughout the RV procedure. The catheter was anchored to the paraspinous muscle with an anchoring device using interrupted sutures of 3-0 Prolene. Antibiotic irrigation and antibiotic soak sponge were placed into the wound, and the catheter was clamped to prevent persistent leakage of cerebrospinal fluid while the SynchroMed-pump pocket was created. Then, I turned my attention to the anterior abdominal wall where an oblique incision was made and carried down through the skin and subcutaneous tissue to the external oblique fascia, which was freed from attachments to the overlying subcutaneous tissue utilizing blunt and sharp dissection with electrocautery. A pocket was created that would encompass the SynchroMed fusion pump. A tunneling device was then passed through the subcutaneous tissue from the back incision to the abdominal incision, and a SynchroMed pump catheter was placed to the tunneling device. The tunneling device was then removed leaving the SynchroMed pump catheter extending from the anterior abdominal wall incision to the posterior back incision. The intrathecal catheter was trimmed. A clear plastic boot was placed over the intrathecal catheter, and the connecting device was advanced from the SynchroMed pump catheter into the intrathecal catheter connecting the 2 catheters together. The clear plastic boot was then placed over the connection, and it was anchored in place with 0-silk ties. Good CSF was then demonstrated flowing through the SynchroMed pump catheter. The SynchroMed pump catheter was connected to the SynchroMed pump and anchored in place with a 0-silk tie. Excess catheter was coiled and placed behind the pump. The pump was placed into the subcutaneous pocket created for it on the anterior abdominal wall. The pump was anchored to the anterior abdominal wall fascia with interrupted sutures of 2-0 Prolene; 4 of the sutures were placed. The subcutaneous tissues were irrigated with normal saline. The subcutaneous tissue of both wounds was closed with running suture of 3-0 Vicryl. The skin of both wounds was closed with staples. Antibiotic ointment and a sterile dressing were applied. The patient was awake and taken to the recovery room. The patient tolerated the procedure well and was stable at the completion of the procedure. All sponge and lap, needle and instrument counts were correct at the completion of the procedure.

pain management, intrathecal, catheter, paraspinous, cerebrospinal, synchromed infusion pump, synchromed pump catheter, synchromed pump, paraspinous muscle, cerebrospinal fluid, tunneling device, infusion pump, subcutaneous tissue, infusion, synchromed, pump, incision,

Consultation for right shoulder pain.

Pain Management

Shoulder Pain Consult

CHIEF COMPLAINT:, Right shoulder pain.,HISTORY OF PRESENT PROBLEM:

pain management, shoulder pain, history of present problem:, cortisone shot, no numbness or tingling, rhomboids, scapula, shoulder impingement, focal findings, shoulder,

Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.

Pain Management

Radiofrequency Thermocoagulation

PROCEDURE: , Right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,ANESTHESIA: ,Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed. The patient was in the operating room in the prone position. The back prepped with Betadine. The patient was given sedation and monitored. Under fluoroscopy, the right sacral alar notch was identified. After placement of a 20-gauge, 10 cm SMK needle into the notch, a positive sensory, negative motor stimulation was obtained. Following negative aspiration, 5 cc of 0.5% of Marcaine and 20 mg of Depo-Medrol were injected. Coagulation was then carried out at 90oC for 90 seconds. The SMK needle was then moved to the mid-inferior third of the right sacroiliac joint. Again the steps dictated above were repeated.,The above was repeated for the posterior primary ramus branch right at S2 and S3 by stimulating along the superior lateral wall of the foramen; then followed by steroid injected and coagulation as above.,There were no complications. The patient was returned to outpatient recovery in stable condition.

pain management, posterior rami, sacroiliac joint, sacral alar notch, radiofrequency thermocoagulation, thermocoagulation, radiofrequency, sacroiliac, sacral, alar, notch

Superior Gluteal Nerve Block, Left - Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome.

Pain Management

Superior Gluteal Nerve Block

PRE-OPERATIVE DIAGNOSIS:, Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome.,POST-OPERATIVE DIAGNOSIS:, Same,PROCEDURE:, Superior Gluteal Nerve Block, Left.,After verbal informed consent, whereby the patient is made aware of the risks of the procedure, the patient was placed in the standing position with the arms flaccid by the side. Alcohol was used to prep the skin 3 times, and a 27-gauge needle was advanced deep to the attachment of the Gluteus Medius Muscle near its attachment on the PSIS. The needle entered the plane between the Gluteus Medius and Gluteus Maximus Muscle, in close proximity to the Superior Gluteal Nerve. Aspiration was negative, and the mixture was easily injected. Aseptic technique was observed at all times, and there were no complications noted.,INJECTATE INCLUDED:,Methyl Prednisolone (DepoMedrol): 20 mg,Ketorolac (Toradol): 6 mg,Sarapin: 1 cc,Bupivacaine (Marcaine): Q.S. 2 cc.,The procedures, above were performed for diagnostic, as well as therapeutic purposes. This treatment plan is medically necessary to decrease pain and suffering, increase activities of daily living and improve sleep.,ZUNG SELF-RATING DEPRESSION SCALE© (SDS) RESULTS:, The patient scored as 'mildly depressed.,NOTE:, The pain was gone post procedure, consistent with the diagnosis, as well as with adequacy of medication placement.

pain management, neurapraxia, impingement syndrome, neuralgia, superior gluteal, superior gluteal nerve block, gluteus medius muscle, gluteus maximus muscle, gluteus medius, nerve block, gluteal nerve, block, gluteus, nerve, gluteal

Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.

Pain Management

Radiofrequency Ablation

PROCEDURE: , Bilateral L5, S1, S2, and S3 radiofrequency ablation.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications. I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing. The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE: , Oxygen saturation and vital signs were monitored continuously throughout the procedure. The patient remained awake throughout the procedure in order to interact and give feedback. The x-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in a prone position on the treatment table with a pillow under the chest and head rotated. The skin over and surrounding the treatment area was cleaned with Betadine. The area was covered with sterile drapes, leaving a small window opening for needle placement. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 20 gauge 10-mm bent Teflon coated needle was gently guided into the groove between the SAP and the sacrum for the dorsal ramus of L5 and the lateral border of the posterior sacral foramen, for the lateral branches of S1, S2, and S3. Also, fluoroscopic views were used to ensure proper needle placement.,The following technique was used to confirm correct placement. Motor stimulation was applied at 2 Hz with 1 millisecond duration. No extremity movement was noted at less than 2 volts. Following this, the needle trocar was removed and a syringe containing 1% lidocaine was attached. At each level, after syringe aspiration with no blood return, 0.5 mL of 1% lidocaine was injected to anesthetize the lateral branch and the surrounding tissue. After completion, a lesion was created at that level with a temperature of 80 degrees for 90 seconds.,All injected medications were preservative free. Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS: ,None.,COMPLICATIONS: , None.,DISCUSSION: , Post-procedure vital signs and oximetry were stable. The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day. The patient was told to resume all medications. The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made at PM&R Spine Clinic in approximately one to two weeks.

pain management, sacroiliac joint pain, sacroiliac, teflon coated needle, fluoroscopy, needle placement, radiofrequency ablation, ablation, tissue, lidocaine, needle,

Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.

