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Excision of left breast mass. The mass was identified adjacent to the left nipple. It was freely mobile and it did not seem to hold the skin.

The case complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.

Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture.

Displaced left subtrochanteric femur fracture. Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade.

An example/template for a routine normal male physical exam.

Cognitive linguistic impairment secondary to stroke. The case was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.

Exploratory laparotomy and right salpingectomy.

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

Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome

Global aphasia. The client is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.

Tracheostomy with skin flaps and SCOOP procedure FastTract. Oxygen dependency of approximately 5 liters nasal cannula at home and chronic obstructive pulmonary disease.

Work restrictions and disability evaluation

Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.

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

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.

Patient referred for narrow angles and possible associated glaucoma.

Generalized abdominal pain, nausea, diarrhea, and recent colonic resection. CT abdomen with and without contrast and CT pelvis with contrast. Axial CT images of the abdomen were obtained without contrast. Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.

MRI report Cervical Spine (Chiropractic Specific)

Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome

Brain CT and MRI - suprasellar mass (pituitary adenoma)

Autopsy of a white female who died of acute combined drug intoxication.

Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.

Upper respiratory illness with apnea, possible pertussis. a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. This involved cough, post-tussive emesis, and questionable fever.

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

Psychiatric consultation for substance abuse.

Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The client is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.

The client continues to suffer from ongoing neck and lower back pain with no recent radicular complaints.

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

Occupational medicine consult with questions-answers and records review.

Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome

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

Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.

Standard hypogastric plexus block procedure note.

Mother states he has been wheezing and coughing.

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

Rotated cuff tear, right shoulder. Glenoid labrum tear. Arthroscopy with arthroscopic glenoid labrum debridement, subacromial decompression, and rotator cuff repair, right shoulder.

The patient was running and twisted her right ankle - right ankle sprain.

Patient presents for care of suspected rheumatoid arthritis.

An example/template for a routine normal female physical exam.

Reflex sympathetic dystrophy of both lower extremities.

Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone.

Right total knee arthroplasty - Osteoarthritis, right knee.

Patient today with multiple issues.

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

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

Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.

Patient had a recurrent left arm discomfort after her stent, three days ago, and this persisted after two sublingual nitroglycerin.

Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.

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

Traumatic injury to bilateral upper extremities. Dressing change under anesthesia. This 6 year old was involved in a traumatic accident. She presents today for evaluation and dressing change.

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

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

Hispanic male client was admitted because of enlarged prostate and symptoms of bladder neck obstruction.

Diagnosis of benign rolandic epilepsy.

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 C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.

2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.

Autopsy - Asphyxia due to ligature strangulation.

CT Brain: Subarachnoid hemorrhage.

Specimen labeled "right ovarian cyst" is received fresh for frozen section.

Aftercare of multiple trauma from an motor vehicle accident.

She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission.

Extraction of teeth #2 and #19 and incision and drainage (I&D) of intraoral and extraoral of left mandibular dental abscess.

Shoulder pain, right shoulder diffusely - Rotator cuff syndrome, right.

Evaluation and recommendations regarding facial rhytids.

Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma.

The client was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The client is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the client to achieve hands-free voicing.

Psychiatric consultation for substance abuse.

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

Markedly elevated PT INR despite stopping Coumadin and administering vitamin K. Patient with a history of iron-deficiency anemia due to chronic blood loss from colitis.

Chronic adenotonsillitis with adenotonsillar hypertrophy. Upper respiratory tract infection with mild acute laryngitis.

Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.

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

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

Specimen labeled "sesamoid bone left foot".

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

Complete laminectomy, L4. and facetectomy, L3-L4 level. A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level. Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System. Posterior spinal fusion, L4 to S1. Insertion of morselized autograft, L4 to S1.

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

Possible inflammatory bowel disease. Polyp of the sigmoid colon.. Total colonoscopy with photography and polypectomy.

Squamous cell carcinoma of right temporal bone/middle ear space. Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.

Is it BNP or BMP?

Closed reduction of mandible fractures with Erich arch bars and elastic fixation. Left angle and right body mandible fractures.

Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm.

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

Autopsy of a white female who died of acute combined drug intoxication.

Patient presents for care of suspected rheumatoid arthritis.

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

Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.

The case has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.

Newborn circumcision. The penile foreskin was removed using Gomco.

A lady with symptoms consistent with possible oligoarticular arthritis of her knees.

MRI Brain: Thrombus in torcula of venous sinuses.

Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome

Patient presents for care of suspected rheumatoid arthritis.

The client with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region. Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.

Evaluation of airway for possible bacterial infection performed using bronchoalveolar lavage.

A sample note on Rheumatoid Arthritis

DDDR permanent pacemaker, insertion of a steroid-eluting screw in right atrial lead, insertion of a steroid-eluting screw in right ventricular apical lead, pulse generator insertion, model Sigma,

A male referred to Wheelchair Clinic for evaluation for a new wheelchair.

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