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Left lower lobectomy.

Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.

The case died of a pulmonary embolism, the underlying cause of which is currently undetermined.

Mother states he has been wheezing and coughing.

Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a case with code last night with CPR and advanced cardiac life support.

Followup of left hand discomfort and systemic lupus erythematosus. Carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.

Work restrictions and disability evaluation

A female for a complete physical and follow up on asthma with allergic rhinitis.

Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.

Right hydronephrosis, right flank pain, atypical/dysplastic urine cytology, extrarenal pelvis on the right, no evidence of obstruction or ureteral/bladder lesions. Cystoscopy, bilateral retrograde ureteropyelograms, right ureteral barbotage for urine cytology, and right ureterorenoscopy.

Ophthalmology followup visit note.

An example of a physical exam

Encephalopathy related to normal-pressure hydrocephalus.

Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.

Diagnosis of bulbar cerebral palsy and hypotonia.

This patient has reoccurring ingrown infected toenails.

Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.

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

Nephrology Consultation - Patient with renal failure.

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

Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.

Consultation for evaluation of thrombocytopenia.

Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure. Cervical spondylotic myelopathy with cord compression and cervical spondylosis.

Dietary consultation for diabetes during pregnancy.

Chiropractic IME with answers to questions from Insurance Company.

Superior labrum anterior and posterior lesion repair.

The client died of a pulmonary embolism, the underlying cause of which is currently undetermined.

Autopsy - Homicide - Blunt force cranial trauma

Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.

Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.

Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.

Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.

Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.

The patient was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.

Speech therapy discharge summary. The client was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.

Hospice visit for 77-year-old gentleman with advanced colon cancer.

A sample note on Rheumatoid Arthritis

Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a client with code last night with CPR and advanced cardiac life support.

Flexible bronchoscopy to evaluate the airway (chronic wheezing).

Evaluation for right L4 selective nerve root block.

Cause of death - Anoxic Encephalopathy

CT Abdomen and Pelvis with contrast

Esophagogastroduodenoscopy and colonoscopy with polypectomy

Direct right inguinal hernia. Marlex repair of right inguinal hernia.

Autopsy - Asphyxia due to ligature strangulation.

Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.

Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.

Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.

Lower lid blepharoplasty.

Pilonidal cyst with abscess formation. Excision of infected pilonidal cyst.

A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.

Repeat low-transverse cesarean section via Pfannenstiel incision. Intrauterine pregnancy at 39 and 1/7th weeks. Previous cesarean section, refuses trial of labor. Fibroid uterus, oligohydramnios, and nonreassuring fetal heart tones.

Squamous cell carcinoma of the larynx. Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.

Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.

Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This client presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.

Release of ventral chordee, circumcision, and repair of partial duplication of urethral meatus.

A 19-year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain.

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

Placement of left ventriculostomy via twist drill. Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.

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

Left hemothorax, rule out empyema. Insertion of a 12-French pigtail catheter in the left pleural space.

Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal. Anterior cervical fusion. Utilization of allograft for purposes of spinal fusion. Application of anterior cervical locking plate.

This is a 24-year-old pregnant patient to evaluate fetal weight and placental grade.

The client is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.

Total thyroidectomy for goiter. Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.

Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.

Mohs Micrographic Surgery for basal cell CA at medial right inferior helix.

A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer.

Patient admitted after an extensive workup for peritoneal carcinomatosis from appendiceal primary.

Psychiatric consultation of case with lethargy.

Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.

Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.

Occupational medicine consult with questions-answers and records review.

Newly diagnosed head and neck cancer. The patient was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa.

Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7

Right foot series after a foot injury.

Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.

Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.

Normal female review of systems template. Negative for fever, weight change, fatigue, or aching.

Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.

Hospice visit for 77-year-old gentleman with advanced colon cancer.

A 16-year-old male with Q-fever endocarditis.

Preop evaluation regarding gastric bypass surgery.

4-day-old with hyperbilirubinemia and heart murmur.

Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.

Tracheostomy and thyroid isthmusectomy. Ventilator-dependent respiratory failure and multiple strokes.

This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema. No confirmed prior history of heart attack, myocardial infarction, heart failure.

Transnasal transsphenoidal approach in resection of pituitary tumor. The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.

True cut needle biopsy of the breast. This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge. On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.

Very high PT-INR. she came in with pneumonia and CHF. She was noticed to be in atrial fibrillation, which is a chronic problem for her.

A 49-year-old man with respiratory distress, history of coronary artery disease with prior myocardial infarctions, and recently admitted with pneumonia and respiratory failure.

A female for a complete physical and follow up on asthma with allergic rhinitis.

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

First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.

Pediatric Gastroenterology - Rectal Bleeding Consult.

Cadaveric renal transplant to right pelvis - endstage renal disease.

Autopsy - Homicide - Blunt force cranial trauma

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

Occupational medicine consult with questions-answers and records review.

A 23-year-old white female presents with complaint of allergies.