Pain Management

Radiofrequency Thermocoagulation - 1

PROCEDURE: , Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: ,INT was placed. The patient was in the operating room in the prone position with the back prepped and draped in a sterile fashion. The patient was given sedation and monitored. Lidocaine 1.5% for skin wheal was made 10 cm from the midline to the bilateral L2 distal vertebral body. A 20-gauge, 15 cm SMK needle was then directed using AP and fluoroscopic guidance so that the tip of the needle was noted to be along the distal one-third and anterior border on the lateral view and on the AP view the tip of the needle was inside the lateral third of the border of the vertebral body. At this time a negative motor stimulation was obtained. Injection of 10 cc of 0.5% Marcaine plus 10 mg of Depo-Medrol was performed. Coagulation was then carried out for 90oC for 90 seconds. At the conclusion of this, the needle under fluoroscopic guidance was withdrawn approximately 5 mm where again a negative motor stimulation was obtained and the sequence of injection and coagulation was repeated. This was repeated one more time with a 5 mm withdrawal and coagulation.,At that time, attention was directed to the L3 body where the needle was placed to the upper one-third/distal two-thirds junction and the sequence of injection, coagulation, and negative motor stimulation with needle withdrawal one time of a 5 mm distance was repeated. There were no compilations from this. The patient was discharged to operating room recovery in stable condition.

pain management, lumbar sympathetic chain, vertebral body, radiofrequency thermocoagulation, motor stimulation, thermocoagulation, radiofrequency, coagulation, needle,

Complex regional pain syndrome, right upper extremity. Stellate ganglion block.

Pain Management

Stellate Ganglion Block

PREOPERATIVE DIAGNOSIS:, Complex Regional Pain Syndrome, right upper extremity.,POSTOPERATIVE DIAGNOSIS:, Same.,OPERATION:,

pain management, chassaignac's tubercle, horner's sign, stellate ganglion block, sheath, vertebral, stellate, ganglion, cervical, block,

Pain management sample progress note.

Pain Management

Pain Management Progress Note

DIAGNOSES:,1. Cervical dystonia.,2. Post cervical laminectomy pain syndrome.,Ms. XYZ states that the pain has now shifted to the left side. She has noticed a marked improvement on the right side, which was subject to a botulinum toxin injection about two weeks ago. She did not have any side effects on the Botox injection and she feels that her activities of daily living are increased, but she is still on the oxycodone and methadone. The patient's husband confirms the fact that she is doing a lot better, that she is more active, but there are still issues yet regarding anxiety, depression, and frustration regarding the pain in her neck.,PHYSICAL EXAMINATION:, The patient is appropriate. She is well dressed and oriented x3. She still smells of some cigarette smoke. Examination of the neck shows excellent reduction in muscle spasm on the right paraspinals, trapezius and splenius capitis muscles. There are no trigger points felt and her range of motion of the neck is still somewhat guarded, but much improved. On the left side, however, there is significant muscle spasm with tight bands involving the multifidus muscle with trigger point activity and a lot of tenderness and guarding. This extends down into the trapezius muscle, but the splenius capitis seems to be not involved.,TREATMENT PLAN:, After a long discussion with the patient and the husband, we have decided to go ahead and do botulinum toxin injection into the left multifidus/trapezius muscles. A total of 400 units of Botox is anticipated. The procedure is being scheduled. The patient's medications are refilled. She will continue to see Dr. Berry and continue her therapy with Mary Hotchkinson in Victoria.

pain management, progress note, management, muscle

Injection of Morton's neuroma.

Pain Management

Mortons Neuroma Injection

POST PROCEDURE INSTRUCTIONS:, The patient has been asked to report to us any redness, swelling, inflammation, or fevers. The patient has been asked to restrict the use of the * extremity for the next 24 hours.

pain management, injection, depo-medrol, morton's neuroma, gauge needle, inflammation, metatarsal ligament, metatarsal space, neuroma, redness, swelling, morton'sNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Cervical spondylosis. Radiofrequency thermocoagulation (RFTC), medial branch posterior sensory rami.

Pain Management

Radiofrequency Thermocoagulation - 3

PREOPERATIVE DIAGNOSIS:, Cervical spondylosis.,POSTOPERATIVE DIAGNOSIS:, Cervical spondylosis.,OPERATION PERFORMED:, Radiofrequency thermocoagulation (RFTC), medial branch posterior sensory rami of cervical at ***.,SURGEON:, Ralph Menard, M.D.,ANESTHESIA:, Local and IV.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: , After proper consent was obtained, the patient was taken to the fluoroscopy suite and placed on a fluoroscopy table in a prone position with a chest roll in place. The neck was placed in a flexed position. The patient was monitored with blood pressure cuff, EKG, and pulse oximetry and given oxygen via nasal cannula. The patient was lightly sedated. The skin was prepped and draped in a sterile classical fashion.,Under fluoroscopy control, the waists of the articular pillars were identified and marked. Local anesthesia infiltrated subcutaneously and deep extending down toward these previously marked points. Once the anesthesia was established, an insulated 10-cm, 22-gauge needle with a 5-mm non-insulated stimulating tip was placed in contact with the waists of the articular pillars at the affected levels that were previously mentioned. This was done under direct fluoroscopic control utilizing a gun barrel technique with PA views initially for orientation and then a lateral view to determine the depth of the needle. For C3 to C6 medial branch RFTC's, the needles are placed along the ventral aspect of a line that connects the greatest antero-posterior diameter of the articular pillar but remains dorsal to the foramen as seen on lateral imaging. For a C7 medial branch RFTC, the needle tip is positioned more superiorly such that it overlies the superior articular process. For a C8 medial branch RFTC, the needle is placed at the junction of the superior articulating facet and the base of the transverse process of T1.,Sensory stimulation was carried out at 50 Hz from 0 to 2.0 volts. Stimulation was stopped once the maximum voltage was delivered or the patient either described a buzzing sensation indicating that it was a nonpainful nerve, or it caused replication of their concordant pain. The stimulation was then changed to 2 Hz for motor stimulation and advanced up to 2.0 volts or until motor stimulation was found at that level. If motor stimulation occurred, the needle was repositioned to abolish it but still cause concordant pain, or the RFTC was aborted at this level.,If the sensory stimulation caused concordant pain without motor stimulation, the area was then anesthetized with 1 cc of Marcaine 0.5% with 5 mg of methyl prednisolone acetate. Once the anesthesia was established, a radiofrequency lesioning was then done at 65 degrees for 60 seconds. The same procedure was carried out at all the affected levels. The patient tolerated the procedure well without any difficulties or complications.

pain management, rami, fluoroscopic control, radiofrequency thermocoagulation, cervical spondylosis, articular pillars, motor stimulation, medial branch, thermocoagulation, rftc, needle, cervical, stimulation

Right sacral alar notch and sacroiliac joint/posterior rami injections with/without fluoroscopy.

Pain Management

Sacral Alar Notch Injection

PROCEDURE:, Right sacral alar notch and sacroiliac joint/posterior rami injections with fluoroscopy.,ANESTHESIA:, Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: ,None.,DETAILS OF PROCEDURE: , INT was placed. The patient was in the operating room with intravenous line in place and intravenous sedation was given. The patient was in the prone position. The back was prepped with Betadine. Under fluoroscopy, the right sacral alar notch was identified and after placement of a 22-gauge, 3-1/2 inch spinal needle in to the notch, negative aspiration was performed and 5 cc of 0.5% Marcaine plus 20 mg of Depo-Medrol was injected. The needle was then placed in to the right sacroiliac joint (distal third) and the same local anesthetic mixture was injected. This was repeated for the right sacral alar notch and the right sacroiliac joint (distal third). The needle was withdrawn. The above was repeated for the posterior primary rami branch at S2 and S3 by stimulating along the superior lateral wall of the foramen; then followed by steroid injection and coagulation as above.,There were no complications. Needles removed. Band-aids were applied over the puncture sites. The patient was discharged to operating room recovery in stable condition.

pain management, fluoroscopy, sacroiliac joint, sacral alar notch, posterior rami, sacroiliac, alar, sacral, notch,

Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.

