Psychiatry
MENTAL STATUS EXAMINATION
This is a 47-year-old female who is alert. Attention and concentration are good. She is oriented to time, place, person, and situation. She has depressed mood with an anxious affect. She has no evidence of psychotic content, thought, or process. She is not apparently delusional or having any auditory or visual hallucinations. Recent, remote, and immediate memory is intact. She has obvious cognitive deficits. She is neatly groomed. She has a neat personal appearance. She has normal language function with no difficulty repeating phrases and naming objects. She has no obvious cognitive deficits. She has normal associations and logical abstract thought processes. Speech is prosodic, articular, coherent, and spontaneous at a normal rate and normal volume. She has fair judgement and fair insight. She is reliable. She is not impulsive. She has psychomotor agitation at the current time.
DIAGNOSTIC IMPRESSION: Major depression.
TREATMENT PLAN
1. Discontinue Valium.
2. Discontinue Prozac.
3. Discontinue Soma.
4. Xanax 0.25 mg p.o. q.i.d.
5. Remeron 15 mg p.o. q.h.s.
6. Remeron 15 mg p.o. p.r.n. insomnia make it once at night between 10 p.m. to 4 a.m.
7. Cymbalta 30 mg p.o. q.a.m.
It is difficult to judge in this patient whether she has legitimate need for narcotics or not. The pain is a very individual experience and different people require different amounts of medications to control their pain. I would probably leave for pain management to pain management specialist such as the anesthesia department possibly treating her depression with the above-mentioned medication changes will help her use less narcotic pain medication in the future.
Thank you for allowing me to share in the treatment of this interesting patient.
MENTAL STATUS EXAMINATION: This is a 25-year-old female who is alert. Attention and concentration is good. She is oriented to time, place, person, and situation. She is not suicidal. She has a depressed mood with an anxious affect. She has no evidence of psychotic thought content or process. She is not paranoia or delusional. She has no auditory or visual hallucinations. Recent, remote and immediate memory is intact. She has no obvious cognitive deficits.
ADMITTING DIAGNOSES
AXIS I:
1. Major depression with psychotic features.
2. Opoid dependence.
3. Anxiolytic dependence.
AXIS II: No diagnosis.
AXIS III: Chronic obstructive pulmonary disease and osteoarthritis.
AXIS IV: Four- severe.
AXIS V: Global assessment functioning of 20.
DISCHARGE DIAGNOSES
AXIS I:
1. Major depression with psychotic features.
2. Opoid dependence.
3. Anxiolytic dependence.
AXIS II: No diagnosis.
AXIS III: Chronic obstructive pulmonary disease and osteoarthritis.
AXIS IV: Four- severe.
AXIS V: Global assessment functioning of 30.
BRIEF HISTORY AND ESSENTIAL PHYSICAL FINDINGS: There were no essential findings on physical exam other than generalized weakness.
BRIEF HISTORY: The patient is a 70-year-old female with history of chronic depression with lost of hope completely. She was seen due to chronic pain from broken back and subsequent to undergo normal activity. She has a kind of difficulty to leave her bed. She was paranoid. She was delusional. She was severely depressed. She was anxious. She had daily crying spells. She was anhedonic. She was addicted to Klonopin and hydrocodone. She was given 6 mg clonazepam plus methadone and hydrocodone daily. She needs emergent calcification for psychiatric stabilization where she would eventually overdosed. She thought to have overdosed and felt suicidal. At the time of admission, very self-destructive. She would have harm herself but not in the hospital.
HOSPITAL COURSE AND TREATMENT RENDERED: The patient in the hospital was detoxified off of Klonopin and narcotics using Subutex, Librium should fairly * detoxification. She was then placed on medication regimen of Cymbalta and Seroquel. Her anxiety would not diminished on Cymbalta and Seroquel. The patient was uncontrollably agitated and has to be placed on Serax. Serax did not do anything with the patient's anxiety, it was stopped and * then returned to the patient to the low dose Klonopin given 0.5 mg p.o. q.i.d. which neutralized lot of the patient's anxiety. In hospital, sleep pattern improved where she starts to sleep two to seven hours per night. Her appetite improved. Her daily crying spells stopped. Her depressed mood progressed to a state of euthymia. Her anxiety diminished. Her paranoia and delusions diminished greatly. Her craving for Benzodiazepine and narcotics also diminished. The patient had individual psychotherapy with Dr. Ivan C. Spector, M.D. centering around dealing with relationship issues. The patient had a great deal of psychological insight into individual psychotherapy, and was very open to empathic interventions. The patient had group psychotherapy in the hospital. She was very open to empathic interventions from group leaders and had a great deal of psychological insight in group psychotherapy. She was able to complete goal-directed projects in occupational therapy and also worked on chemical dependency counseling from *. She had a very successful hospitalization.
CONDITION ON DISCHARGE: The patient is oriented to time, place, person, and situation. She has euthymic mood with an anxious affect. She has minimal residual paranoia. She is not delusional. She had no auditory or visual hallucinations. Recent, remote, and immediate memory is intact. She has no obvious cognitive deficits. She is not suicidal.
DISCHARGE DIET: Whatever she would like to eat.
DISCHARGE PHYSICAL ACTIVITIES: Whatever she can tolerate.
DISCHARGE CONDITION: Back to her home with office follow up with Dr. Spector within the next month.
DISCHARGE MEDICATIONS
1. Klonopin 0.5 mg p.o. q.i.d. #120.
2. Cymbalta 60 mg p.o. q.a.m. #30.
3. Seroquel 100 mg p.o. q.i.d. #120.
4. Albuterol patch 14 mg 5 q.a.m. #30.
5. Peri-Colace to one tablet p.o. q.h.s. #30.
All the medications written by Dr. Botto, which included the pulmonary medications.
PSYCHIATRIC CONSULTATION
LOCATION: Room# 209, North Park Plaza Hospital.
CHIEF COMPLAINT: "I feel depressed."
HISTORY OF PRESENT ILLNESS: The patient is a 25-year-old female with history of depression secondary dealing with multitude of medical problems, which have all recently occurred. She is not suicidal. She sleeps two to four hours per night of interrupted sleep. She has very low energy level. She is anhedonic. She is frequently hopeless concerning the future. She has not been attending to activities of daily living. Most recently delivered a premature baby and has ended up with the tracheotomy. She is very frustrated currently.
ALLERGIES: NONE.
PAST MEDICAL HISTORY AND PAST SURGICAL HISTORY: Respiratory and delivery.
PAST PSYCHIATRIC HISTORY: None.
FAMILY PSYCHIATRIC HISTORY: None.
FAMILY HISTORY AND SOCIAL HISTORY: The patient is single. She has one son. She lives by herself. She is a telephone operator. She enjoys singing. She uses no tobacco, alcohol, or illegal drugs.
MENTAL STATUS EXAMINATION: This is a 25-year-old female who is alert. Attention and concentration is good. She is oriented to time, place, person, and situation. She is not suicidal. She has a depressed mood with an anxious affect. She has no evidence of psychotic thought content or process. She is not paranoia or delusional. She has no auditory or visual hallucinations. Recent, remote and immediate memory is intact. She has no obvious cognitive deficits.
DIAGNOSTIC IMPRESSION: Major depression.
TREATMENT PLAN
1. Discontinue Ambien.
2. Zoloft 50 mg p.o. q.a.m.
3. Remeron 15 mg p.o. q.h.s.
4. Remeron 15 mg p.o. p.r.n. insomnia, make it once at night between 10 p.m. to 4 a.m.
Thank you for allowing me to share in the treatment of this interesting patient.
MENTAL STATUS EXAMINATION: 75-year-old male, who is alert. Attention and concentration are compromised. He is oriented to time, place, person and situation. He has an anxious mood with an anxious affect. He has auditory or visual hallucinations, paranoia and delusions. He has short-term and immediate memory deficits. Remote memory appears to be intact. He has few small cognitive deficits. He is not reliable. He is impulsive. He has disheveled personal appearance and disheveled grooming. He has above-average average fund of knowledge. He has normal associations with somewhat illogical, concrete thought processes. He has poor judgment and poor insight at the current time. He has an anxious mood with an anxious affect. Again he has paranoia, delusions and auditory individual hallucinations. He has some deficits in language functioning with difficulty in repeating phrases and naming objects. Speech is prosodic, articulate, impoverished and normal rate and normal volume. It is coherent. He is not suicidal.
PSYCHIATRY CONSULTATION
VITAL SIGNS: Blood pressure of 102/52, pulse is 79, temperature is 98.2, respiratory rate of 24.
CHIEF COMPLAINT: "I feel depressed."
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old gentleman, who is very depressed secondary to dealing with multiple medical problems with prolonged course of hospitalization. He has very depressed mood with an anxious affect. He is not suicidal. He is anhedonic. He has a low energy level. He is not attending to activities of daily living. He is hopeless concerning the future. He has poor appetite. He sleeps two to four hours per night of interrupted sleep. He has occasional intermittent crying spells. His ability to concentrate is good. He is not suicidal. He desires to feel better and * he is very discouraged secondary to his medical condition and his inability to recover quickly.
ALLERGIES: NONE.
PAST MEDICAL HISTORY AND PAST SURGICAL HISTORY: Type 2 diabetes mellitus, hypertension, hypothyroidism, hyperlipidemia, atrial fibrillation, coronary artery disease, poly arthritis, head and neck cancer and tracheostomy.
PAST PSYCHIATRIC HISTORY: None.
FAMILY PSYCHIATRIC HISTORY: None.
REVIEW OF SYSTEMS
HEAD: The patient has tracheostomy in his neck.
CHEST: He has shortness of breath.
GASTROINTESTINAL SYSTEM: He has poor appetite.
GENITOURINARY SYSTEM: He has no urinary hesitancy, frequency, dysuria, or urinary incontinence.
MUSCULOSKELETAL SYSTEM: Generalized weakness.
INTEGUMENTARY SYSTEM: No complaints.
PAST PSYCHIATRIC HISTORY: None.
FAMILY PSYCHIATRIC HISTORY: None.
FAMILY HISTORY AND SOCIAL HISTORY: He is divorced, lives alone. Uses no tobacco or alcohol. He is a retired truck driver. Enjoys yard work and watching sports, movies and programs on television.
MENTAL STATUS EXAMINATION: This 70-year-old male who is alert. Attention and concentration are good. He is oriented to time, place, person and situation. He has disheveled personal appearance and disheveled grooming. He has a depressed mood with an anxious affect. He has no evidence of psychotic thought content or processes. He has no paranoid, delusional, or auditory or visual hallucinations. Recent, remote, and immediate memory is intact. He has no obvious cognitive deficits. Speech could not be properly evaluated since he does have tracheostomy and used a laryngeal * to talk. His speech is coherent * apparatus to speak. His language function is normal. He has no difficulty repeating phrases or naming objects. He has an average fund of knowledge and average intellectual functioning. He has no obvious cognitive deficits. He has fair judgement and fair insight. He is reliable. He is not impulsive. He has mild psychomotor agitation. He has normal associations and logical abstract though processes. He is not suicidal.
DIAGNOSTIC IMPRESSION: Major depression.
TREATMENT AND PLAN
1. Zoloft 50 mg p.o. q.a.m.
2. Remeron 15 mg p.o. q.h.s.
3. Remeron 15 mg p.o. p.r.n. insomnia, make it once a night between 10 p.m. and 4 a.m.
4. Discontinue Ambien.
Thank you for allowing me to share in the treatment of this interesting patient.
