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

History of abdominal pain, obstipation, and distention with nausea and vomiting - paralytic ileus and mechanical obstruction.

Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5. Songer wire. Right iliac bone graft.

Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.

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.

Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,

Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.

Cause of death - Anoxic Encephalopathy

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

Procedure note on Keller Bunionectomy

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.

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.

Dilation and curettage (D&C) and hysteroscopy. A female presents 7 months status post spontaneous vaginal delivery, has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.

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

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.

Repair of nerve and tendon, right ring finger and exploration of digital laceration. Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.

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

Right hand-assisted laparoscopic cryoablation of renal lesions x2. Lysis of adhesions and renal biopsy.

CT maxillofacial for trauma. CT examination of the maxillofacial bones was performed without contrast. Coronal reconstructions were obtained for better anatomical localization.

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

This is a middle-aged female with two month history of low back pain and leg pain.

The case was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The case attended nine outpatient skilled speech therapy sessions.

A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall.

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.

CT of Brain - Subacute SDH.

Consult for laparoscopic gastric bypass.

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

Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.

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.

Colonoscopy. The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum.

A sample note on bilateral myringotomy tubes

Abdominal pain right lower quadrant, radiating around her side to her right flank. Etiology is unclear.

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

Qualified healthcare evaluation report of a patient with back pain.

Autopsy - Homicide - Blunt force cranial trauma

Normal upper GI endoscopy.

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

Right nodular malignant mesothelioma.

Consultation for evaluation of thrombocytopenia.

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

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

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

Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth ache to both upper and lower teeth on the left side for approximately three days..

Closed reduction percutaneous pinning, left distal humerus. Closed type-III supracondylar fracture, left distal humerus. Tethered brachial artery, left elbow.

Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.

CT scan of the abdomen and pelvis without and with intravenous contrast.

MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal.

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

Common CT C-Spine template

The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse.

A sample note on Rheumatoid Arthritis

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

Left carpal tunnel release. Left carpal tunnel syndrome. Severe compression of the median nerve on the left at the wrist.

Release of A1 pulley, right thumb. Stenosing tendinosis, right thumb (trigger finger). There was noted to be thickening of the A1 pulley. There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.

Cause of death - Anoxic Encephalopathy

A sample note on Rheumatoid Arthritis

Work restrictions and disability evaluation

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

A 61-year-old white male with a identification of mantle cell lymphoma status post autologous transplant with BEAM regimen followed by relapse. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.

Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.

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

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

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

Penile discharge, infected-looking glans. A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans. It seems that the patient has had multiple catheterizations recently and has history of peripheral vascular disease.

Specimen labeled "sesamoid bone left foot".

EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.

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

Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,

Chest x-ray on admission, no acute finding, no interval change. CT angiography, negative for pulmonary arterial embolism. Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.

Consultation for wrist pain.

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.

Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.

The case underwent an overnight polysomnogram.

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

This is a 53-year-old man, who presented to emergency room with multiple complaints including discomfort from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain.

Lower quadrant discomfort with nausea, vomiting, and diarrhea. CT abdomen without contrast and CT pelvis without contrast. Noncontrast axial CT images of the abdomen and pelvis are obtained.

Left orchiectomy, scrotal exploration, right orchidopexy.

The patient is with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue. His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves.

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

Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft.

Patient in ER complaining of shortness of breath (COPD)

Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore-Tex graft. Chronic renal failure and thrombosed left forearm arteriovenous Gore-Tex bridge fistula.

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

Total abdominal hysterectomy and bilateral salpingo-oophorectomy.

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

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

Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture and placement of antibiotic-impregnated beads. Open calcaneus fracture on the right.

Evaluation of possible tethered cord. She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.

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

Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.

Patient today with ongoing issues with diabetic control.

Is it BNP or BMP?

Patient presents for care of suspected rheumatoid arthritis.

Patient discharged after laparoscopic Roux-en-Y gastric bypass.

Emergency cesarean section.

Cardiology office visit sample note.

Pain management for post-laminectomy low back syndrome and radiculopathy.

Bronchoscopy with bronchoalveolar lavage. Refractory pneumonitis. A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.

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

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