Pain Management

Neuroplasty

PREOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:, Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS:, None.,SUMMARY: ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details). Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle. After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle. These needles were removed and the patient was discharged in stable condition.

pain management, nerve root decompression, discectomy, epidural fibrosis, nerve root entrapment, transforaminal neuroplasty, neural foramen, nerve root, foramen, neuroplasty, transforaminal, needle, epidural,

Complex Regional Pain Syndrome Type I. Stellate ganglion RFTC (radiofrequency thermocoagulation) left side and interpretation of Radiograph.

Pain Management

Radiofrequency Thermocoagulation - 2

PREOPERATIVE DIAGNOSIS:, Complex Regional Pain Syndrome Type I.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1. Stellate ganglion RFTC (radiofrequency thermocoagulation) left side.,2. Interpretation of Radiograph.,ANESTHESIA: ,IV Sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None.,INDICATIONS: , Patient with reflex sympathetic dystrophy, left side. Positive for allodynia, pain, mottled appearance, skin changes upper extremities as well as swelling.,SUMMARY OF PROCEDURE: , Patient is admitted to the Operating Room. Monitors placed, including EKG, Pulse oximeter, and BP cuff. Patient had a pillow placed under the shoulder blades. The head and neck was allowed to fall back into hyperextension. The neck region was prepped and draped in sterile fashion with Betadine and alcohol. Four sterile towels were placed. The cricothyroid membrane was palpated, then going one finger's breadth lateral from the cricothyroid membrane and one finger's breadth inferior, the carotid pulse was palpated and the sheath was retracted laterally. A 22 gauge SMK 5-mm bare tipped needle was then introduced in between the cricothyroid membrane and the carotid sheath and directed inferiomedially. The needle is advanced prudently through the tissues, avoiding the carotid artery laterally. The tip of the needle is perceived to intersect with the vertebral body of Cervical #7 and this was visualized by fluoroscopy. Aspiration was cautiously performed after the needle was retracted approximately 1 mm and held steady with left hand. No venous or arterial blood return is noted. No cerebral spinal fluid is noted. Positive sensory stimulation was elicited using the Radionics unit at 50 Hz from 0-0.1 volts and negative motor stimulation was elicited from 1-10 volts at 2 Hz. After negative aspiration through the 22 gauge SMK 5mm bare tipped needle is absolutely confirmed, 5 cc of solution (solution consisting of 5 cc of 0.5% Marcaine, 1 cc of triamcinolone) was then injected into the stellate ganglion region. This was done with intermittent aspiration vigilantly verifying negative aspiration. The stylet was then promptly replaced and neurolysis (nerve decompression) was then carried out for 60 seconds at 80 degrees centigrade. This exact same procedure using the exact same protocol was repeated one more time to complete the two lesions of the stellate ganglion. The patient was immediately placed in the sitting position to reduce any side effect from the stellate ganglion block associated with cephalad spread of the solution. Pressure was placed over the puncture site for approximately five minutes to eliminate any hemorrhage from blood vessels that may have been punctured and a Band-Aid was placed over the puncture site. Patient was monitored for an additional ten to fifteen minutes and was noted to have tolerated the procedure well without any adverse sequelae. Significant temperature elevation was noted on the affected side verifying neurolysis of the ganglion. ,Interpretation of radiograph reveals placement of the 22-gauge SMK 5-mm bare tipped needle in the region of the stellate ganglion on the affected side. Four lesions were carried out.

pain management, sheath, vertebral body, regional pain syndrome, radiofrequency thermocoagulation, stellate ganglion, rftc, radiofrequency, radiograph, cricothyroid, thermocoagulation, ganglion,

Plantar Fascia Injection

Pain Management

Plantar Fascia Injection

PROCEDURE:,: Informed consent was obtained from the patient. Special mention was made of the possibility of infection and necrosis of the heel pad. The patient was placed in the supine position. The tender area in the medial aspect of the heel was identified by palpation. After proper preparation with antiseptic solution of the skin, a syringe containing 2 mL of 1% lidocaine was attached to 1.5" 27 gauge needle. The needle was carefully advanced through the carefully identified point at a right angle to the skin, directly towards the central and medial aspect of the calcaneus. The needle was advanced very slowly until the needle impinged on the bone, and then was withdrawn slowly. The contents of the syringe were then gently injected. Subsequently, the needle was left in place and a syringe containing 2 mL of 0.25% Marcaine and 1 mL of Depo-Medrol was attached to the needle and injected after aspiration at this site. Subsequently the needle was removed. Pressure was applied at the site of insertion and once it was made sure there was no bleeding taking place, a small bandage was applied.,POST PROCEDURE INSTRUCTIONS:, The patient has been asked to report to us any redness, swelling, inflammation, or fevers. The patient has been asked to restrict the use of the * extremity for the next 24 hours.

pain management, plantar fascia injection, plantar fascia, calcaneus, heel pad, necrosis, depo-medrol, bandage, medial aspect, heel, syringe, injection, needleNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Lumbar epidural steroid injection, L5-S1. Low back pain.

Pain Management

Lumbar Epidural Steroid Injection - 2

PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE: , Lumbar epidural steroid injection, L5-S1.,ANESTHESIA: , Local.,SPECIAL EQUIPMENT: , Fluoroscopic unit.,DETAILS OF PROCEDURE: , The patient was taken to the Radiology Suite and was placed in the prone position where the entire back region was scrubbed, prepped, and draped in a sterile fashion with Betadine solution. The lumbar area was then draped with sterile towels and sterile drapes. The surgeon was gloved with sterile gloves and mask in order to create a sterile environment for the epidural injection. The fluoroscopy x-ray unit was then brought into the sterile field for a PA x-ray visualization of the spine. A Steinmann pin was then placed across the spine to localize the level of the planned injection. Local infiltration using 0.5% preservative-free Xylocaine via a 25-gauge needle was then placed into the dermis and subcutaneous tissue. A Tuohy needle was then oriented perpendicular to the skin and was then advanced through the dermis and subcutaneous tissues. Continuous injection of 0.5% preservative-free Xylocaine was used during the advancement of the Tuohy needle into the deeper spinous tissues. A solution of 80 mg of Depo-Medrol with 2 cc of 1% Xylocaine injectable and 5 cc of normal saline were then injected into the epidural space.

pain management, back pain, lumbar epidural steroid injection, tuohy needle, steroid injection, subcutaneous, epidural, steroid, lumbar, sterile, injection

Lumbar epidural steroid injection for lumbar radiculopathy.

Pain Management

Lumbar Epidural Steroid Injection - 3

PREOPERATIVE DIAGNOSIS: ,Lumbar radiculopathy, 724.4.,POSTOPERATIVE DIAGNOSIS:, Lumbar radiculopathy, 724.4.,PROCEDURE:, Lumbar epidural steroid injection.,ANESTHESIOLOGIST:, Monitored anesthesia care,INJECTATE USED:, 10 mL of 0.5% lidocaine and 80 mg of Depo-Medrol.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None.,DETAILS OF THE PROCEDURE:, The patient arrived at the preoperative holding area where informed consent, stable vital signs, and intravenous access were obtained. A thorough discussion of the potential risks, benefits, and complications was made prior to the procedure including potential for post-dural puncture headache and its associated treatment as well as potential for increased neurological dysfunction and/or nerve root injury, infection, bleeding and even death. There were no known EKG, chest X-ray, or laboratory contraindications to the procedure.,The patient has presented with significant apprehension concerning the proposed procedure and is fearful of movement during the procedure producing further neurological injury. Arrangements will be made to have an anesthesia care provider present to provide heavier sedation while in the prone position with optimal airway management for improved patient safety and comfort.,The L4-L5 interspace was identified fluoroscopically. A left paramedian insertion was marked and after sedation was established by the anesthesia department the skin and subcutaneous tissue over the proposed insertion site was infiltrated with 3 millimeters of 0.5% Lidocaine initially through a #25-gauge 5/8-inch needle later a #22-gauge 1-1/2-inch needle.,A number #18-gauge Tuohy epidural needle was then inserted and advanced with fluoroscopic guidance until passing just superior to the lamina of L5. Needle tip position was confirmed in the anterior posterior fluoroscopic view. The epidural space was located with the loss of pulsation technique. Aspiration of the syringe was negative for blood or cerebrospinal fluid. One millimeter of 0.9% preservative was injected with good loss resistance noted.,DISCHARGE SUMMARY:, Following the completion of this procedure, the patient underwent monitoring in the recovery room and was discharged, to be followed as an outpatient.

pain management

Medial branch rhizotomy, lumbosacral. Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.