MENTAL STATUS EXAMINATION: 75-year-old male, who is alert. Attention and concentration are compromised. He is oriented to time, place, person and situation. He has an anxious mood with an anxious affect. He has auditory or visual hallucinations, paranoia and delusions. He has short-term and immediate memory deficits. Remote memory appears to be intact. He has few small cognitive deficits. He is not reliable. He is impulsive. He has disheveled personal appearance and disheveled grooming. He has above-average average fund of knowledge. He has normal associations with somewhat illogical, concrete thought processes. He has poor judgment and poor insight at the current time. He has an anxious mood with an anxious affect. Again he has paranoia, delusions and auditory individual hallucinations. He has some deficits in language functioning with difficulty in repeating phrases and naming objects. Speech is prosodic, articulate, impoverished and normal rate and normal volume. It is coherent. He is not suicidal.
DIAGNOSTIC IMPRESSION
1. Psychosis *.
2. Generalized anxiety disorder.
TREATMENT PLAN
1. Discontinue all prior Xanax, Haldol *.
2. Risperdal 0.5 mg p.o. q.h.s.
3. Ativan 0.5 mg p.o. IV push q.i.d.
4. Haldol 0.5 mg p.o. IV push q.6 hours p.r.n. severe agitation, anxiety and insomnia.
Thank you for allowing me to share in the treatment of this interesting patient.
PSYCHIATRY CONSULTATION
VITAL SIGNS: Blood pressure of 102/52, pulse is 79, temperature is 98.2, respiratory rate of 24.
CHIEF COMPLAINT: "I feel depressed."
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old gentleman, who is very depressed secondary to dealing with multiple medical problems with prolonged course of hospitalization. He has very depressed mood with an anxious affect. He is not suicidal. He is anhedonic. He has a low energy level. He is not attending to activities of daily living. He is hopeless concerning the future. He has poor appetite. He sleeps two to four hours per night of interrupted sleep. He has occasional intermittent crying spells. His ability to concentrate is good. He is not suicidal. He desires to feel better and * he is very discouraged secondary to his medical condition and his inability to recover quickly.
ALLERGIES: NONE.
PAST MEDICAL HISTORY AND PAST SURGICAL HISTORY: Type 2 diabetes mellitus, hypertension, hypothyroidism, hyperlipidemia, atrial fibrillation, coronary artery disease, poly arthritis, head and neck cancer and tracheostomy.
PAST PSYCHIATRIC HISTORY: None.
FAMILY PSYCHIATRIC HISTORY: None.
REVIEW OF SYSTEMS
HEAD: The patient has tracheostomy in his neck.
CHEST: He has shortness of breath.
GASTROINTESTINAL SYSTEM: He has poor appetite.
GENITOURINARY SYSTEM: He has no urinary hesitancy, frequency, dysuria, or urinary incontinence.
MUSCULOSKELETAL SYSTEM: Generalized weakness.
INTEGUMENTARY SYSTEM: No complaints.
PAST PSYCHIATRIC HISTORY: None.
FAMILY PSYCHIATRIC HISTORY: None.
FAMILY HISTORY AND SOCIAL HISTORY: He is divorced, lives alone. Uses no tobacco or alcohol. He is a retired truck driver. Enjoys yard work and watching sports, movies and programs on television.
MENTAL STATUS EXAMINATION: This 70-year-old male who is alert. Attention and concentration are good. He is oriented to time, place, person and situation. He has disheveled personal appearance and disheveled grooming. He has a depressed mood with an anxious affect. He has no evidence of psychotic thought content or processes. He has no paranoid, delusional, or auditory or visual hallucinations. Recent, remote, and immediate memory is intact. He has no obvious cognitive deficits. Speech could not be properly evaluated since he does have tracheostomy and used a laryngeal * to talk. His speech is coherent * apparatus to speak. His language function is normal. He has no difficulty repeating phrases or naming objects. He has an average fund of knowledge and average intellectual functioning. He has no obvious cognitive deficits. He has fair judgement and fair insight. He is reliable. He is not impulsive. He has mild psychomotor agitation. He has normal associations and logical abstract though processes. He is not suicidal.
DIAGNOSTIC IMPRESSION: Major depression.
TREATMENT AND PLAN
1. Zoloft 50 mg p.o. q.a.m.
2. Remeron 15 mg p.o. q.h.s.
3. Remeron 15 mg p.o. p.r.n. insomnia, make it once a night between 10 p.m. and 4 a.m.
4. Discontinue Ambien.
Thank you for allowing me to share in the treatment of this interesting patient.
MENTAL STATUS EXAMINATION: 75-year-old male, who is alert. Attention and concentration are compromised. He is oriented to time, place, person and situation. He has an anxious mood with an anxious affect. He has auditory or visual hallucinations, paranoia and delusions. He has short-term and immediate memory deficits. Remote memory appears to be intact. He has few small cognitive deficits. He is not reliable. He is impulsive. He has disheveled personal appearance and disheveled grooming. He has above-average average fund of knowledge. He has normal associations with somewhat illogical, concrete thought processes. He has poor judgment and poor insight at the current time. He has an anxious mood with an anxious affect. Again he has paranoia, delusions and auditory individual hallucinations. He has some deficits in language functioning with difficulty in repeating phrases and naming objects. Speech is prosodic, articulate, impoverished and normal rate and normal volume. It is coherent. He is not suicidal.
OPERATIVE REPORT
PROCEDURE: Laparoscopic small pouch Roux-en-Y gastric bypass.
PREOPERATIVE DIAGNOSIS: Morbid obesity.
POSTOPERATIVE DIAGNOSIS: Morbid obesity.
SURGEON: Hadar Spivak, M.D.
ASSISTANT: Oscar Beltran, Certified Surgical Assistant.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Essentially nothing.
DRAINS: One closed drain left.
DESCRIPTION OF PROCEDURE: The patient was placed on the operating table. After general anesthesia was induced, the patient's abdomen was prepped and draped in the usual fashion. A Veress needle was introduced into the upper abdomen, and the abdomen was insufflated to a pressure of 15 mmHg of CO2. This was followed by an 11-mm trocar that was introduced in the same area. Using a side viewing scope and reverse Trendelenburg position, exploration of the abdomen revealed essentially normal and anatomy could be seen laparoscopically. A second trocar was probed and * was placed in the left side of the abdomen mid axillary line and a third trocar was introduced in between the first and second trocar. A 12-mm trocar was introduced slightly of the midline on the right side, and the last 5-mm trocar was introduced in the subxiphoid area. The ligament of Treitz was identified and, counting 45 cm from the ligament of Treitz, I applied the Ethicon white stapler and transected the bowel. I counted 80 cm going distally and performing anastomosis between the side jejunum to the side functional end biliopancreatic limb using stay sutures and using the Bovie cautery to create wide enough anastomosis. I introduced the wide stapler to create a wide anastomosis horizontally; the anterior gap was closed with the white stapler as well. I also placed sutures on the meso in order to repair it using two Nurolon that were tied extracorporeally. At that point, attention was made to the small pouch part of the operation. The liver was retracted using a probe from the subxiphoid area and then using blunt and sharp dissection, I cleaned the fundus from the * two and half to 3 cm on the below the GE junction, going to the lesser sac, then the lesser sac was entered and introduced the blue staple line of Ethicon in to second the pouch horizontally and then I performed a gastrostomy using the Bovie cautery, and introduced the blue tip connected to the anvil. The anvil was placed into the stomach, and the blue tip * by the surgeon's hand and was introduced just posteriorly to the staple line. The anvil followed and was secured. A couple of more applications of the blue staple line were needed in order to transect the angle of His.
This was done under the calibration of the bougie #40 was placed by the anesthesiologist. I closed the gastrostomy opening and removed the blue staple from the abdomen then I elevated jejunal limb anterior colic anterior gastric opened its staple line, using the Bovie cautery introduced a circular stapler #25 French to the left side opening then to be large likely in to the jejunal limb and its tip for the antimesenteric aspect connected to the anvil and anastomosis was created in the usual fashion, receiving very good *. I added two Steri sutures on both side of the anastomosis, and closed the opening the jejunum using the right staple line. I closed the * potential hernia space using a #3-0 interrupted figure of eight #2-0 Nylon * Prolene. I inspected anastomosis and inspected staple line everything appeared to be well. No bleeding no complication. No discoloration and therefore I closed the * trocar using transabdominal needle #1 to the edge * close drain coming from the medial trocar incision secured to the skin with silk. The left upper quadrant and at that point * and pad were correct and the packing was applied to the left side wound and Monocryl was applied to the skin. The patient tolerated procedure very well and then left to the recovery room in stable condition.
OPERATIVE REPORT
PROCEDURE: Laparoscopic small pouch Roux-en-Y gastric bypass.
PREOPERATIVE DIAGNOSIS: Morbid obesity.
POSTOPERATIVE DIAGNOSIS: Morbid obesity.
SURGEON: Hadar Spivak, M.D.
ASSISTANT: Oscar Beltran, Certified Surgical Assistant.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Essentially nothing.
DRAINS: One closed drain left.
DESCRIPTION OF PROCEDURE: The patient was placed on the operating table. After general anesthesia was induced, the patient's abdomen was prepped and draped in the usual fashion. A Veress needle was introduced into the upper abdomen, and the abdomen was insufflated to a pressure of 15 mmHg of CO2. This was followed by an 11-mm trocar that was introduced in the same area. Using a side viewing scope and reverse Trendelenburg position, exploration of the abdomen revealed essentially normal and anatomy could be seen laparoscopically. A second trocar was probed and * was placed in the left side of the abdomen mid axillary line and a third trocar was introduced in between the first and second trocar. A 12-mm trocar was introduced slightly of the midline on the right side, and the last 5-mm trocar was introduced in the subxiphoid area. The ligament of Treitz was identified and, counting 45 cm from the ligament of Treitz, I applied the Ethicon white stapler and transected the bowel. I counted 80 cm going distally and performing anastomosis between the side jejunum to the side functional end biliopancreatic limb using stay sutures and using the Bovie cautery to create wide enough anastomosis. I introduced the wide stapler to create a wide anastomosis horizontally; the anterior gap was closed with the white stapler as well. I also placed sutures on the meso in order to repair it using two Nurolon that were tied extracorporeally. At that point, attention was made to the small pouch part of the operation. The liver was retracted using a probe from the subxiphoid area and then using blunt and sharp dissection, I cleaned the fundus from the * two and half to 3 cm on the below the GE junction, going to the lesser sac, then the lesser sac was entered and introduced the blue staple line of Ethicon in to second the pouch horizontally and then I performed a gastrostomy using the Bovie cautery, and introduced the blue tip connected to the anvil. The anvil was placed into the stomach, and the blue tip * by the surgeon's hand and was introduced just posteriorly to the staple line. The anvil followed and was secured. A couple of more applications of the blue staple line were needed in order to transect the angle of His.
This was done under the calibration of the bougie #40 was placed by the anesthesiologist. I closed the gastrostomy opening and removed the blue staple from the abdomen then I elevated jejunal limb anterior colic anterior gastric opened its staple line, using the Bovie cautery introduced a circular stapler #25 French to the left side opening then to be large likely in to the jejunal limb and its tip for the antimesenteric aspect connected to the anvil and anastomosis was created in the usual fashion, receiving very good *. I added two Steri sutures on both side of the anastomosis, and closed the opening the jejunum using the right staple line. I closed the * potential hernia space using a #3-0 interrupted figure of eight #2-0 Nylon * Prolene. I inspected anastomosis and inspected staple line everything appeared to be well. No bleeding no complication. No discoloration and therefore I closed the * trocar using transabdominal needle #1 to the edge * close drain coming from the medial trocar incision secured to the skin with silk. The left upper quadrant and at that point * and pad were correct and the packing was applied to the left side wound and Monocryl was applied to the skin. The patient tolerated procedure very well and then left to the recovery room in stable condition.
OPERATIVE REPORT
The patient's procedure is done in the outpatient department at Park Plaza Hospital.
PROCEDURE: Bone-marrow biopsy and aspiration.
