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Qualified medical evaluation report of a case with back pain.

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

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.

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

A sample note on Rheumatoid Arthritis

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

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.

Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots. Right L4-S1 posterolateral fusion with local bone graft. Left L4 through S1 segmental pedicle screw instrumentation. Preparation harvesting of local bone graft.

Patient scheduled for laparoscopic gastric bypass.

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

Right knee total arthroplasty. Degenerative osteoarthritis, right knee.

Aortogram with bilateral, segmental lower extremity run off. Left leg claudication. The patient presents with lower extremity claudication.

Work restrictions and disability evaluation

The client with continued problems with her headaches.

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

Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.

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

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

Progressive low-grade glioma, now more than 20 years since initially diagnosed. She is status post craniotomy for debulking and has done well with the surgery.

Overactive bladder with microscopic hematuria.

Acute appendicitis and 29-week pregnancy. Appendectomy.

Template for History and Physical for a newborn.

Right inguinal hernia. Right inguinal hernia repair. The case is a 4-year-old boy with a right inguinal bulge, which comes and goes with Valsalva standing and some increased physical activity.

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

Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.

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.

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

Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. Right C5-C6 herniated nucleus pulposus.

The skin biopsy was performed on the right ankle and right thigh. The client was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient.

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

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

Consult for laparoscopic gastric bypass.

Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.

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 discomfort to both upper and lower teeth on the left side for approximately three days..

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

Patient today with ongoing issues with diabetic control.

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

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

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

Cardiology office visit sample note.

Itchy red rash on feet - Tinea Pedis

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

Work restrictions and disability evaluation

Status post left hip fracture and hemiarthroplasty. Rehab transfer as soon as medically cleared.

A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back ache radiating into the right leg.

Work restrictions and disability evaluation

Ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700. Nonfunctioning inflatable penile prosthesis and Peyronie's disease.

Pars plana vitrectomy, pars plana lensectomy, exploration of exit wound, closure of perforating corneal scleral laceration involving uveal tissue, air-fluid exchange, C3F8 gas, and scleral buckling, right eye.

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

Specimen labeled "sesamoid bone left foot".

The patient had temperature of 104 degrees F. It has been spiking ever since and she has had left sacroiliac type hip pain. She does have degenerative disk disease of her lumbar spine but no hip pathology. She has swollen inguinal nodes bilaterally.

Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.

Adenotonsillar hypertrophy and chronic otitis media. Tympanostomy and tube placement and adenoidectomy.

Specimen labeled "sesamoid bone left foot".

Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement. Right renal mass and ureteropelvic junction obstruction and hematuria.

Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity. Risk factors for coronary heart disease.

Right frontal craniotomy with resection of right medial frontal brain tumor. Stereotactic image-guided neuronavigation and microdissection and micro-magnification for resection of brain tumor.

Chiropractic IME with answers to questions from Insurance Company.

Anterior spine fusion from T11-L3. Posterior spine fusion from T3-L5. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.

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

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

Negative for any nausea, vomiting, fevers, chills, or weight loss.

The client was originally hospitalized secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.

Left orchiectomy, scrotal exploration, right orchidopexy.

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

Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.

Sleep study - client with symptoms of obstructive sleep apnea with snoring.

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

A sample note on Rheumatoid Arthritis

Chronic laryngitis, hoarseness. The client was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.

The client is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.

Vasectomy 10 years ago, failed. Azoospermic. Reversal two years ago. Interested in sperm harvesting and cryopreservation

Phacoemulsification with posterior chamber intraocular lens implant in the right eye.

A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago.

A sample note on Rheumatoid Arthritis

Aortogram with bilateral, segmental lower extremity run off. Left leg claudication. The patient presents with lower extremity claudication.

Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury

The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm.

The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis.

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

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

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

Complete eye examination - Normal eye and vision exam.

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

Laparoscopy. An incision was made in the umbilicus, allowing us to insert a micro-laparoscopic trocar. We then insufflated the abdomen with approximately 3 liters of carbon dioxide gas and inserted the micro-laparoscopic instrument.

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.

Adenotonsillar hypertrophy and chronic otitis media. Tympanostomy and tube placement and adenoidectomy.

Blepharoplasty with direct brow repair.

Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.

The patient had hematuria, and unable to void. The patient had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed.

Consultation for evaluation of thrombocytopenia.

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.

Degenerative disk disease at L4-L5 and L5-S1. Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.

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.

Hardware removal, right ulnar

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

Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.

Repeat low transverse cervical cesarean section with delivery of a viable female neonate. Bilateral tubal ligation and partial salpingectomy. Lysis of adhesions.

Work restrictions and disability evaluation

The patient is in complaining of headaches and dizzy spells.