Pain Management

Medial Branch Rhizotomy

PROCEDURE: , Medial branch rhizotomy, lumbosacral.,INFORMED CONSENT:, The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications. I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing. The patient understood the informed consent and desired to have the procedure performed.,SEDATION: , The patient was given conscious sedation and monitored throughout the procedure. Oxygenation was given. The patient's oxygenation and vital signs were closely followed to ensure the safety of the administration of the drugs.,PROCEDURE: ,The patient remained awake throughout the procedure in order to interact and give feedback. The x-ray technician was supervised and instructed to operate the fluoroscopy machine. The patient was placed in the prone position on the treatment table with a pillow under the abdomen to reduce the natural lumbar lordosis. The skin over and surrounding the treatment area was cleaned with Betadine. The area was covered with sterile drapes, leaving a small window opening for needle placement. Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine. With fluoroscopy, a Teflon coated needle, ***, was gently guided into the region of the Medial Branch nerves from the Dorsal Ramus of ***. Specifically, each needle tip was inserted to the bone at the groove between the transverse process and superior articular process on lumbar vertebra, or for sacral vertebrae at the lateral-superior border of the posterior sacral foramen. Needle localization was confirmed with AP and lateral radiographs.,The following technique was used to confirm placement at the Medial Branch nerves. Sensory stimulation was applied to each level at 50 Hz; paresthesias were noted at,*** volts. Motor stimulation was applied at 2 Hz with 1 millisecond duration; corresponding paraspinal muscle twitching without extremity movement was noted at *** volts.,Following this, the needle Trocar was removed and a syringe containing 1% lidocaine was attached. At each level, after syringe aspiration with no blood return, 1cc 1% lidocaine was injected to anesthetize the Medial Branch nerve and surrounding tissue. After completion of each nerve block a lesion was created at that level with a temperature of 85 degrees Celsius for 90 seconds. All injected medications were preservative free. Sterile technique was used throughout the procedure.,COMPLICATIONS:, None. No complications.,The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable. The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day. The patient was told to resume all medications. The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week.

pain management, lumbosacral, medial branch rhizotomy, medial branch nerves, rhizotomy, fluoroscopy,

Lumbar discogram L2-3, L3-4, L4-5, and L5-S1. Low back pain.

Pain Management

Lumbar Discogram

PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1. Lumbar discogram L2-3.,2. Lumbar discogram L3-4.,3. Lumbar discogram L4-5.,4. Lumbar discogram L5-S1.,ANESTHESIA: ,IV sedation.,PROCEDURE IN DETAIL: ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table. The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained. We then proceeded to prepare the low back with a Betadine solution and draped sterile. Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space. A metallic marker was then placed laterally and a needle entrance point was determined. A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections. A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus. We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.

pain management, back pain, c-arm, fluoroscopic projections, disc space, lumbar discogram, fluoroscopic, needle,

Lumbar epidural steroid injection without fluoroscopy. A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted.

Pain Management

Lumbar Epidural Steroid Injection

PROCEDURE:, Lumbar epidural steroid injection without fluoroscopy.,ANESTHESIA:, Local sedation.,VITAL SIGNS:, See nurse's records.,COMPLICATIONS:, None.,DETAILS OF PROCEDURE:, INT was placed. The patient was in the sitting position and the back was prepped with Betadine. Lidocaine 1.5% was used for skin wheal made between __________. A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted. After negative aspiration, a mixture of 10 cc of preservative free normal saline and 160 mg of preservative free Depo-Medrol was injected. Neosporin and a band-aid were applied over the puncture site. The patient was then placed in supine position. The patient was discharged to the recovery room in stable condition.

pain management, neosporin, band-aid, epidural space, lumbar epidural steroid injection, loss of resistance, tuohy needle, fluoroscopy, cerebrospinal, lumbar, epidural, injection,

Bilateral lumbar sympathetic block. The patient was in the prone position and the back prepped with Betadine. The patient was given sedation and monitored.

Pain Management

Lumbar Sympathetic Block

PROCEDURE:, Bilateral lumbar sympathetic block.,ANESTHESIA: , Local sedation.,VITAL SIGNS:, See nurse's notes.,COMPLICATIONS:, None.,DETAILS OF PROCEDURE: , INT was placed. The patient was in the prone position and the back prepped with Betadine. The patient was given sedation and monitored. Xylocaine 1.5% for skin wheal 6 cm lateral and slightly inferior to the bilateral L2 transverse process was made. A 20-gauge, 15 cm LSB needle was then directed using AP and lateral fluoroscopic guidance until the tip of the needle was just inside the lateral aspect of the vertebral body and on the lateral projection, it was noted to be along the anterior vertebral body, at the junction of the upper two thirds, lower one third of the body. After negative aspiration 3 cc of Omnipaque dye was injected showing linear spread along the body. After negative aspiration 18 cc of 0.25% Marcaine was injected. Attention was then directed to the L3 level with the tip of the needle guided to the junction of the upper one third, lower two third of L3. At this point, after confirmation of the linear spread of dye along the anterior portion of the body, negative aspiration was performed and 18 cc of 0.25% Marcaine was injected. Neosporin and band-aids were applied over the sites. The patient was taken to the outpatient recovery room in stable condition.

pain management, transverse process, fluoroscopic guidance, lateral projection, lumbar sympathetic block, vertebral body, sympathetic, betadine, needle, aspiration, lumbar,

Osteoarthritis of the right knee. Right knee joint steroid injection.

Pain Management

Knee Injection - 1

PROCEDURE: , Right knee joint steroid injection.,PREOPERATIVE DIAGNOSIS:, Osteoarthritis of the right knee.,POSTOPERATIVE DIAGNOSIS:, Osteoarthritis of the right knee.,PROCEDURE: ,The patient was apprised of the risks and the benefits of the procedure and consented. The patient's right knee was sterilely prepped with Betadine. A 4 mg of dexamethasone was drawn up into a 5 mL syringe with a 3 mL of 1% lidocaine. The patient was injected with a 1.5-inch 25-gauze needle at the medial aspect of his right flexed knee. There were no complications. The patient tolerated the procedure well. There was minimal bleeding. The patient was instructed to ice his knee upon leaving clinic and refrain from overuse over the next 3 days. The patient was instructed to go to the emergency room with any usual pain, swelling, or redness occurred in the injected area. The patient was given a followup appointment to evaluate response to the injection to his increased range of motion and reduction of pain.

pain management, injection, knee joint, steroid injection, osteoarthritis, knee

Lumbar facet injections done under fluoroscopic control. Lumbar spondylosis.