PREOPERATIVE DIAGNOSES
1. Heavy history of adult T-cell leukemia.
2. Anemia.
3. History of Hypertensive disease.
POSTOPERATIVE DIAGNOSES
1. Heavy history of adult T-cell leukemia.
2. Anemia.
3. History hypertensive disease.
DESCRIPTION OF PROCEDURE: Informed consent obtained. The patient was given constant sedation with 2 mg of Versed IV and Demerol 50 mg IV. The patient was then positioned in the ventral position lying in bed. The area the left posterior iliac crest was prepped in the usual manner with Betadine. The skin and periosteum were then anesthetized with 1% of Xylocaine a total of 3 cc was given. The skin was then perforated with a #11 sharp blade. We then proceeded with aspiration of bone marrow with aspirating needle. A total of 6 cc of bone marrow blood was obtained and was given to the lab technician to make the smears and also was sent off for flow cytometry and cytogenetic studies. The needle was then withdrawn. We then proceeded with a core biopsy with a Jamshidi needle. A total of 1.5 cm of core biopsy was obtained and was given to the lab technician in the fixation solution to send to the lab for further processing. Total estimated blood loss is about 6 cc. The patient tolerated well with the procedure.
OPERATIVE REPORT
PROCEDURE: Central venous catheter placement.
INDICATIONS: Need for venous access.
PROCEDURE: The patient was placed supine. Her left anterior chest was scrubbed with chlorhexidine. She was given 1% lidocaine local anesthetic and a triple-lumen catheter was placed over a J-wire using modified Seldinger technique. There was good blood return in all ports. The line was sutured in place.
OPERATIVE REPORT
PROCEDURE: Bone marrow biopsy and aspiration.
INDICATIONS FOR PROCEDURE
1. Anemia.
2. Monoclonal gammopathy, rule out multiple myeloma.
PROCEDURE IN DETAIL: Informed consent obtained. The patient was given conscious sedation with 1 mg of Versed IV and 5 mg Demerol IV before procedure. The patient was then positioned in the ventral position, flat in bed. The area of the left posterior iliac crest was prepped in the usual manner with Betadine. The skin and periosteum were then anesthetized with 1% Xylocaine, a total of 3 cc was given. The skin was then perforated with a number 11 sharp blade. We then proceeded with aspiration of bone marrow with aspirating a total of 6 cc of bone marrow blood was obtained and was given to the lab technician to make the smear and also sent off for flow cytometry and cytogenetic studies. The needle was then withdrawn. We then proceeded with a core biopsy with a Jamshidi needle. A total of 1 cm of core biopsy was obtained and was given to the lab technician in the fixation solution for further processing. Total estimated blood loss is about 6 cc. The patient tolerated the procedure well.
OPERATIVE REPORT
PROCEDURE: Quinton catheter placement.
INDICATION: Nonfunctional cath.
The patient was placed supine. Her right anterior chest was scrubbed with chlorhexidine. A J-wire was placed through the pigtail catheter and the old Quinton catheter removed. The tip was sent for CNS. A new Quinton triple-lumen was placed, sutured in place. Good blood return in all ports, which were flushed with heparin. The line was sutured. Quinton of dialysis is resumed. Chest x-ray is pending.
OPERATIVE REPORT
PROCEDURE: Pleurodesis with talc.
INDICATION: Recurrent left pleural effusions.
The patient has an indwelling left chest tube. Output yesterday in this tube was 35 cc. The patient was given 5 mg of IV Morphine and 5 percent talc was mixed with 20 cc of 2 percent lidocaine, and 20 cc of normal saline. Chest tube was flushed with this mixture and clamped.
OPERATIVE REPORT
PROCEDURE: Left Quinton catheter placed in subclavian position.
INDICATION: Need for dialysis.
DESCRIPTION OF PROCEDURE: The patient was placed supine. Her left anterior chest was scrubbed with Chlorhexidine. She was given 1% lidocaine local anesthetic and a Quinton catheter placed over J wire. There was good blood return. One side sluggish and the other line was sutured in place. Chest x-ray is pending. We going to try dialysis now, if not, we are going to have try a groin position. She has very little venous access left.
OPERATIVE REPORT
PROCEDURE: Laparoscopic placement of lap band, 10 cm, pars flaccida approach.
PREOPERATIVE DIAGNOSIS: Morbid obesity.
POSTOPERATIVE DIAGNOSIS: Morbid obesity.
SURGEON: Hadar Spivak, M.D.
ASSISTANT: Oscar Beltran, Licensed surgical assistant.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Essentially nothing.
PROCEDURE: The patient was placed on the operating table. After general anesthesia was induced, the patient's abdomen was prepped and draped in the usual fashion. A Veress needle was introduced into the abdomen and the abdomen was insufflated to a pressure of 15 mm Hg of CO2. This was followed by an 11-mm trocar that was introduced in the same area and using a side-view scope in reverse of the position, exploration of the abdomen revealed essentially normal * could be seen laparoscopically. A second trocar was introduced in the left subcostal area and then a third trocar was introduced 5-mm lateral to it. A 5-mm trocar was introduced in the subxiphoid area and the last 5-mm trocar was introduced slightly off the midline on the right side. The liver was retracted using the port from the subxiphoid area. Using blunt and sharp dissection, the angle of His was completely cleaned from fundus attachments. The decision was made to perform the 10 cm band placement using the pars flaccida approach. Therefore, the pars flaccida dissected, the right crus was identified and dissection was made over the right crus, aiming for the angle of His. A curved dissector was placed in the angle of His and curved. The band itself was introduced into the abdomen through the left-side porthole. Its tube was grasped by the curved dissector and pulled all the way to a posterior gastric location. The band was released from posterior attachment and it was locked, creating a very small gastric pouch. Two gastrogastric sutures were placed approximating the fundus below the band to the small gastric pouch using 2-0 Nurolon that were tied extracorporeally on the left side of the locking mechanism. When all this was done, inspection was performed and everything appeared to be well, and therefore the tube was brought to the tunnel all the way to the subxiphoid area where it was connected to the access port and the access port was placed over the fascia using two interrupted 2-0 Prolene sutures. After irrigation, we have the Monocryl to cover the fat above the access port and Monocryl was applied to the skin. The patient tolerated the procedure very well, and went up to recovery room in stable condition. There were no complications.
OPERATIVE REPORT
PROCEDURE: Laparoscopic placement of lap band, 10 cm, pars flaccida approach.
PREOPERATIVE DIAGNOSIS: Morbid obesity.
POSTOPERATIVE DIAGNOSIS: Morbid obesity.
SURGEON: Hadar Spivak, M.D.
ASSISTANT: Oscar Beltran, Licensed surgical assistant.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Essentially nothing.
PROCEDURE: The patient was placed on the operating table. After general anesthesia was induced, the patient's abdomen was prepped and draped in the usual fashion. A Veress needle was introduced into the abdomen and the abdomen was insufflated to a pressure of 15 mm Hg of CO2. This was followed by an 11-mm trocar that was introduced in the same area and using a side-view scope in reverse of the position, exploration of the abdomen revealed essentially normal * could be seen laparoscopically. A second trocar was introduced in the left subcostal area and then a third trocar was introduced 5-mm lateral to it. A 5-mm trocar was introduced in the subxiphoid area and the last 5-mm trocar was introduced slightly off the midline on the right side. The liver was retracted using the port from the subxiphoid area. Using blunt and sharp dissection, the angle of His was completely cleaned from fundus attachments. The decision was made to perform the 10 cm band placement using the pars flaccida approach. Therefore, the pars flaccida dissected, the right crus was identified and dissection was made over the right crus, aiming for the angle of His. A curved dissector was placed in the angle of His and curved. The band itself was introduced into the abdomen through the left-side porthole. Its tube was grasped by the curved dissector and pulled all the way to a posterior gastric location. The band was released from posterior attachment and it was locked, creating a very small gastric pouch. Two gastrogastric sutures were placed approximating the fundus below the band to the small gastric pouch using 2-0 Nurolon that were tied extracorporeally on the left side of the locking mechanism. When all this was done, inspection was performed and everything appeared to be well, and therefore the tube was brought to the tunnel all the way to the subxiphoid area where it was connected to the access port and the access port was placed over the fascia using two interrupted 2-0 Prolene sutures. After irrigation, we have the Monocryl to cover the fat above the access port and Monocryl was applied to the skin. The patient tolerated the procedure very well, and went up to recovery room in stable condition. There were no complications.
OPERATIVE REPORT
PROCEDURE: Bronchoscopy with transbronchial biopsy.
INDICATION: Left perihilar mass, right upper lobe nodule.
DESCRIPTION OF PROCEDURE: The patient was given 4% lidocaine to the oro-and nasopharynx. The bronchoscope was passed through the right naris. She received oxygen nasal cannula at 5 liters per minute and 2 mg of IV versed. Bronchoscopy was done in the Bronchoscopy suite today on August 25, 2006. The vocal cords were visualized and moved normally. The entire tracheobronchial tube was grossly normal. Under fluoroscopic guidance, I lavaged the right upper lobe nodule. I then went into the left lingula and we lavaged, brushed and biopsied the lingular or perihilar mass. The patient tolerated the procedure well and was returned to her room.
OPERATIVE REPORT
PROCEDURE: Bronchoscopy entrance and lavage.
INDICATION: Hemoptysis.
DESCRIPTION OF PROCEDURE: The patient is on a ventilator, 100 percent oxygen, assist control motor ventilation. The patient was given 2 mg of IV Versed. Bronchoscope was passed through the adaptor between the patient and the bronchoscope. The entire tracheobronchial tree was grossly normal. There was no evidence of old or new blood in either lung. There were thick plugs, however, especially on the right. The both lungs were washed * received no further plug washings and the bronchoscopy was completed. Specimens are being sent for cultures and sensitivity, AFB routine fungus. The patient tolerated the procedure well.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Recurrent hematuria and catheter obstruction secondary to clot.
POSTOPERATIVE DIAGNOSES
1. Prostatitis.
2. Benign prostate hyperplasia
PROCEDURE: Cystourethroscopy, irrigation of clots for bladder, placement of a Foley catheter.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed under satisfactory general anesthesia. He was then placed in the lithotomy position and prepped and draped in a sterile manner. A
25-French cystoscope was introduced into the urethra under direct vision and there was no evidence of urethral stricture or other distal urethral abnormality. The prostatic urethra was approximately 3.5 cm to 4 cm in length and showed marked friability of the mucosa with edema and increased vascularity. The median lobe was moderately enlarged, but the orifices could be easily visualized. There was some bullous edema at the bladder neck and increased vascularity of the mucosa near the left trigone. The bladder showed no evidence of tumor. There were numerous clots within the bladder, which were irrigated with the tumi syringe. After the clots were irrigated free from the bladder the bladder showed only slight degree of catheter reaction of the posterior bladder wall, and otherwise showed only slight trabeculation. There is clearly no evidence of bladder tumor and no evidence of active bleeding once the clots have been irrigated from the bladder. A 20-French Foley catheter was left in place and bladder irrigations were completely clear and the patient was transferred to the recovery room in stable condition.
OPERATIVE REPORT
PROCEDURE: Bronchoscopy and lavage.
INDICATION: Left lower lobe loss volume.
DESCRIPTION OF PROCEDURE: The patient has a #8 tracheostomy tube and an adaptor was placed in line. The patient was put on 100 percent oxygen. Bronchoscope was passed through the adaptor there were thick secretions coming from both side of the carina. As I entered the left main stem, however, the secretions thickened up and there were multiple plugs. These were washed until clear. On the right there were fixed secretions, but no plugs. Specimens were sent for AFB fungus stain culture and sensitivity, as well as routine gram stains culture and sensitivity.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Severe dysplasia.
POSTOPERATIVE DIAGNOSIS: Severe dysplasia.
NAME OF PROCEDURE: Loop electrosurgical excision procedure procedure.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 15 cc.
ANESTHESIA: General endotracheal anesthesia.