Pain Management

Lumbar Facet Injections

PREOPERATIVE DIAGNOSIS:, Lumbar spondylosis.,POSTOPERATIVE DIAGNOSIS:, Lumbar spondylosis.,OPERATION PERFORMED:, Lumbar facet injections done under fluoroscopic control.,ANESTHESIA:, Local and IV.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,After proper consent was obtained, the patient was taken to the fluoroscopy suite and placed in a prone position on a fluoroscopy table with abdominal rolls in place. The skin was prepped and draped in a sterile classical fashion. The patient was monitored with blood pressure cuff, electrocardiogram, and pulse oximeter. The patient was given oxygen, intravenous sedation and analgesics as needed. The facets were identified and marked under fluoroscopic control by rotating the C-arm obliquely, laterally and caudocranial as needed for optimal visualization of the facet joint's "Scottie dog" and the opening of the facet.,After each facet joint was identified and marked, local anesthesia was infiltrated subcutaneously and deep over each of the identified facets. A 22-gauge spinal needle was then utilized to cannulate the facet joint under fluoroscopic control utilizing a gun barrel technique. After negative aspiration, 0.25 - 0.5 cc of Omnipaque 240 contrast media was injected into the facet as an arthrogram to visualize the joint and the capsule. After another negative aspiration, 1cc of a 10cc solution of Marcaine 0.5% and 100 milligrams of methyl prednisolone acetate was injected into each facet. The patient tolerated the procedure well without apparent difficulty or complication unless otherwise noted.

pain management, fluoroscopic control, c-arm, lumbar facet injections, lumbar spondylosis, fluoroscopy, spondylosis, fluoroscopic, lumbar, injections, facet

Lumbar epidural steroid injection, intralaminar approach, seated position. An 18-gauge Tuohy needle was then placed in the epidural space utilizing a midline intralaminar approach with loss of resistance technique and a saline-filled syringe.

Pain Management

Lumbar Epidural Steroid Injection - 1

OPERATION:, Lumbar epidural steroid injection, intralaminar approach, seated position.,ANESTHESIA:,

pain management, loss of resistance technique, methylprednisolone acetate, lumbar epidural steroid injection, epidural steroid injection, tuohy needle, steroid injection, epidural space, intralaminar approach, injection, intralaminar, saline, epidural

Evaluation for right L4 selective nerve root block.

Pain Management

Lower Extremity Pain

REASON FOR REFERRAL:, Evaluation for right L4 selective nerve root block.,CHIEF COMPLAINT:,

She is a 14-year-old Hispanic female with history of pauciarticular arthritis in particular arthritis of her left knee, although she has complaints of arthralgias in multiple joints. Under general anesthesia, 20 mg of Aristospan were injected on the left knee.

Pain Management

Knee Injection - 2

INDICATIONS FOR PROCEDURE: , The patient was here for joint injection. She is a 14-year-old Hispanic female with history of pauciarticular arthritis in particular arthritis of her left knee, although she has complaints of arthralgias in multiple joints. What bother her the most is the joint swelling of her left knee that has been for several months. She has been taking Naprosyn on her last visit. She was feeling better but still has significant symptoms especially when she was active. After evaluation in the clinic, she decided to have a joint injection as it was discussed before. I discussed the side effects and the complications with the parents and the patient and the possibility of doing it in the clinic, but she decided that she did not want to do it in the clinic and she wanted to be sedated for this.,DESCRIPTION OF PROCEDURE: , So under aseptic technique and under general anesthesia, 20 mg of Aristospan were injected on the left knee. No fluid was obtained. Her swelling was about 1+. No complications. No bleeding was observed, and the patient tolerated the procedure without any complications or side effects. After that she went to the recovery room where is going to be discharged with her parents and see her back in the clinic for re-evaluation in a few weeks after the procedure. If the patient has any problems overnight, she is going to call us. If she had any fevers or strange swelling, she is to call us for advice. We will see her in the clinic as scheduled.

pain management, arthralgias, aristospan, pauciarticular arthritis, joint injection, injection, swelling, arthritis, joints, kneeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Intercostal block from fourth to tenth intercostal spaces, left. Chest pain secondary to fractured ribs, unmanageable with narcotics.

Pain Management

Intercostal block - 1

PREPROCEDURE DIAGNOSIS:, Chest pain secondary to fractured ribs, unmanageable with narcotics.,POSTPROCEDURE DIAGNOSIS:, Chest pain secondary to fractured ribs, unmanageable with narcotics.,PROCEDURE: , Intercostal block from fourth to tenth intercostal spaces, left.,INDICATIONS: , I was requested by Dr. X to do an intercostal block on this lady who fell and has fractured ribs, whose chest pain is paralyzing and not responding well to increasing doses of narcotics.,PROCEDURE DETAIL:, After obtaining an informed consent with the patient on her bedside, she was placed in the right decubitus position with the left side up. The posterior left chest wall was prepped and draped in the usual fashion and then a mixture of 1% Xylocaine 20 mL and Marcaine 0.25% 20 mL were mixed together and the intercostal spaces from the fourth to the tenth ribs were anesthetized. A total of 30 mL worth of solution was used. I also injected some local anesthetic subcutaneously into an area of contusion in the left lumbar area.,The patient tolerated the procedure well. She had no respiratory distress. Immediately, the patient felt some relief from the pain. Chest x-ray was ordered for the following day.

pain management, xylocaine, marcaine, intercostal spaces, intercostal block, fractured ribs, intercostal, fractured, narcotics, chest,

Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance. The patient is a 78-year-old female with back pain referring into the left side.

Pain Management

Kenalog Injection

PROCEDURE:, Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance.,INDICATIONS: ,The patient is a 78-year-old female with back pain referring into the left side. She has had a couple of epidurals in the past, both of which led to only short-term improvement with intralaminar and caudal placements. Therefore, transforaminal approach was selected for today's procedure.,Risks and benefits were discussed with the patient. She agreed to accept the risks and signed informed consent to proceed.,PROCEDURE DETAILS:, The patient was placed prone on the table. The skin was thoroughly cleansed with betadine swabs x3 and wiped off with a sterile gauze. The subcutaneous intramuscular and interligamentous region was anesthetized with buffered 1% lidocaine.,A 5-inch, 22-gauge spinal needle was directed under intermittent fluoroscopic guidance using an oblique approach at the opening of the L5 nerve root. Once bony contact was made, a lateral was obtained and showed the needle tip to be against the posterior spinal body in the anterior epidural space. Then an AP view was obtained which showed the needle tip to be below the 6 o'clock position of the pedicle.,EPIDUROGRAM: , Omnipaque 300, 1 mL, was placed through the foraminal opening of the L5 nerve root on the left. This did show dye spread pattern which was narrowed consistent with foraminal stenosis. The dye did traverse the foraminal opening and was seen spreading around the pedicle into the anterior epidural space. It was also spreading peripherally along the L5 nerve root.,The patient tolerated the procedure well. She did feel that the needle tip was placed at the epicenter of her pain, and this was improved with the placement of the anesthetic.,I will see the patient back in the office in the next few weeks to monitor response of the injection.

pain management, transforaminal approach, epidural steroid injection, nerve root, needle tip, kenalog, transforaminal, fluoroscopic, guidance, foraminal, injection

Knee injection

Pain Management

Knee Injection

The patient was told that the injection may cause more pain for two to three days afterwards and if this occurred they would best be served by icing the area 15-20 minutes every 6 hours. The patient was advised to protect the knee by limiting repetitive bending, squatting , kneeling and excessive heavy use for a week. Also, they were asked to follow up in two weeks p.r.n.

pain management, knee injection, hibistat, xylocaine, bending, epinephrine, knee joint, kneeling, needle, patella, squatting, superolateral approach, cleansed, kneeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

Hip injection. Fluoroscopy was used to identify the boney landmarks of the hip and the planned needle approach. The femoral artery was located by palpation of the pulse. The skin, subcutaneous tissue, and muscle within the planned needle approach were anesthetized with 1% Lidocaine.

Pain Management

Hip Injection

PROCEDURE: , Hip injection.,INFORMED CONSENT: ,The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications. I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing. The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE: ,Oxygen saturation and vital signs were monitored continuously throughout the procedure. The patient remained awake throughout the procedure in order to interact and give feedback. The X-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in the prone position on the treatment table. The skin over and surrounding the treatment area was cleaned with Betadine. The area was covered with sterile drapes, leaving a small window opening for needle placement. Fluoroscopy was used to identify the boney landmarks of the hip and the planned needle approach. The femoral artery was located by palpation of the pulse. The skin, subcutaneous tissue, and muscle within the planned needle approach were anesthetized with 1% Lidocaine. All injected medications were preservative free. With fluoroscopy, a *** spinal needle was gently guided into the ***. Multiple fluoroscopic views were used to ensure proper needle placement. Approximately *** nonionic contrast agent was injected under direct real-time fluoroscopic observation. Correct needle placement was confirmed by production of an appropriate arthrogram without concurrent vascular dye pattern. Finally, the treatment solution, consisting of ***. All injected medications were preservative free. Sterile technique was used throughout the procedure,COMPLICATIONS: , None. No complications. The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable. The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day. The patient was told to resume all medications. The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week.

pain management, boney landmarks, fluoroscopy, femoral artery, planned needle approach, hip injection, injection, hip, needle

Standard hypogastric plexus block procedure note.

Pain Management

Hypogastric Plexus Block

NAME OF PROCEDURE:, Hypogastric plexus block.,ANESTHESIA:, Local.,PROCEDURE: , The patient was in the operating room in the prone position with the back prepped and draped in sterile fashion. Local anesthesia was used to make a skin wheal 8-10 cm lateral to the L4 spinous process bilaterally from the midline. Starting from the left side, a 20-gauge 6-inch needle was placed to the left L5-S1 facet level under AP fluoroscopic view. On lateral view, the tip of the needle was at the inferior one-third of the LS vertebral body, anterior aspect. Next 5 cc of Omnipaque dye was injection showing a linear spread along the anterior portion of L5 down the sacral promontory. After negative aspiration 18 cc of 0.25% Marcaine plus 40 mg of Depo-Medrol was injection. There were no complications. The above sequence was repeated for the right side. There were no complications. The patient was discharged back to outpatient recovery in stable condition.

pain management, vertebral body, fluoroscopic view, omnipaque, hypogastric plexus blockNOTE

Caudal epidural steroid injection without fluoroscopy.

Pain Management

Epidural Steroid Injection - 2

PROCEDURE: ,Caudal epidural steroid injection without fluoroscopy.,ANESTHESIA:, Local sedation.,VITAL SIGNS: , See nurse's records.,PROCEDURE DETAILS: , INT was placed. The patient was in the prone position. The back was prepped with Betadine. Lidocaine 1.5% was used to make a skin wheal over the sacral hiatus. A 18-gauge Tuohy needle was then placed into the epidural space. There were no complications from this (no blood or CSF). After negative aspiration was performed, a mixture of 10 cc preservative free normal saline plus 160 mg preservative free Depo-Medrol was injected. Neosporin and band-aid were applied over the puncture site. The patient was then placed in supine position. The patient was discharged to outpatient recovery in stable condition.

pain management, epidural space, epidural steroid injection, caudal epidural, caudal, fluoroscopy, steroid, epidural, injection

Intercostal block, left. Severe post thoracotomy pain.

Pain Management

Intercostal Block

PREOPERATIVE DIAGNOSIS: , Severe post thoracotomy pain.,POSTOPERATIVE DIAGNOSIS: , Severe post thoracotomy pain.,PROCEDURE: , Intercostal block, left.,PROCEDURE DETAIL: , With the patient in the ICU bed who was having a large amount of intravenous narcotic to control his thoracotomy pain, after obtaining informed consent, his left posterior chest was prepped and draped in the usual fashion and Marcaine 0.025% was injected in the spaces four to eight sequentially. A total of 40 mL of Marcaine was used.,The patient tolerated the procedure well and experienced immediate benefit out of the procedure.

pain management, thoracotomy pain, intercostal block, marcaine, thoracotomy, intercostal,

Bilateral facet Arthrogram and injections at L34, L45, L5S1. Interpretation of radiograph. Low Back Syndrome - Low Back Pain.

Pain Management

Facet Arthrogram & Injection

PREOPERATIVE DIAGNOSIS: , Low Back Syndrome - Low Back Pain.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1. Bilateral facet Arthrogram at L34, L45, L5S1.,2. Bilateral facet injections at L34, L45, L5S1.,3. Interpretation of radiograph.,ANESTHESIA: ,IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS: ,None.,INDICATION: , Pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x-ray studies and imaging scans.,SUMMARY OF PROCEDURE: , The patient was admitted to the OR, consent was obtained and signed. The patient was taken to the Operating room and was placed in the prone position. Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring. Prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain, EKG, respiration and heart rate and at intervals of three minutes for blood pressure. After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral regions were prepped and draped in sterile fashion with Betadine prep and four sterile towels.,The facets in the lumbar regions were visualized with Fluoroscopy using an anterior posterior view. A skin wheal was placed with 1% Lidocaine at the L34 facet region on the left. Under fluoroscopic guidance a 22 gauge spinal needle was then placed into the L34 facet on the left side. This was performed using the oblique view under fluoroscopy to the enable the view of the "Scotty Dog," After obtaining the "Scotty Dog" view the joints were easily seen. Negative aspiration was carefully performed to verity that there was no venous, arterial or cerebral spinal fluid flow. After negative aspiration was verified, 1/8th of a cc of Omnipaque 240 dye was then injected. Negative aspiration was again performed and 1/2 cc of solution (Solution consisting of 9 cc of 0.5% Marcaine with 1 cc of Triamcinolone) was then injected into the joint. The needle was then withdrawn out of the joint and 1.5 cc of this same solution was injected around the joint. The 22-gauge needle was then removed. Pressure was place over the puncture site for approximately one minute. This exact same procedure was then repeated along the left-sided facets at L45, and L5S1. This exact same procedure was then repeated on the right side. At each level, vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid.,The patient was noted to have tolerated the procedure well without any complications.,Interpretation of the radiograph revealed placement of the 22-gauge spinal needles into the left-sided and right-sided facet joints at, L34, L45, and L5S1. Visualizing the "Scotty Dog" technique under fluoroscopy facilitated this. Dye spread into each joint space is visualized. No venous or arterial run-off is noted. No epidural run-off is noted. The joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis.

pain management, low back syndrome, low back pain, facet injection, fluoroscopy, iv sedation, spinal fluid, facet arthrogram, aspiration, arthrogram, injection, facet,

Epidural steroid injection. A total of 5 mL containing 4 mL of 0.25% bupivacaine and 80 mg of methylprednisolone acetate were infiltrated.

Pain Management

Epidural Steroid Injection - 3

PROCEDURE NOTE:, The patient was placed in a prone position. The neck was sterilely prepped using a cervical prep set. A lidocaine skin wheal was raised over the C5-6 interspace. A 20-gauge Tuohy needle was used. Loss of resistance was obtained using hanging drop technique. This was followed by 2 mL of radiograph contrast material which showed spread of the dye into the epidural space. A total of 5 mL containing 4 mL of 0.25% bupivacaine and 80 mg of methylprednisolone acetate were then infiltrated. Following the infiltration, the patient noted warming of his arms and dramatic improvement of his symptoms. He was observed for 30 minutes and discharged home in good condition. There were no apparent complications to the procedure.

pain management, methylprednisolone acetate, steroid, bupivacaine, methylprednisolone, acetate, epidural, injectionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

L3-L5 epidural steroid injection with epidural catheter under fluoroscopy.