DESCRIPTION OF THE OPERATIVE PROCEDURE: The patient was taken to the operating room. She was prepped and draped in the usual sterile fashion. The bladder was drained and then ablated. Speculum was placed in the vagina and cervix was identified. The diagram with previous biopsy showed area that we need to cover. Then a loop excision was performed and once that was done a second * smaller loop excision was performed as the patient has very deep involvement of the cervical tissue based on the previous biopsy. Once it was done, the base of the cervix was then coagulated with a rollerball tip. Hemostasis was obtained then all the instruments were removed from the vagina. The patient was extubated and taken to the recovery room in stable condition.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: History of right renal calculi, right hydronephrosis and right pyelonephritis.
POSTOPERATIVE DIAGNOSIS: No evidence of residual hydronephrosis or ureteral pelvic junction stone.
PROCEDURE: Cystourethroscopy, bilateral retrograde pyelogram.
The patient was brought to the operating room and placed under a satisfactory general anesthesia. A plain abdominal film was obtained immediately prior to this procedure. There was still some residual contrast within the left collecting system, which showed a non-dilated collecting system. There was a question of stones in the vicinity of the right ureteropelvic junction although subsequent retrograde pyelograms performed with an 8-French, cold-tip catheter showed no evidence of stone in the vicinity of the right ureteropelvic junction. There was a vague calcification in the lower pole of the right kidney, although it is uncertain whether this actually represented a stone because the patient had been administered intravenous contrast earlier in the day. Multiple drainage films were obtained over five minutes. These drainage films confirmed that there was no ureteral obstruction and no evidence of stone within the right ureter. There were multiple pelvic *, but these were all noted to be upside the right renal collecting system. For this reason, I do not elect to perform a right ureteral stent placement. A left retrograde pyelogram showed no gross abnormality although there was some over injection of contrast, but this injection film failed to demonstrate any evidence of filling defect. The patient tolerated these procedures well and was transferred to the recovery room in stable condition after the bladder been emptied of all irrigation fluid.
OPERATIVE REPORT
TYPE OF OPERATION: Insertion of right femoral Quinton catheter.
SURGEON: Samuel Magnus-Lawson, M.D.
INDICATION: As above.
PREOPERATIVE DIAGNOSES: Acute renal failure in patient with GFR of 8, uremia, hyperkalemia with potassium of 5.9, BUN of 73, creatinine of 6.3. The patient's phosphate was also extremely elevated at 9.1.
POSTOPERATIVE DIAGNOSES: Acute renal failure in patient with GFR of 8, uremia, hyperkalemia with potassium of 5.9, BUN of 73, creatinine of 6.3. The patient's phosphate was also extremely elevated at 9.1.
ANESTHESIA: 1% Xylocaine.
PROCEDURE: The patient is in the supine recumbent position, the right groin area was shaved, cleaned with soap and water, then painted and also cleaned with *. The area was then draped in the usual sterile surgical manner. The right femoral arterial pulse was identified and the area immediately medial to the pulse was infiltrated with 1% Xylocaine. The needle with syringe attached was used to access the right femoral vein without difficulty, at which time free flow of venous blood was obtained in and out of the syringe, which was removed. A J wire was then introduced into the needle with the pliable end first, after which, the needle was withdrawn over the J wire. A stab incision wound was made at the junction of the J wire and the skin was excised with an 11 blade, after which a venous dilator was applied over the J wire withdrawn. The Quinton catheter was then introduced via the J wire, which was removed through the venous port of the catheter. Free flow of venous blood was obtained in and out of both ports of the catheter, which was flushed with heparinzed saline, clamped and cut and ligatured to the skin with 2-0 silk sutures. Post insertion, there was no change in exam. The patient tolerated the procedure well. Estimated blood loss 2 cc.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Symptomatic uterine leiomyoma.
POSTOPERATIVE DIAGNOSIS: Symptomatic uterine leiomyoma.
NAME OF PROCEDURE: A myomectomy.
SURGEON: Dr. Ta.
ESTIMATED BLOOD LOSS: About 100 cc.
COMPLICATIONS: None.
FINDINGS: Multiple fibroids in the uterus. The patient biggest one is about 7 cm to 8 cm at the fundus of the uterus. Normal fusion ovaries noted.
DESCRIPTION OF THE OPERATIVE PROCEDURE: The patient was taken to the operating room. She was prepped and draped in the usual sterile fashion. A Pfannenstiel incision was made, which carried down to the underlying fascia. Fascia was extended bilaterally. Rectus muscle dissected off the fascia and peritoneum was identified entered sharply with Metzennaum scissors with the visualization of above the bladder. Deaver retractor was placed. Bowel was packed away with moist laparotomy sponge. The uterus was identified and the fibroids were also identified on the uterus. An injection of the Pressyn was performed until blanching occurred and then above needle tip Bovie was used to cut into the serosa and the fibroid was dissected away with the needle tip Bovie. At the first we dissected that 7 cm to 8 cm fibroid from the fundus. Once it was dissected away the base of the uterus was then closed with interrupted Vicryl suture. The empty space was then closed in subsequent layer until all the empty spaces were closed and good hemostasis was noted. We then sew the serosa together with the running Vicryl suture.
Myeloid fibroid was noted on the surface of the uterus. We were able to dissect this away with the needle tip Bovie some of them were so small that once we cut it away with the Bovie that it was already haemostatic. There was a total of four leiomyoma. The next biggest one is about 3 cm. It was at the anterior uterus, which is just above the bladder. Again needle point Bovie was used to dissect into the serosa after the dressing has been injected. Progressive dissection of the fibroid was performed. Once the fibroid was taken out then the empty space is closed with the Vicryl suture in two layers with interrupted Vicryl suture. Then the serosa was re-approximated with running fibroid. Once the hemostasis was noted, then the laparotomy sponges were then removed and the retractor was removed. Irrigation was performed again good hemostasis was noted.
The peritoneum was re-approximated in a running fashion and then fascia identified and re-approximated with Vicryl in a running fashion. The subcutaneous tissue was reapproximated with plain gut and skin was closed with staple.
TYPE OF PROCEDURE: Bone marrow aspiration and biopsy.
HISTORY: The patient is a 78-year-old female patient with a suspected diagnosis of multiple myeloma. The patient is undergoing a bone marrow aspiration and biopsy for diagnostic purposes. The patient was explained the reason for the procedure, the potential side effects and toxicities of the test as well as that of conscious sedation.
DESCRIPTION OF THE PROCEDURE: The patient was placed in the left lateral decubitus position and the right posterior iliac crest was identified. The skin was cleaned in a customary manner and sterile fields were placed. The skin, subcutaneous tissue, and periosteum were infiltrated with a total of 6 cc of 1% Xylocaine. The patient received a total of 25 mg of Demerol and 4 mg of Versed for the purpose of conscious sedation. Subsequently, the skin was incised with a fine scalpel and a bone marrow aspiration was obtained without difficulty. This was followed by a core needle biopsy, which was also obtained without difficulty and providing a good specimen. The patient sustained a normal vital signs and saturation of oxygen throughout the procedure. She experienced no significant discomfort or pain. The patient is alert and awake at the time of completion of the procedure. The patient will be discharged within 60 to 120 minutes pending full recovery from the sedation.
RECOMMENDATIONS: The patient was advised to leave the patch at the site of incision for 24 hours before removing and bathing. The patient is to return next week for followup in the clinic and to review the results of the test.
OPERATIVE REPORT
PROCEDURE: Bone marrow biopsy and aspiration.
INDICATIONS FOR PROCEDURE
1. Anemia.
2. Neutropenia.
3. Rule out myelodysplastic syndrome.
PROCEDURE IN DETAIL: Informed consent was obtained. The patient was given premedication with Demerol 25 mg to 5 mg IV and Phenergan 12.5 mg IV before procedure. The patient was then positioned in the left lateral decubitus with the help of a nurse. The area of the right posterior iliac crest was prepped in the usual manner with Betadine. The skin and periosteum were then anesthetized with 1% Xylocaine, a total of 3 cc was given. The skin was then perforated with #11 sharp blade. We then proceeded with aspiration of bone marrow with aspirating needle. A total of 6 cc of bone marrow blood was obtained and was given to the lab technician to make the smears and also was sent off for flow cytometry and cytogenetic studies. The needle was then withdrawn. We then proceeded with a core biopsy with a Jamshidi needle. A total of 3 cm of core biopsy was obtained and was given to the lab technician in the fixation solution to send to the lab for further processing. The patient tolerated the procedure well. Total estimated blood loss is about 6 cc.
LABORATORY DATA: Human immunodeficiency virus is negative. Hepatitis profile showed hepatitis B surface antigen is negative, hepatitis B surface antibody is reactive, hepatitis B core antibody is totally reactive with IGM negative. Hepatitis C antibody positive. Total protein 6.4, albumin 3.0. SGPT 32, SGOT 62, normal up to 42. Alkaline phosphatase is 91, bilirubin 2.8 with direct of 1.9. Iron is 24 with the total iron binding capacity of 257, iron saturation less than 10%. Haptoglobin less than 7, ferritin 16. On 1/22 the hemoglobin was 8.3, hematocrit 24, white blood count 6,900, platelets 72,000.
OPERATIVE RECORD
PROCEDURE: Colonoscopy.
INSTRUMENT: Pentax colonoscope.
PREMEDICATION: Fentanyl 2 cc IV, Versed 2 mg IV, Benadryl 25 mg IV.
SURGEON: Dr. James Hixon.
FINDINGS: Rectal: No masses. Good sphincter tone. Anoscopic examination shows slightly friable internal hemorrhoids, no fissures. The anoscope was removed. The colonoscope was inserted in the usual fashion from the rectum to the cecum. The mucosa was carefully examined in its entirety. The mucosa was normal, nonfriable with no mass lesions, polyps, arteriovenous malformations or mucosal lesions identified. Diverticula noted in the sigmoid colon.
IMPRESSION:
1. No polyps or carcinoma - personal history of colon polyps.
2. Diverticulosis.
3. Internal hemorrhoids.
PLAN: Tucks Wipes after each bowel movement and witch hazel soaks to the rectum at bedtime. Repeat the colonoscopy in two years, to be followed by Dr. Vance Moore.
PROCEDURE: Colonoscopy.
INSTRUMENT: Pentax colonoscope.
OPERATOR: Dr. Hixon.
PREMEDICATION: Fentanyl 2 cc IV, Versed 10 mg IV, Benadryl 50 mg IV.
FINDINGS: Rectal: No masses. Good sphincter tone. Anoscopic examination shows friable internal and external hemorrhoids, no fissures. The anoscope was removed. The colonoscope was inserted in the usual fashion from the rectum to the cecum. The mucosa was carefully examined in its entirety. The mucosa was normal, nonfriable with no mass lesions, polyps, arteriovenous malformations or mucosal lesions identified.
IMPRESSION:
1. Friable internal and external hemorrhoids.
PLAN: I feel this patient will be best served by having surgery to remove the external and internal hemorrhoids. In the interim, we will place him on Anusol HC suppositories one per rectum t.i.d. for 8 days, sitz baths b.i.d. to t.i.d. for 2 weeks, Tucks Wipes after each bowel movement and at bedtime for 2 weeks, Mycolog Cream to the perirectal area, Ultra Charmain white toilet tissue. Witch hazel soaks to the rectum at bedtime. Citrucel, Fiber-Con, Juice Plus. Referred to surgeon for hemorrhoidectomy. See us in one year in followup.
PROCEDURE: Esophagogastroduodenoscopy.
INSTRUMENT: Pentax endoscope.
PREMEDICATION: Fentanyl 2 cc IV, Versed 5 mg IV, Benadryl 50 mg IV, topical Endocaine spray.
OPERATOR: Dr. Hixon.
FINDINGS: The scope was advanced in the usual fashion without difficulty. The patient tolerated the procedure well.
Esophagus: The upper and middle third of the esophagus appeared normal. In the distal esophagus there was a peptic stricture with a mild reflux esophagitis. With gentle pressure, we passed through the stricture into the stomach.
Stomach: The cardia, fundus, body, antrum and pylorus all appeared normal.
Duodenum: The bulb was smooth and distended well with no lesions noted. The scope was passed into the second and third portion of the duodenum where the mucosa was normal and nonfriable with no lesions identified. Duodenal aspirate for Giardia was obtained. The scope was brought back across the esophagogastric junction and dilated to 20-mm TTS, successfully dilating the peptic stricture.
IMPRESSION:
1. Peptic stricture of the esophagus at the esophagogastric
junction, dilated to 20-mm TTS.
2. Mild esophagitis.
3. Substernal pain, probable esophageal spasm.
PLAN: Antacids, antireflux program. Proton pump inhibitor b.i.d. for 2 weeks and then 1 daily. Add Cardizem 30 mg 1/2 hour a.c. and h.s. for 2 weeks only. See us in 4 months for a followup.
PROCEDURE: Esophagogastroduodenoscopy.
INSTRUMENT: Pentax endoscope.
OPERATOR: Dr. Hixon.
PREMEDICATION: Fentanyl 2 cc IV, Versed 2.5 mg IV, Benadryl 50 mg IV,
topical Endocaine spray.
FINDINGS: The scope was advanced in the usual fashion without difficulty.
The patient tolerated the procedure well.
Esophagus: The upper and middle third of the esophagus appeared normal. In the distal esophagus was noted a moderate reflux esophagitis. No rings, webs or strictures noted.
Stomach: The cardia, fundus, body, antrum and pylorus all appeared normal.
Duodenum: The bulb was smooth and distended well with no lesions noted. The scope was passed into the second and third portion of the duodenum where the mucosa was normal and nonfriable with no lesions identified. Duodenal aspirate for Giardia obtained.
IMPRESSION:
1. Moderate esophagitis.
PLAN: Protonix 40 mg p.o. b.i.d. for 2 weeks and then 40 mg q. a.m.
Zelnorm 6 mg p.o. 1 hour before and 2 hours after breakfast and supper.
1,500 calorie ADA diet with no milk, ice cream, fried foods, raw fruits or raw vegetables.
Transderm scopolamine patch 1 behind the ear q. 3 days.
PROCEDURE: Colonoscopy.
INSTRUMENT: Pentax colonoscope.
OPERATOR: Dr. Hixon.
PREMEDICATION: Continuation of sedation from the esophagogastroduodenoscopy
with Fentanyl 2 cc IV, Versed 9 mg IV.
FINDINGS: Rectal: No masses. Good sphincter tone. Anoscopic examination shows slightly friable internal hemorrhoids. No fissures. The anoscope was removed. The colonoscope was inserted in the usual fashion from the rectum to the cecum. The mucosa was carefully examined in its entirety. The mucosa was normal, nonfriable with no mass lesions, polyps, arteriovenous malformations or mucosal lesions identified.
IMPRESSION:
1. Hemoccult-positive stools.
2. Internal hemorrhoids.
3. Otherwise, normal to the cecum.
PLAN: Resume nasogastric suction, and as soon as there are normal bowel sounds, we will stop the nasogastric suction and begin feeding. I feel this patient most likely has carcinomatosis, mesenteric and bowel implants. Hopefully we will get normal bowel sounds and can stop the NG and begin feeding.
PROGNOSIS: Poor.
PROCEDURE: Esophagogastroduodenoscopy.
INSTRUMENT: Pentax endoscope.
OPERATOR: Dr. Hixon.
PREMEDICATION: Fentanyl 2 cc IV, Versed 9 mg IV.
FINDINGS: The scope was advanced in the usual fashion without difficulty. The patient tolerated the procedure well.
Esophagus: The upper, middle and distal esophagus appeared normal.
Stomach: The cardia, fundus, body, antrum and pylorus all appeared normal.
Duodenum: The bulb was smooth and distended well with no lesions noted. The scope was passed into the second and third portion of the duodenum where the mucosa was normal and nonfriable with no lesions identified.
IMPRESSION: Normal esophagogastroduodenoscopy.
PLAN: Colonoscopy.
PREOPERATIVE DIAGNOSIS
PROCEDURE: Endoscopic retrograde cholangiopancreatography.
OPERATOR: Dr. Hixon
PREMED: Fentanyl 2 cc IV, Versed 8 mg IV, Demerol 50 mg IV, topical
endocaine spray, Glucagon 0.25 mg IV.
FINDINGS: Initially the end viewing scope was inserted in the usual fashion without difficulty. The patient tolerated the procedure well.
Esophagus: The upper and middle third of the esophagus appeared normal. The distal esophagus shows a mild reflux esophagitis with a peptic stricture. We gentle pressure we passed through the stricture into the stomach. The cardia, fundus, body of the stomach appeared normal. The antrum showed a mild antritis with some erosions. Biopsy taken. The pylorus was normal.
Duodenum: The bulb showed mild duodenitis. No ulcers. The scope was passed into the second and third portion of the duodenum where the mucosa was normal, nonfriable with no lesion noted. Bowel was present. CLOtest was taken, may be false-negative given the fact the patient is on proton pump inhibitor. The end-viewing scope was removed and the side-viewing scope was inserted, inserted through the pylorus into the duodenum. The ampulla of Vater identified. It appeared to be fairly petulant suggesting possible common duct stone had passed through this or common duct stones had passed through this. There was no sign of any malignancy present at the ampulla. The catheter was induced into the ampulla. The common duct was cannulated, slightly dilated but no stone or stricture was noted which filled both the left and right hepatic radicals and the cystic duct stump. In addition we
did feel the head, body and tail of the pancreas, it was normal, it did not get any acinarization. We then removed the scope. The patient was turned in multiple positions. No stone, stricture or mass lesions were noted in the common bile duct.
IMPRESSIONS
1. Dilated but normal common bile duct.
2. Normal pancreatic system.
3. Mild antritis, duodenitis and esophagitis.
Of note, this patient was dilated with a 50 French Maloney dilator on
termination of the procedure thus the additional diagnosis of the peptic stricture of the esophagus.
PLAN: Increase Protonix to 40 mg IV q.12h. We will discontinue NG tube and we will see how patient responds. May well have had common duct stone in the past as I am suspicious of this.
PREOPERATIVE DIAGNOSIS
POSTOPERATIVE DIAGNOSIS
NAME OF PROCEDURE: Esophagogastroduodenoscopy
INSTRUMENT: Pentax endoscope
OPERATOR: Dr. Hixon
PREMED: Fentanyl 2 cc IV, Versed 1.5 mg IV, Benadryl 50 mg IV, topical
endocaine spray.
FINDINGS: The scope was advanced in the usual fashion without difficulty. The patient tolerated the procedure well. The posterior pharynx, vallecular and piriform sinuses appeared normal.
Esophagus: The upper third of the esophagus appeared normal. Beginning at 32 cm and extending to the EG junction at 40 cm was a large exophytic mass in places occupying 80% of the lumen and the other areas coming up in a linear fashion with a mass seen submucosal and popping out in an area 2 cm above most consistent with carcinoma. We passed through the EG junction into the stomach.
Cardia: There is a fungating mass in the cardia most consistent with
carcinoma, again adenocarcinoma most likely arising in Barrett esophagus progressing up to the esophagus. Biopsies were taken. The fundus, body, antrum appeared normal. The pylorus is normal.
Duodenum: The bulb was smooth, distended well with no lesion identified. The scope was passed into the second and third portion of the duodenum where the mucosa was normal, nonfriable with no lesion noted. Biopsies were taken of the cardia and the distal esophagus.
IMPRESSION: Carcinoma of the esophagus 32 cm to the EG junction at 40 cm with involvement of cardia.
PLAN: He needs a referral to oncology and radiation therapy for their
consideration for immediate treatment prior to any surgical intervention. Question is should this man have a PEG tube for feeding purposes and maintenance with radiation and chemotherapy. He may get a stricture of the EG junction and a tumor growth may block this off. Abdominal sonogram revealed the gallbladder is not seen well. This may be contracted versus stone filled and probably should be further evaluated. We will assume he will be getting screening with CAT scan, PET scan, etc.
Prognosis is poor.
POSTOPERATIVE DIAGNOSIS
PROCEDURE: Esophagogastroduodenoscopy.
OPERATOR: Dr. Hixon
PREMED: Fentanyl 2 cc IV, Versed 10 mg IV, Demerol 100 mg IV.
FINDINGS: The scope was advanced in the usual fashion without difficulty.
The patient tolerated the procedure well.
Esophagus: The upper and middle third of the esophagus appeared normal. The distal esophagus showed a mild reflux esophagitis with a small hiatal hernia. No hyperemia, friability or erosion noted in the hernia pouch or stomach.
Cardia: The cardia, fundus, body, antrum and pylorus were normal.
Duodenum: The bulb was smooth, distended well with no lesion identified. The scope was passe into the second and third portion of the duodenum where the mucosa was normal, nonfriable with no lesion noted. The scope was then brought back to the EG junction where we injected 2 cc in each four quadrants with Enteryx getting good fluoroscopic placement into the muscle layer of the esophagus. No extravasation. No transmural injection. The patient tolerated the procedure well.
IMPRESSION: Severe reflux esophagitis treated with Enteryx injection.
PLAN: The patient is to be on proton pump inhibitor b.i.d. for two weeks. Antacids one hour and three hours p.c. and h.s. for two weeks. Lorcet Plus for pain. He was instructed that he will have a temp of
100 to 101 for the next two weeks. See us in one month.
PREOPERATIVE DIAGNOSIS
PROCEDURE: Colonoscopy
INSTRUMENT: Pentax colonoscope
OPERATOR: Dr. Hixon
PREMED: Fentanyl 2 cc IV, Versed 10 mg IV, Benadryl 50 mg IV.
FINDINGS: Rectal: No masses, good sphincter tone. Anoscopic exam shows
slightly friable internal hemorrhoids. No fissures. Anoscope removed and colonoscope inserted in the usual fashion from the rectum to the cecum in its entirety. The mucosa was normal, nonfriable with no mass lesions, polyps, AV malformation or mucosal lesion identified. Transvaginal sonogram showed the uterus was removed. There is a 1.7 cm right ovary and 1.7 cm left ovary that appeared normal.
IMPRESSIONS
1. Heme positive stools.
2. Friable internal hemorrhoids.
3. Abdominal pain.
PLAN: Empiric trial of Levsinex one b.i.d., Anusol HC Suppositories one per rectum t.i.d. for eight days. Sitz bath b.i.d. to t.i.d. for two weeks. Tucks wipes after each bowel movement and at bedtime for two weeks. Mycolog Cream to the perirectal area t.i.d. for two weeks. Ultra Charmin white toilet tissue. Continue Cozol 750 mg one t.i.d. with meals. See us in four months for followup. We will followup
on PIPIDA with ejection fraction.
PREOPERATIVE DIAGNOSIS
POSTOPERATIVE DIAGNOSIS
PROCEDURE: Esophagogastroduodenoscopy
INSTRUMENT: Pentax endoscope
OPERATOR: Dr. Hixon
PREMED: Fentanyl 2 cc IV, Versed 10 mg IV, Benadryl 50 mg IV, topical
endocaine spray.
FINDINGS: The scope was advanced in the usual fashion without difficulty. The patient tolerated the procedure well. Esophagus: The upper, middle and third of the esophagus appeared normal. The distal esophagus shows a mild reflux esophagitis. No rings, webs or stricture.
Stomach: The cardia, fundus, body and antrum and pylorus were normal.
Duodenum: The bulb was smooth, distended well with no lesion identified. The scope was passed into the second and third portion of the duodenum where the mucosa was normal, nonfriable with no lesion noted. Duodenal aspirate for Giardia obtained.
IMPRESSION: Mild esophagitis.
PLAN: Add Nexium 40 mg every a.m., antacids antireflux program. Of note, abdominal sonogram shows a 5.5 right cm right renal cyst, otherwise unremarkable. We will get PIPIDA with ejection fraction. It is possible she could have occult biliary tract disease. Proceed with
colonoscopy.