Pain Management

Epidural Steroid Injection - 1

PREOPERATIVE DIAGNOSIS:, Herniated lumbar disk with intractable back pain.,POSTOPERATIVE DIAGNOSIS: , Herniated lumbar disk with intractable back pain.,OPERATION PERFORMED: , L3-L5 epidural steroid injection with epidural catheter under fluoroscopy.,ANESTHESIA: , Local/IV sedation.,COMPLICATIONS: , None.,SUMMARY: ,The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion. The patient was given sedation and monitored. Local anesthetic was used to insufflate the skin over sacral hiatus. A 16-gauge RK needle was placed at the sacral hiatus into the caudal canal with no CSF or blood. A Racz tunnel catheter was then placed to the needle and guided up to the L3-L4 level. After negative aspiration 4 cc of 0.5% Marcaine and 80 mg of Depo-Medrol were injected. The catheter was then repositioned at the L4-L5 level where after negative aspiration same local anesthetic steroid mixture was injected. Needle and catheter were removed intact. The patient was discharged in stable condition.

pain management, epidural catheter, epidural steroid injection, lumbar disk, steroid injection, fluoroscopy, herniated, lumbar, needle, steroid, epidural, catheter, injection

Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.

Pain Management

Epidurogram

PREOPERATIVE DIAGNOSES: ,1. Right lower extremity radiculopathy with history of post laminectomy pain.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES: ,1. Right lower extremity radiculopathy with history of post laminectomy pain.,2. Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED: , Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS: , None.,SUMMARY: , The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion. The patient was given sedation and monitored. Local anesthetic was used to insufflate the skin and paraspinal tissues and the L5 disk level on the right was noted to be completely collapsed with no way whatsoever to get a needle to the neural foramen of the L5 root. The left side was quite open; however, that was not the side of her problem. At this point using a oblique fluoroscopic projection and gun-barrel technique, a 22-gauge 3.5 inch spinal needle was placed at the superior articular process of L5 on the right, stepped off laterally and redirected medially into the intervertebral foramen to the L4 nerve root. A second needle was taken and placed at the S1 nerve foramen using AP and lateral fluoroscopic views to confirm location. After negative aspiration, 2 cc of Omnipaque 240 dye was injected through each needle.,There was a defect flowing in the medial epidural space at both sides. There were no complications.

pain management, laminectomy, radiculopathy, nerve root entrapment, epidural fibrosis, nerve root, epidurogram, neural, epidural, foramen, nerve, needle

Transforaminal epidural steroid block with fluoroscopy.

Pain Management

Epidural Steroid Block

DIAGNOSIS: , Left sciatica.,ANESTHESIA: , Intravenous sedation,NAME OF OPERATION:,1. Left L5-S1 transforaminal epidural steroid block with fluoroscopy.,2. Left L4-5 transforaminal epidural steroid block with fluoroscopy.,3. Monitored intravenous Versed sedation.,PROCEDURE: , The patient was taken to the block room. He was placed prone on the fluoroscopy table. He was monitored appropriately. He was administered Versed 2 mg IV. His O2 saturation remained greater than 90%. His back was prepped and draped. The C-arm was brought in. The endplates at L5-S1 were squared off. The C-arm was rotated to the left. The L5 pedicle, the superior articular process of the L5-S1 facet, and the "neck of the scotty dog" were all visualized. After adequate local anesthesia, a 22-gauge, 3-1/2-inch spinal needle was inserted using down-the-barrel-of-the-needle technique. The needle was advanced into the posterior aspect of the foramen and then advanced anteriorly toward the 6 o'clock position on the pedicle. No paresthesias were noted. One-half cc of contrast was injected and spread medially around the pedicle and into the epidural space, and the L5 nerve root was visualized. Depo-Medrol 80 mg plus 1 cc of 4% preservative-free lidocaine was injected. The needle was flushed and removed.,I then went up to the L4-5 level, and using a similar technique, injected the patient transforaminally at the L4-5 level. Depo-Medrol 80 mg plus 1 cc of 4% preservative-free lidocaine was injected at the L4-5 level just as at the L5-S1 level. The patient had pain down his left leg during the injection, primarily at the L5-S1 level similar to what he normally experiences. He was awake and alert, and taken to the recovery room in good condition. His left leg pain was relieved.

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Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block for sacroiliac joint pain. Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.

Pain Management

Dorsal Ramus & Branch Block

PROCEDURE: , Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible vascular entry of medications. I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing. The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE: ,Oxygen saturation and vital signs were monitored continuously throughout the procedure. The patient remained awake throughout the procedure in order to interact and give feedback. The X-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in the prone position on the treatment table, pillow under the chest, and head rotated contralateral to the side being treated. The skin over and surrounding the treatment area was cleaned with Betadine. The area was covered with sterile drapes, leaving a small window opening for needle placement. Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 25-gauge 3.5-inch spinal needle was gently guided into the groove between the SAP and sacrum through the dorsal ramus of the L5 and the lateral and superior border of the posterior sacral foramen with the lateral branches of S1, S2, and S3. Multiple fluoroscopic views were used to ensure proper needle placement. Approximately 0.25 mL of nonionic contrast agent was injected showing no concurrent vascular dye pattern. Finally, the treatment solution, consisting of 0.5% of bupivacaine was injected to each area. All injected medications were preservative free. Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS: , This was then repeated on the left side.,COMPLICATIONS: , None.,DISCUSSION: ,Postprocedure vital signs and oximetry were stable. The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day. The patient was told to resume all medications. The patient was told to resume normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes or changes in bowel or bladder function.,Follow up appointment was made at the PM&R Spine Clinic in approximately 1 week.

pain management, sacroiliac, lateral branch block, ramus block, branch block, sacroiliac joint, dorsal ramus, fluoroscopic, branch, dorsal, ramus, bilateral, needle, block,

Epidural Blood Patch. An 18-gauge Tuohy needle was then placed in the epidural space on the first pass utilizing loss of resistance technique with a saline filled syringe.

Pain Management

Epidural Blood Patch

OPERATION:,

pain management, epidural space, loss of resistance technique, epidural blood patch, tuohy needle, tourniquet, epidural

Epidural steroid injection, epidurogram, fluroscopy - Low back pain, herniated disc, lumbosacral Facet, arthropathy.