PREOPERATIVE DIAGNOSIS
POSTOPERATIVE DIAGNOSIS
PROCEDURE: Esophagogastroduodenoscopy and endoscopic retrograde
cholangiopancreatography.
OPERATOR: Dr. Hixon
PREMED: Fentanyl 2 cc IV, Versed 8 mg IV, Benadryl 50 mg IV, Glucagon 0.25 mg IV.
FINDINGS: Initially the end-viewing scope was inserted in the usual fashion without difficulty. The patient tolerated the procedure well.
Esophagus: The upper and middle esophagus appeared normal. The distal
esophagus shows severe esophagitis. There is a moderate size hiatal hernia.
No hyperemia, friability, ulceration or erosion noted in the hernia pouch.
Stomach: The cardia, fundus, body, antrum and pylorus were normal.
Duodenum: The bulb was smooth, distended well with no lesion identified. The scope was passed into the second and third portion of the duodenum where the mucosa was normal, nonfriable with no lesion noted. The end-viewing scope was removed after biopsy was taken of the EG junction and the side-viewing scope passed through the pylorus into the duodenum. The ampulla of Vater appeared normal, cannulated and injected. Pancreatic duct had some narrowing in the head of the pancreas as did the common bile duct. They then both dilated. The pancreatic duct dilated massively with the side branches consistent with the findings of chronic pancreatitis. The common bile duct
was dilated above after the exit to the head of the pancreas. We dilated into the common duct, left and right hepatic radicles, however, the cystic duct was patent, the gallbladder filled and gallstones were present.
IMPRESSIONS
1. Gallstones.
2. Dilated common bile duct and pancreatic duct with narrowing of
ducts in the head of the pancreas, probably chronic
pancreatitis. I cannot exclude a mass.
3. Chronic pancreatitis.
4. Severe esophagitis.
PLAN: The patient should have choledochoduodenostomy with biopsy of the head
of the pancreas and removal of the gallbladder.
PROCEDURE: Colonoscopy.
INSTRUMENT: Pentax colonoscope.
PREMED: Fentanyl 2 cc IV, Versed 10 mg IV, Benadryl 50 mg IV, Demerol 50 mg IV.
FINDINGS: Rectal: No masses. Good sphincter tone. Anoscopic exam showed a rectal fissure at 9:00 with the patient in the left lateral decubitus position. The anoscope was removed. The colonoscope was inserted in the usual fashion from the rectum to the cecum. The ileocecal valve was identified. Despite multiple attempts in
positioning, could never get into the ileum. Stool was heme positive above the rectal fissure.
IMPRESSION:
1. Hemoccult positive stools above the rectal fissure.
2. Rectal fissure.
PLAN: Anusol HC suppositories one per rectum t.i.d. for eight days, sitz baths b.i.d. to t.i.d. for two weeks, Tucks Wipes after each bowel movement and at bedtime for two weeks, Mycolog Cream to perirectal area t.i.d. for two weeks, Ultra Charmin white toilet tissue. Levsinex one tab p.o. b.i.d. Proceed with capsule endoscopy to exclude Crohn's of the terminal ileum,especially given heme positive stools above the rectum.
PROCEDURE: Colonoscopy.
INSTRUMENT: Pentax colonoscope.
PREMED: Fentanyl 2 cc IV, Versed 10 mg IV, Benadryl 50 mg IV.
FINDINGS: Rectal: No masses. Good sphincter tone. Anoscopic exam shows friable internal hemorrhoids. No fissures. The anoscope was removed.
The colonoscope was inserted in the usual fashion from the rectum to the cecum. The mucosa was normal, nonfriable with no mass lesions, polyps, AV malformations or mucosal lesions identified.
IMPRESSION:
1. Heme positive stools.
2. Friable internal hemorrhoids.
3. Fecal incontinence probably secondary to hemorrhoids.
PLAN: Anusol HC suppositories one per rectum t.i.d. for eight days, sitz baths b.i.d. to t.i.d. for two weeks, Tucks Wipes after each bowel movement and at bedtime for two weeks, Mycolog Cream to perirectal area t.i.d. for two weeks, Ultra Charmin white toilet tissue. Witch hazel soaks to rectum at bedtime. Citrucel, FiberCon or Juice-Plus. See us in a month for follow-up. Will follow-up on CLOtest.
PROCEDURE: Esophagogastroduodenoscopy.
INSTRUMENT: Pentax endoscope.
PREMED: Fentanyl 2 cc IV, Versed 10 mg IV, Benadryl 50 mg IV, topical
Endocaine spray.
FINDINGS: The scope was advanced in the usual fashion without difficulty. The patient tolerated the procedure well.
Esophagus: The upper, middle and distal esophagus was normal.
Stomach: The cardia, fundus, body of the stomach appeared normal. The
antrum showed a moderate antritis. Biopsy taken. The pylorus was normal.
Duodenum: The bulb showed mild duodenitis. No ulcer. The scope was passed into the second and third portion of the duodenum where the mucosa was normal, nonfriable with no lesions noted. CLOtest was taken of the antrum.
IMPRESSION:
1. Moderate antritis.
2. Mild duodenitis.
PLAN: Antacids, antireflux program, Nexium 40 mg q.a.m. If Helicobacter positive, add Helidac pack. Of note, abdominal sonogram is normal. Proceed with colonoscopy.
PROCEDURE: Esophagogastroduodenoscopy.
INSTRUMENT: Pentax endoscope.
PREMED: Fentanyl 2 cc IV, Versed 3 mg IV, Benadryl 25 mg IV, topical
Endocaine spray.
FINDINGS: The scope was advanced in the usual fashion without difficulty. patient tolerated the procedure well.
Esophagus: The upper, middle and distal esophagus was dilated with fluid present. This was removed. There was a large epiphrenic diverticulum at the EG junction. The EG junction is off at an angle with narrowing. We passed through this rather narrowed area into the stomach.
PROCEDURE: Esophagogastroduodenoscopy.
INSTRUMENT: Pentax endoscope.
PREMED: Fentanyl 2 cc IV, Versed 10 mg IV, Benadryl 50 mg IV, Demerol 50 mg IV, topical Endocaine spray.
FINDINGS: The scope was advanced in the usual fashion without difficulty. The patient tolerated the procedure well.
Esophagus: The upper and middle esophagus appeared normal. The distal
esophagus shows a mild reflux esophagitis. No rings, webs or strictures.
Stomach: The cardia, fundus, body, antrum and pylorus were normal.
Duodenum: The bulb was smooth, distended well with no lesions identified. The scope was passed into the second and third portion of the duodenum where the mucosa was normal, nonfriable with no lesions noted. Duodenal aspirate for Giardia was obtained. Random biopsy of a normal appearing small bowel obtained in this patient with chronic diarrhea. Abdominal sonogram shows aorta and pancreas obscured by gas. He is post cholecystectomy and has mild enlarged spleen, 14 cm, but this is consistent with his size.
IMPRESSION: Mild esophagitis.
PLAN: Nexium 40 mg q.a.m. Proceed with colonoscopy.
PROCEDURE: Colonoscopy.
INSTRUMENT: Pentax colonoscope. PREMEDS: Continuation of sedation from EGD with fentanyl 2 cc IV, Versed 10 mg IV, Demerol 100 mg IV, Benadryl 50 mg IV. FINDINGS: Rectal: No masses. Good sphincter tone. Anoscopic exam shows friable internal hemorrhoids. No fissures. Anoscope removed. Colonoscope inserted in the usual fashion from the rectum to the cecum. Diverticula noted in the sigmoid colon. Mucosa normal, nonfriable, no mass lesions, polyps, AV malformations or mucosal lesions identified. Stool for ova and parasites obtained. Random colon biopsies taken to exclude collagenous or lymphocytic colitis. IMPRESSION 1. Heme positive stool. 2. Diverticulosis. 3. Internal hemorrhoids. 4. Chronic diarrhea. PLAN: Diet of no milk, no ice cream, no raw fruits, no raw vegetables. Citrucel, Fibercon or Juice Plus. Anusol-HC suppositories 1 per rectum t.i.d. for 8 days, Sitz baths b.i.d. and t.i.d. for 2 weeks. Tucks Wipes after each bowel movement and bedtime for 2 weeks. Mycolog cream to perirectal area t.i.d. for 2 weeks. Trial of Alinia 500 mg p.o. b.i.d. for 3
days. Stop the Zelnorm. Begin Librax 1 a.c. and h.s. See us in 1 month for follow-up.
PROCEDURE: Esophagogastroduodenoscopy.
DATE OF PROCEDURE: January 12,2005
INSTRUMENT: Pentax endoscope.
OPERATOR: Dr. Hixon.
PREMED: Fentanyl 2 cc IV, Versed 10 mg IV, Benadryl 50 mg topical Endocaine spray.
FINDINGS: The scope was advanced in the usual fashion without difficulty. The patient tolerated the procedure well. Esophagus: The upper, middle, and distal esophagus appeared normal. Stomach: The cardia, fundus, body, antrum and pylorus all appeared normal.
Duodenum: Showed a severe duodenitis despite Prilosec 20 mg a day. The scope was passed into the second and third portion of the duodenum where the mucosa as normal, nonfriable with no lesions identified. Biopsy of the antrum was taken to evaluate for Helicobacter by CLOtest. We will also get a serum Ig for Helicobacter as may have a false-negative CLOtest.
IMPRESSION: Severe duodenitis despite Prilosec. PLAN: Await biopsy for CLOtest and serum Ig for Helicobacter. Increase
Prilosec to 20 mg b.i.d. for 1 month, then cut back to 20 mg a day. If Helicobacter pylori positive, add Helidac Pak. Proceed with colonoscopy.
PROCEDURE: Colonoscopy.
DATE: January 12, 2005.
OPERATOR: Dr. Hixon.
INSTRUMENT: Pentax colonoscope. PREMED: Fentanyl 2 cc IV, Versed 10 mg IV, Benadryl 50 mg IV. FINDINGS: Rectal: No masses. Good sphincter tone. Anoscopic examination showed friable internal and external hemorrhoids. No fissures. The anoscope was removed. The colonoscope was inserted in the usual fashion from the rectum to the
cecum. The mucosa was carefully examined in its entirety. The mucosa was normal, nonfriable with no mass lesions, polyps, AV malformations or mucosal lesions identified.
MPRESSION 1. Friable internal and external hemorrhoids. 2. Hemoccult-positive stools secondary to #1. PLAN: Anusol HC suppositories 1 per rectum t.i.d. for 8 days, sitz baths
b.i.d. to t.i.d. for 2 weeks, Tucks Wipes after each bowel movement and at bedtime for 2 weeks, Mycolog Cream to the perirectal area, Ultra Charmin white toilet tissue. Citrucel, FiberCon, or Juice Plus. See us in 4 months for followup.
NAME OF PROCEDURE: Esophagogastroduodenoscopy.
INSTRUMENT: Pentax endoscope.
SURGEON: Dr. Hixon. PREMEDICATIONS: Fentanyl 2 mL IV, Versed 4.5 mg IV, and topical endocaine spray.
FINDINGS: The scope was advanced in the usual fashion without difficulty. The patient tolerated the procedure well. Esophagus: The upper and middle third of the esophagus appeared normal. The distal esophagus showed mild esophagitis. No rings, webs, strictures or stones. Stomach: The cardia, fundus, and body appeared normal. The antrum showed a moderate antritis, biopsies were taken. The Helicobacter pylori breath test was positive. The pylorus was normal. Duodenum: Showed severe erosive duodenitis. No ulcers. The scope was
passed into second and third portion of the duodenum and the mucosa was
normal, nonfriable, and no lesion identified.
IMPRESSION 1. Severe duodenitis. 2. Helicobacter pylori positive. 3. Moderate antritis. 4. Mild esophagitis. PLAN: Nexium 40 mg every morning, Helidac pack. Proceed with colonoscopy.
PREOPERATIVE DIAGNOSIS
Severe osteoarthritis of the left knee.
POSTOPERATIVE DIAGNOSIS
Severe osteoarthritis of the left knee.
PROCEDURE PERFORMED
1. Minimally invasive approach, left total knee replacement, #7 femur, #7 tibia, 7 x 8 patella, 7 x 12 tibial insert.
2. The patient also had significant laxity of the medial collateral ligament requiring advancement of the superficial and deep medial collateral ligament, medial staple, and multiple sutures.
DESCRIPTION OF PROCEDURE: The patient was placed supine on the operating table and adequate spinal anesthesia was achieved. The left leg was elevated, prepped and draped in the usual manner. Using a longitudinal incision over the anterior aspect of the knee, the skin was incised, continued through the subcutaneous tissue down to the level of the fascia. Medial parapatellar incision was made. Exposure of the joint was carried out with significant osteoarthritis to be present. The suprapatellar fat pad was removed. The fat pad behind the patellar tendon was removed. The deep medial collateral ligament was released and the medial meniscus was excised. Anterior cruciate ligament was removed. There was pretty severe spurring along the medial
tibial plateau and there was severe spurring in the notch which required notchplasty in order to release the ligament. Once we did that, we were able to sublux the tibia forward. Drill hole was made in the tibia, in-between the tibial spines. Intermedullary guide system was used to make our proximal tibial cut. Once that had been done, distal femoral drill hole followed by insertion of the intermedullary guide. First our anterior cut was made using the anterior cutting guide and then the distal cut with the distal femoral cutting guide at 10 mm. Once that had been accomplished, we measured the femoral condyle and selected a #7. Our anterior, posterior, and chamfer cuts were made using a #7 cutting guide. Once that was done, the Scorpio System
was utilized for a notch cut. We went ahead and used the laminar spreader for incision of the posterior portion of the meniscus, medially, andlaterally. It was noted early on and throughout the procedure, that she had extreme laxity. Once we had released these deep medial collateral ligament, the superficial medial collateral ligament seemed quite incompetent and was very lax. We went ahead and proceeded with pinning our tibial cutting block in top of the tibia. We made our delta wings cuts and then trial reduced the femoral component and then the tibial component. Prior to doing the femur, we had removed the posterior aspect of the patella and prepared the patella. We trial reduced all three components. Good alignment and good position was
achieved but there was medial laxity and there was medial laxity more than would be easily corrected just by going to a larger implant. It was obvious that we were going to have to do some medial ligament advancement. It appeared that our superficial medial collateral ligament, perhaps from old injury or degenerative change was just incompetent and once the deep medial collateral ligament was released, as it is normally done, then she really just did not have much constraint medially. We went ahead and prepared all three components. We cemented the femoral component and the tibial component with the first batch of cement. We cemented the tibial component with a
second batch of cement. After that had been accomplished, copious irrigation was carried out with removal of all excess cement. The 12 mm tibial insert of the standard variety was utilized. Once that was done, we carefully exposed the medial and collateral ligament. We went ahead and initially advanced our superficial medial collateral ligament, which was quite lax and stapled it using a Richards ligament staple medially. Once we had accomplished that, we went beneath that and took the deep medial collateral ligament, and we advanced that and sutured it down to the stapled superficial medial collateral ligament. We were able to tighten up the medial side of the joint quite well with both advancement of the deep medial collateral and advancement of the superficial medial collateral. We will go slow with her postop rehab program. We will use the knee-immobilizer when ambulating and we
will only go CPM through the first 60-degrees for the first four weeks. We will slowly go through the remainder of the rehab program being very careful, bracing her knee for three months. After a ligament reconstruction had been accomplished with a nice good stable knee, copious irrigation was carried out and closure of the wound in layers. The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.
PREOPERATIVE DIAGNOSIS:
1. Loose total knee with synovitis and lateral ligament
instability.
POSTOPERATIVE DIAGNOSIS:
1. Loose total knee with synovitis and lateral ligament
instability.
PROCEDURE: Revision right total knee replacement, #5 femoral component with a 10-mm medial spacer, 5-mm lateral spacer and 14-mm stem, 4-mm posterior off -set, a #7 tibial component with 12-mm stem, 10-mm full tibial block and an 18-mm tibial insert.
SURGEON: Dr. John Payne.
ASSISTANT: Brenda Jacobs.
ANESTHESIA: Spinal.
TOURNIQUET TIME: 151 minutes.
1 gram of Ancef given preoperatively and another 1 gram of Ancef given
intraoperatively. Antibiotic-impregnated cement was utilized.
DESCRIPTION OF PROCEDURE: The patient was placed supine on the operating room table and adequate spinal anesthesia was achieved. The right leg was elevated, prepped and draped in the usual manner. Using a longitudinal incision, the skin was incised. This was continued through the subcutaneous tissue down to the level of the fascia. Medial parapatellar incision made with a mid-vastus extension. We dissected down to the tibial tubercle, but did not have to do a tibial tubercle osteotomy. After exposure of the joint, we went ahead and did our medial release and subluxed our tibial component forward. The tibial component was loose and the fluid was expressed from underneath the tibial component. We initially went ahead and removed the tibial component and removed the bone cement. After all bone cement was removed, we then exposed the patella. The patella implant was not
loose. We then exposed our femoral component. Our femoral component
appeared to be reasonably stable, however, the patient had lateral ligament instability which will require a deeper box, so the femoral component was removed using osteotomes and saw. After that had been accomplished, the femoral component was removed. Good bone stock was left. We then went ahead and removed all soft fibrous growth insert. Once that was done, good exposure of the joint was accomplished. The patellar component was in good condition, it was not loose and was left. We went ahead then with copious irrigation of the joint. We went ahead initially with our femur. We did sequential reaming of the femur and reamed up to 14 mm. We went ahead and did our trial cuts and selected a #5 femoral component with a posterior off-set of 4-mm. Good approximation was achieved. 5-mm lateral insert, 10-mm
medial insert, and good reapproximation of the femoral alignment and position was accomplished. Attention was then turned to the tibial component, where we went ahead and inserted out intramedullary guide. We did sequential reaming and we then made our proximal tibial cut, removing 10 mm. We then went ahead and reamed up to 12-mm distal and used the long 12-mm stem. We decided on a full tibial insert with a trial in order to gain maximum stability. 18-mm tibial insert
gave us the best circumstance. Copious irrigation was carried out, at this time. We did a rather radical synovectomy of the joint using the
arthroscopic shaver and suction. Once that had been accomplished, we went ahead again with copious irrigation and then went ahead with mixing our cement. The components were assembled. We cemented our femoral component first, and again this was a 5-mm femoral component, 10-mm medial off-set, 5-mm lateral off-set, a 14-mm stem with 4-mm posterior off-set. This was cemented into place and excess cement was removed. Good alignment and good position was achieved. Excess cement was removed. We then mixed our second batch of cement. Again, antibiotic-impregnated cement was utilized on both sides. We then cemented the tibial component, a #7 tibial component with 12-mm stem, 10-mm full tibial block with 18-mm tibial insert. Careful
attention to alignment was accomplished, based on the tibial tubercle. Once this had been accomplished, copious irrigation was carried out. All excess cement was removed and once everything was night and tight, we then went ahead and did our trial reduction and selected an 18-mm tibial insert. The final 18-mm tibial insert was inserted. Copious irrigation was carried out and insertion of a drain. Good alignment and good position was achieved. Closure of the wound was done in layers. Final tourniquet time was 151 minutes. Estimated blood loss was minimal. Again, 1 gram Ancef was given prior to the procedure and 1 gram in the procedure, as well as gentamicin-
impregnated cement.
The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.
PREOPERATIVE DIAGNOSIS:
1. Rotator cuff tear of the right shoulder.
POSTOPERATIVE DIAGNOSIS:
1. Rotator cuff tear of the right shoulder, with global tear
of the rotator cuff of the rotator cuff, right shoulder.
PROCEDURE: Arthroscopy of right shoulder, debridement, followed by
arthrotomy and rotator cuff repair of right shoulder with acromioplasty.
SURGEON: Dr. John Payne.
ASSISTANT: Brenda Jacobs.
ANESTHESIA: General.
DESCRIPTION OF PROCEDURE: The patient was placed supine on the operating room table and adequate general anesthesia was achieved. Arthroscopy was carried out with an initial debridement of synovial tissue in the joint. We went ahead and smoothed the edges of the rotator cuff. The rotator cuff initially seemed bigger. We went ahead and made a small incision out laterally, tried to bring the rotator cuff over as far as we could, it did not look like we could mobilize it enough, however, the muscle appeared to be bigger than I expected. We decided that we would go ahead and open and attempt to repair. I hated not to proceed with the open repair for in his occupation he needs that use of the shoulder if at all possible. We made a small, 2-inch incision over the lateral aspect of the acromion, continued through the subcutaneous tissue down to the level of the muscle. The muscle
was split longitudinally, exposure was carried out. Debridement of the
bursa, careful exposure of the rotator cuff. The rotator cuff was pretty mobile anteriorly, the farther posteriorly, the less mobile. Went ahead and used the Cobb elevator underneath and on top and mobilized the rotator cuff as much as possible. Once we had done that, we brought the rotator cuff back out over the humeral head and created a very small trough at the edge of the articular surface. Four super Mitek anchors were utilized for repair of the rotator cuff. After this was done, we went ahead and took the same suture passing it through the tendon and used that to advance and go down through a hole in the bone. This was to increase the footprint of the repair and seal it. This went nicely. The rotator cuff was fairly well repaired. It is
probably less coverage posteriorly and better coverage anteriorly.
Nevertheless, pretty good coverage of the humeral head was achieved. Copious irrigation was carried out. Injection of Marcaine with epinephrine. Closure of the wound in layers.
The patient tolerated the procedure well.
The patient will be admitted for pain control because of the magnitude of surgery.
PREOPERATIVE DIAGNOSIS: Severe osteoarthritis, right knee.
POSTOPERATIVE DIAGNOSIS: Severe osteoarthritis, right knee.
PROCEDURE: Minimally invasive approach, right total knee replacement, #9
femur, #7 tibia, 15 tibial insert, 7x8 patella.
SURGEON: Dr. John Payne.
ASSISTANT: Brenda Jacobs.
ANESTHESIA: Spinal.
ESTIMATED BLOOD LOSS: Minimal.
TOURNIQUET TIME: 108 minutes.
DESCRIPTION OF PROCEDURE: The patient was placed supine on the operating room table and adequate spinal anesthesia was achieved.
The right leg was elevated, prepped and draped in the usual manner. Using a longitudinal incision, 8-cm in length, extending 1.5-cm below the joint line, extending proximally, the skin was incised and continued through the subcutaneous tissue down to the fascia. Medial peripatellar incision was made with exposure of the joint. We debrided the patellar synovial tissue and then we went ahead and debrided the menisci and cruciate ligament. We released the deep medial collateral ligament, leaving the superficial medial collateral ligament intact. After that had been accomplished, we went ahead with subluxation of the tibia anteriorly. We made a drill hole in between the tibial spines, slightly placed posteriorly in order to allow for flexion of the component. We inserted the intramedullary guide and made our proximal
tibial cut. Once that was done, attention was turned to the distal femur. The distal femoral drill hole was made, followed by insertion of intramedullary guide. Anterior cuts, followed by distal cuts. We then measured our condyle, and selected #9 femoral component. We made our anterior approach with chamfer cuts with #9 cutting guide. Once this was done, we used the lamina spreader to expose the joint and we debrided the remainder of the meniscus. Once that was done, we went ahead and did our Scorpio notch cuts. After than had been accomplished, copious irrigation was carried out. With exposure of the tibia, the tibial plate was pinned in place. Delta-wing cuts were made. We then trial reduced the femoral and the tibial component. Posterior aspect of the patella had been previously removed, a drill hole had been inserted. We then went ahead and trial reduced all three components. Good alignment and good position was achieved. There was a moderate degree of laxity and looked like a larger
component than usual would be necessary. We then went ahead and mixed our cement and after copious irrigations, we cemented our femoral component and patellar component with the first batch of cement. We cemented the tibial component with the second batch of cement. All excess cement was removed. We then went ahead and did our trial reduction with varying size tibial inserts and a 15 tibial insert gave us the greatest stability, good flexion and good extension, good stability and good extension. Copious irrigation was carried out, followed by insertion of a drain and closure of the wound in layers. Bulky dressing was applied.