Pain Management

Epidural Steroid Injection

PRE-OP DIAGNOSES:, Low back pain - 724.2, Herniated disc - 722.10, Lumbosacral Facet, arthropathy - 724.4.,POST-OP DIAGNOSES: , Low back pain - 724.2, Herniated disc - 722.10, Lumbosacral Facet, arthropathy - 724.4.,INTERVAL HISTORY:, Plans, risks and options were reviewed with the patient in detail. The patient understands and agrees to proceed.,ANESTHESIA: , General Anesthesia,PROCEDURE PERFORMED:, Epidural steroid injection, epidurogram, fluroscopy.,PROCEDURE:, After informed consent, the patient was taken to the procedure room and placed in the prone position. EKG, blood pressure and pulse oximetry were monitored and remained stable throughout the procedure. The area was prepped and draped in the usual sterile fashion. Local anesthetic was infiltrated at the appropriate level. Fluoroscopic guidance was used to place a #20-gauge Tuohy epidural needle gently into the epidural space at L4-L5 using a paramedian approach. No blood or CSF was obtained on aspiration.,RADIOLOGY: , Injection of 3 cc of OMNIPAQUE showed spread of the dye into the epidural space on AP and Lateral imaging. The Needle was injected with Depo-Medrol 80 mg with Bupivacaine 1/16th , 8 cc total vol. Patient tolerated procedure well and was transferred to recovery room. Patient was discharged home with escort. Discharge instructions were given.,POST-OP PLAN:, I will see the patient back in my office in two weeks. Continue p.r.n. medications as needed.

pain management, back pain, herniated disc, lumbosacral facet, epidural needle, lumbosacral facet arthropathy, epidural steroid injection, facet arthropathy, epidural space, injection, epidurogram, fluroscopy, herniated, lumbosacral, steroid, arthropathy, epidural,

Cervical Selective Nerve Root Block

Pain Management

Cervical Selective Nerve Root Block

CERVICAL SELECTIVE NERVE ROOT BLOCK,PREPROCEDURE PREPARATION:, After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form. The patient was placed in the prone position and standard ASA monitors applied. Intravenous access was established and IV sedation was used. For further details of IV sedation and infusion, please refer to anesthesia notes. The patient was able to respond appropriately throughout the procedure. * Fluoroscopy was used to identify the appropriate anatomy. The skin was prepped and draped in a sterile fashion and sterile technique was maintained throughout the procedure.,PROCEDURE DETAILS:, The patient was laid supine. Oblique placement was achieved by placing pillow below the shoulder and turning the head. The C# neural foramina was identified by counting down from the C2-3 foramen. The external carotid artery was marked off by palpation. The neck was aseptically prepared. 1% lidocaine was used for local infiltration and subsequently a 25-gauge spinal needle was passed down to the C# neural foramen under fluoroscopic control. The posterior inferior edge of the foramen bone was contacted. The needle was then redirected and slowly walked off the bone into the foramen by a few millimeters. Care was taken to remain in the posterior inferior edge of the foramen. Positioning was checked by AP view, in which the needle tip extended no further medially than the midpoint of the adjacent pedicle. 1 mL of contrast was used to confirm position under fluoroscopy after aspiration. Acceptable dye pattern was seen. Subsequent 1 mL of 1% lidocaine was injected after aspiration and the patient was monitored. No adverse affects with 1% lidocaine were noted and subsequently 1 mL of Celestone was injected. Compression bandage was applied to the neck and no complications were noted.,POSTPROCEDURE EVALUATION:, After a 30-minute recovery period, during which no complications were noted, the patient was discharged home. Pulse oximetry was carried out on room air in recovery and all oxygen saturations were above 95% with no respiratory distress observed.

pain management, nerve root block, 1% lidocaine, asa monitors, cervical selective nerve root block, fluoroscopy, iv sedation, nerve root, oblique, selective nerve root, carotid artery, foramen, neural foramina, edge of the foramen, selective nerve root block, cervical,

Coccygeal injection

Pain Management

Coccygeal injection

COCCYGEAL INJECTION,PROCEDURE:,: Informed consent was obtained from the patient. A gloved little finger was inserted into the anal region and the sacral/coccygeal joint was palpated and the coccyx was moved and it was confirmed that this reproduced pain. After aseptic cleaning, a 25-gauge needle was inserted through the skin into the sacral/coccygeal joint. It was confirmed that the needle was not entering the rectal cavity by finger placed in the rectum. After aspiration, 1 mL of cortisone and 2 mL of 0.25% Marcaine were injected at the site. Postprocedure, the needle was withdrawn. A small pressure dressing was placed and no hematoma was observed to form.,POST PROCEDURE INSTRUCTIONS:, The patient has been asked to report to us any redness, swelling, inflammation, or fevers. The patient has been asked to restrict the use of the * extremity for the next 24 hours.

pain management, coccygeal injection, 0.25% marcaine, 1 ml of cortisone, coccygeal joint, coccyx, fevers, inflammation, redness, sacral, swelling, coccygeal, injectionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

Cervical spondylosis. Cervical medial branch blocks under fluoroscopic control.

Pain Management

Cervical Medial Branch Blocks

PREOPERATIVE DIAGNOSIS:, Cervical spondylosis.,POSTOPERATIVE DIAGNOSIS:, Cervical spondylosis.,OPERATION PERFORMED:, Cervical Medial Branch Blocks under fluoroscopic control.,ANESTHESIA:, Local and IV.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE:, After proper consent was obtained, the patient was taken to the fluoroscopy suite and place on a fluoroscopy table in a prone position with a chest roll in place. The neck was placed in a flexed position. The patient was monitored with blood pressure cuff, EKG, and pulse oximetry and given oxygen via nasal cannula. The patient was lightly sedated. The skin was prepped and draped in a sterile classical fashion.,Under fluoroscopy control, the waists of the articular pillars were identified and marked. Local anesthesia infiltrated subcutaneously and deep extending down toward these previously marked points. Once the anesthesia was established, a 10-cm, 22-gauge needle was placed in contact with the waists of the articular pillars at the affected levels that were previously mentioned. This was done under direct fluoroscopic control with PA views initially for orientation utilizing a gun barrel technique and then a lateral view to determine the depth of the needle. The needle tip was positioned such that the tip was at the posterior aspect of the articular pillar's waist and was then incrementally advanced until the tip was at the center of the pedicle, where the medial branch lies. For C3 to C6, the medial branch is along the ventral aspect of a line that connects the greatest antero-posterior diameter of the articular pillar but remains dorsal to the foramen as seen on lateral imaging. For a C7 medial branch block, the needle tip is positioned more superiorly such that it overlies the superior articular process. For a C8 medial branch block, the needle is placed at the junction of the superior articulating facet and the base of the transverse process of T1.,Once the needles were in place, each level was then injected with 1cc of a 10 cc solution of Marcaine 0.5% mixed with 50mg on methyl prednisolone acetate. The patient tolerated the procedure well without any difficulties or complications.

pain management, fluoroscopic control, fluoroscopy, cervical medial branch blocks, medial branch blocks, cervical spondylosis, articular pillars, cervical, anesthesia, spondylosis, fluoroscopic, blocks, needle, medial, branch,

Costochondral Cartilage Injection

Pain Management

Costochondral Cartilage Injection

COSTOCHONDRAL CARTILAGE INJECTION,PROCEDURE PREPARATION:, After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form. The patient was placed in the supine position.,Intravenous access was established. The patient was given mild narcotics for sedation. For further details, please refer to anesthesia note.,DESCRIPTION OF PROCEDURE:, The area of discomfort was palpated under fluoroscopy and the costochondral cartilages that were symptomatic were marked out. After careful asepsis, local anesthesia was given subcutaneously and a 0.25-gauge hypodermic needle was inserted into the costochondral cartilage junction, taking care not to stray from the rib. Fluoroscopy in AP and lateral positions confirmed good position of the needle in the * costochondral junction and subsequently after aspiration, 0.5 mL of Depo-Medrol 80 and 0.5 mL of 0.5% Marcaine was injected. The same procedure was carried out at the * costochondral junction.,POSTPROCEDURE INSTRUCTIONS:,1. After a period of 30 minutes of observation, during which there was no distress and good relief of symptoms was noted, the patient was discharged home.,2. The patient has been given instructions on watching for possible pneumothorax and any respiratory distress. The patient will call us if any inflammation, swelling, or other associated discomfort arises. We will call the patient in 48 hours.

pain management, costochondral cartilage injection, 0.5% marcaine, ap and lateral, costochondral, depo-medrol, costochondral junction, fluoroscopy, hypodermic needle, pneumothorax, subcutaneously, supine position, cartilage injection, costochondral cartilage, needle, distress, cartilage, injection,