The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.
PREOPERATIVE AND POSTOPERATIVE DIAGNOSES: Avascular necrosis of the left hip with lymphoma and pathological fractures. She has had a fracture of the femoral neck on the right side that appeared to heal in varus and I think this healed spontaneously. She has pathological lesions with tumor in numerous areas. She is status post chemotherapy. She has avascular necrosis of the left hip and this is where the majority of her pain is. She also has tumor involving the pelvis.
NAME OF PROCEDURE: Left total hip replacement, minimal invasive approach, #10 femoral component, 16 mm distal size, 50 mm acetabular cup, two screws, 32 mm liner and plus 5 head.
ANESTHESIA: Spinal.
DESCRIPTION OF PROCEDURE: The patient was placed supine on the operating room table and adequate spinal anesthesia was achieved. The left hip was prepped and draped in the usual manner. Using a 10 cm incision extending slightly posteriorly, the skin was incised and continued through the subcutaneous tissue down to the trochanter. The trochanter was mobilized in the anterolateral approach, approaching the hip capsule anteriorly. We took down the anterior one-third of the gluteus, anterior capsulectomy. We exposed the hip joint proper. We went ahead with sequential reaming of the acetabulum and reamed up to 48 mm. We trialed the 50 and also the 52 and the 52 was selected. That would allow us a little larger size prosthesis. We then went ahead and inserted the 50 mm acetabulum which is a Trident cup,
which is 1.8 mm oversized. A good snug fit was achieved. A 40 mm screw and a 35 mm screw were used for fixation. Once that had been accomplished, standard liner was inserted. Good alignment and good position achieved. We then went down to the femur. We went ahead with sequential reaming. The femoral shaft was very osteoporotic and very wide. She had severe avascular necrosis of the hip. Sequential reaming was carried out. Extremely thin medial cortex. We inserted a distal size 16 mm prosthesis with #10 femoral stem. X-ray showed some deficiency in the medial cortex. We debated whether or not to go in and put a plate or bone strut there medially, but I think this is stable and I think this has a chance to heal if she just doesn't fall
and have a pathological fracture. With her overall general poor health, I was hesitant to prolong the procedure. We then went ahead and inserted the plus 5 mm neck with 32 mm head. Final reduction accomplished good alignment, good position, good stability. Copious irrigation carried out. A drain was left in the depths of the wound. Closure of the wound in layers. The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.
PREOPERATIVE DIAGNOSIS
Severe osteoarthritis of the left hip.
POSTOPERATIVE DIAGNOSIS
Severe osteoarthritis of the left hip.
PROCEDURE
Minimally-invasive-approach left total hip replacement using 50-mm cup with two screws, standard liner, secure-fit #7 femoral component, and -5-mm neck/32-mm head.
SURGEON: Dr. John Payne.
ASSISTANT: Brenda Jacobs; Dr. Everett Veach.
ANESTHESIA: Spinal.
DESCRIPTION OF PROCEDURE: The patient was placed in the right lateral
decubitus position. The left hip was prepped and draped in the usual manner. Using a straight incision 8 cm in length and excising a scab from a burn that she had received recently from a heating pad, the skin was incised, continued through the subcutaneous tissue. Once we had excised the area of the burn, we passed off the instruments and changed gloves. Betadine was poured into the open area where we excised the scab. A longitudinal incision was made in the fascia, exposing the trochanter. The anterior one-third of the gluteus was taken down and retractors were inserted. Exposure of the anterior hip capsule was carried out. Once that had been accomplished, anterior capsulectomy was performed. Dislocation of the femoral head. The femoral neck was cut along the trochanteric line. After the femoral head was removed, we measured this and it measured 46 mm. We then carefully exposed
the acetabulum with excision of the labrum and surrounding tissue. Once that had been done, sequential reaming was carried out and we reamed up to 51 mm. We inserted the 52-mm trial which fit nicely. Good alignment and good position were achieved. We opened the 50-mm Trident cup and it was inserted. The 50-mm cup was oversized 1.8 mm and we inserted the 52 trial and had good fit. Once the cup had been inserted, two fixation screws were utilized. Good fixation was
achieved. Copious irrigation was carried out. We went ahead and inserted the standard liner. Once that was done, good alignment and good position were achieved with the acetabular component. Attention was then turned to the femur. We went ahead and used the cookie
cutter to make an incision laterally. We then went ahead with sequential reaming followed by the rasp. The #7 rasp was nice and firm-fit with good rotational stability. Trial reduction was carried out. We had good length, and a -5 was the most stable with a good, firm reduction. We considered shortening the neck further. However, at -5 we had a nice, stable reduction of the hip. Leg length seemed to be restored. We probably had gained about 0.5 cm. She was slightly short by x-ray. Clinically, she was unaware of whether she was short on that side. We felt we had gained an adequate amount with the -5, so instead of cutting the neck shorter we went ahead and left it
as it was.
We then went ahead and inserted the final secure-fit regular prosthesis. The -5-degree head was inserted and the hip was reduced. Copious irrigation was carried out. Final x-rays were noted. The final x-rays looked good. Copious irrigation was carried out. The wound was closed in layers. Two drill holes were made. The anterior one-third of the gluteus was reattached using Mersilene tape. The fascia was closed with #0 Vicryl. Copious irrigation was carried out. Drain was left in the depths of the wound. Closure of the wound in layers. The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.
PREOPERATIVE DIAGNOSIS
Malunion of prior fracture of hip with prior infection, antibiotic cement beads in place, resulting in avascular necrosis of the femoral head, six previous operations.
POSTOPERATIVE DIAGNOSIS
Malunion of prior fracture of hip with prior infection, antibiotic beads in place, resulting in avascular necrosis of the femoral head, six previous operations.
PROCEDURE
Revision of prior infected malunion fracture of the hip to a total hip
replacement using 60-mm Trident cup, three screws, 36-mm standard liner, #10 femur (secure-fit plus), distal stem size 16, 36-mm/+5 head and two Dall-Miles cables. We also performed removal of antibiotic-impregnated cement beads.
DESCRIPTION OF PROCEDURE: The patient was placed supine on the operating room table and then turned to the left lateral decubitus position. The right hip was prepped and draped in the usual manner. Longitudinal incision was made through the prior incision, dissected through the subcutaneous tissue down to the fascia. The fascia was incised. Exposure of the lateral aspect of the femur. The antibiotic-impregnated beads were carefully one by one exposed and numerous antibiotic-impregnated beads were removed along with a large cylinder that extended up the femoral neck. After this was done, an anterior approach to the hip itself was carried out with anterior capsulectomy. Once this was done, we carefully did significant capsular release in order to try to regain as much length as possible. He was 2-1/2 inches short with a varus malunion of the hip. We went ahead with cutting of the femoral neck and removal of the femoral head. We then exposed the acetabulum, and after extensive debridement of soft tissues and scar
tissue we then went ahead with sequential reaming and reamed up to 60 mm of the acetabulum. The 62-mm trial fit nicely. We then went ahead and inserted a 60-mm Trident cup. Three screws were utilized for fixation.
Once that had been accomplished, attention was turned to the femur. There was great deformity of the proximal femur. We went ahead and identified what seemed to be the area where femoral neck would have normally been. We opened the canal and did sequential reaming. We removed further antibiotic-impregnated cement that had been packed into the femoral canal. Once that had been accomplished, we were able to do sequential reaming up to 16 mm. We then started out with sequential rasping and very tedious and painstaking rasping was carried out with both stiles of the rasp handles. We made a decision instead of going with a fully porous-coated stem to go with a secure -fit plus for distal fixation because of the very large canal size. There
was a mis-size between the distal size. The canal was very large and the proximal femur was relatively small. We were able to compensate for that with a secure-fit plus prosthesis. We went ahead with sequential reaming. After careful advancement, we were
able to get up to a #10 secure-fit plus prosthesis. This was proud, but we wanted it to be proud to try to gain length. Good proximal fit. Two Dall-Miles cables were inserted to prevent cracking, and there was a little bit of cracking laterally in the trochanter. Once that had been accomplished, copious irrigation was carried out. We had
trial fitting and we selected a 36-mm standard liner. This was inserted. We reduced it with a 36-mm, +5 head. We were able to achieve good alignment, good position, and fairly-good restoration of leg length. The Gram stain taken in the early portion of the case was negative for bacteria and only a few polys. Cultures have been sent and are pending.
Final copious irrigation was carried out. The final reduction looked good. Insertion of a drain. Closure of the wound in layers. The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.
PREOPERATIVE DIAGNOSIS: Fractured radial head with traumatic arthritis of the left elbow. POSTOPERATIVE DIAGNOSIS: Fractured radial head with traumatic arthritis of the left elbow.
PROCEDURE: Radial head resection and radial head implant, arthroplasty of the left elbow.
ASSISTANT: Brenda Jacobs.
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Minimal.
TOURNIQUET TIME: 46 minutes. 1 gm Ancef given preoperatively.
DESCRIPTION OF THE PROCEDURE: The patient was placed supine on the operating room table. An adequate general anesthesia was achieved. The left arm was elevated, prepped and draped in the usual manner. Using a longitudinal incision over the lateral aspect of the elbow, the elbow was opened by dissection through the skin, subcu and then split longitudinally through the muscle fibers. Exposure of the joint was carried out down to the annular ligament. After the annular ligament was carefully retracted, we went ahead and resected the radial head. It was in 1 piece. The previous fracture had been healed with fibrous union. Once that had been accomplished, we carefully inspected the joint and did synovectomy of the joint. Once that was done, we selected radial head implant. We went head with sequential
reaming up to 6.5-mm into the ulnar canal. Once we had a nice firm, good fit, we went ahead with insertion of the trial prosthesis. Good alignment, good position was achieved. With the capsular ligament open, there was a certain degree of instability of the radial head so we went back in very carefully, tightened the capsular ligament to give as much stability as possible to that radial head. Copious irrigation had been carried out prior to closure. The final implant had been applied. It was a 22-mm head with a 6.5-mm stem. Closure of the wound in layers, after capsular repair. Patient tolerated the procedure well and returned to the recovery room in satisfactory condition. Long arm splint applied. The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.
PREOPERATIVE DIAGNOSIS: Displaced fracture of the right long finger, distal phalanx, open fracture. POSTOPERATIVE DIAGNOSIS: Displaced fracture of the right long finger, distal phalanx, open fracture. PROCEDURE: Irrigation and debridement, open reduction and internal fixation of displaced fracture of the right long finger, distal phalanx. Longitudinal pin fixation.
ANESTHESIA: General.
DESCRIPTION OF THE PROCEDURE: The patient was placed supine on the operating room table and adequate general anesthesia was achieved. The right hand was elevated, prepped and draped in the usual manner. Copious irrigation was carried out with a water pick. The posterior portion of the nail was removed but the anterior portion of the nail was left intact. We went ahead and reduced the fracture of the mid distal phalanx. After removal of the nail, we could get the nail matrix and everything back aligned. We went ahead and did longitudinal pin fixation of that distal phalanx followed by suture repair of the nail matrix. Tolerated that well. Copious irrigation carried out. Splint applied. Jergen pin ball was placed on the tip of the finger. Patient tolerated the procedure well, returned to the recovery room in satisfactory condition.
