REASON FOR REFERRAL:  Weakness.

HISTORY OF PRESENT ILLNESS:  This is a patient who was admitted on (XX) for altered mental status, history of fall, evaluated in the emergency room and admitted for further workup.  There is a history of hypertension, coronary artery disease, dementia, diabetes, and osteoarthritis.

PREMORBID FUNCTIONAL STATUS:  Independent in ADL and ambulated without assistive device.

CURRENT FUNCTIONAL STATUS:  Bed mobility, rolling with modified independent, and able to sit at the edge of the bed, and for a short time able to feed herself after a setup.  Socially, lives with the daughter in a house.

MEDICATIONS:  As per reconciliation.

ALLERGIES:  PENICILLIN.

SOCIAL HISTORY:  Denies smoking, drinking, or drugs.

FAMILY HISTORY:  Noncontributory.

REVIEW OF SYSTEMS:

CONSTITUTIONAL:  Just face weakness, tired.

CARDIOVASCULAR:  No chest pain.

RESPIRATORY:  No cold.  No cough.

GASTROINTESTINAL:  No nausea.  No abdominal pain.  No vomiting.

GENITOURINARY:  No GU complaints.

NEURO-MUSCULOSKELETAL:  Just weakness and arthritic pain.

PHYSICAL EXAMINATION:

GENERAL:  Alert and obese.

VITAL SIGNS:  Temperature 97.7, pulse 96, blood pressure 122/62, respirations 18.

HEENT:  Normocephalic.  Extraocular movements are intact.  Pupils are equal and reactive to light and accommodation.

NECK:  Supple.  No JVD.  No carotid bruits.

HEART:  RSR.  No murmur.  No S3, no S4.

LUNGS:  Clear to auscultation and percussion.

ABDOMEN:  Soft.  Bowel sounds plus.  No guarding.  No rigidity.  No organomegaly.

NEURO-MUSCULOSKELETAL:  Speech is functional.  Hearing is functional.  Cranial nerves are intact.  Swallowing is functional with the current diet.  Cognition impaired.  Able to move both upper extremities with 3+/5 strength.  Both lower extremities 3/5.  Passive range of motion is within functional limits.  Sensation is intact.  Deep tendon reflexes are 2+.

SKIN:  Intact.

LABORATORY DATA:  The workup done here demonstrates hemoglobin 11.6, hematocrit 35.7, WBC 8.8, platelets 225,000.  Chemistry shows sodium 147, potassium 3.9, chloride 108, carbon dioxide 28.5, glucose 144, troponin is less than 0.04.

ASSESSMENT:

1. Debility.
2. Altered mental status.
3. Dementia.
4. Osteoarthritis.
5. Hypertension.
6. Diabetes.

PLAN OF TREATMENT:  Rehab potential is fair.  Physiatry recommendations are to continue physical therapy.  Continue fall precautions and short-term subacute rehab when medically stable.

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SUBJECTIVE: The patient has had a biopsy from her left nose, which showed actinic keratosis. The lesion, however, continues to recur. She was being treated with liquid nitrogen in the past. She has also noted a rough area below her left lower lip.

OBJECTIVE: She has a small rough scaly macule on the left side of the nose and other on the left lower lip. The area on the nose is just above the biopsy site.

ASSESSMENT: Actinic keratosis.

PLAN:
1. Recommended to treat with light Efudex cream twice daily for 3 weeks on both lesions.
2. Asked to call me if lesion recurs.
3. She was warned about hypopigmentation.

Sample #2

SUBJECTIVE: The patient is an (XX)-year-old woman who comes for followup of basal cell carcinoma to left thigh treated in January (XXXX). She has noted a rough area on the left nose but no other skin, hair, nail complaints. She did have a small stroke in July from which she has recovered.

OBJECTIVE: Full exam done. She has a well-healed scar on the left thigh. Her skin is clear. No lesions appreciated with the exception of a rough scaly papule on the left nose. She has scattered seborrheic keratosis also.

ASSESSMENT:
1. Actinic keratosis, left nose. This is treated with liquid nitrogen spray.
2. History of basal cell carcinoma left thigh, January (XXXX).

PLAN:
1. She will return in one year’s time.
2. Lesion will be also treated with cryosurgery.

Sample #3

This is a (XX)-year-old gentleman with a history of squamous cell carcinoma on his lip a year ago who returns for a skin exam. No lesions on his skin he is concerned about. He denies itching, pain or bleeding at any skin lesion.

MEDICATIONS: Atenolol, lisinopril, and hydrochlorothiazide.

ALLERGIES: NONE KNOWN.

Review of systems, social history, family history is being updated per the patient information sheet placed in his medical record.

OBJECTIVE: On examination of the face, neck, chest, abdomen, back, upper and lower extremities, hands and feet bilaterally, there are rough keratotic 2-4 mm macules on both cheeks in 4 locations altogether. The rest of the skin exam is unremarkable.

ASSESSMENT: Actinic keratoses.

PLAN: Liquid nitrogen, 10 seconds, for destruction of actinic keratoses. Continue sun screen. She is to followup in 1 year.

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She still feels too big. She cannot buy shirts that button down the front. She feels like everybody stares at her when she is in a bathing suit, and she does live on a lake and spends a lot of time in a bathing suit. She is looking at what options she has. Before the first surgery, she said she was a D or a big C. She currently wears a DD or DDD bra. She is unable to find bathing suits.

She wants to have a smaller, more narrow breast and complains of having a lot of breast tissue she feels against her arms. She does report having a weight gain of 10 pounds this winter. She currently has 200 cc smooth, round gel implants. The patient has a negative family history of breast cancer and has no personal history of breast disease.

Her most recent mammogram was six months ago and it was negative. She is G3, P3, and has children aged 5, 6, and 7. She breast-fed all of them. She does report her breasts increased in size after the birth of her children. The patient’s other significant medical history is significant for an abdominoplasty, rhinoplasty, a DCR on the left eye, and a left forehead lift.

Medications: She takes no medicines.

Allergies: She has no known drug allergies.

Social History: She is a nonsmoker, occasional drinker, non drug user. She has a supportive husband and works as a stay-at-home mother.

Examination: The examination reveals that the patient is 5 feet 3 inches tall. She weighs 134 pounds. Examination of the breasts revealed macromastia bilaterally with grade II breast ptosis. Wise pattern scars are present bilaterally. The right nipple sits a little bit higher than the left, and the left breast is slightly longer than the right. No masses are palpable on examination. Nipple sensation is intact, but according to the patient, not very sensitive. She has no nipple discharge. The breast tissue itself is fibrocystic. There is a loose skin envelope present with stretch marks noted.

Assessment: Macromastia. Could benefit from the removal of 200 cc breast implant with mastopexy.

Plan: We discussed with the patient that as she feels that she is too large, our recommendation would be to remove her breast implant and do a breast lift. She does have a fair amount of her own breast tissue that is present. She would probably drop two cup sizes, if she had the breast implant removed and a lift performed; this being based on the notion that 100 cc is equivalent to a cup in a standard sized woman with a standard sized breast. We drew for her a Wise pattern mastopexy and implant removal. This would give her scars around the nipple-areolar complex down vertically to the crease and in the crease itself. We would try to make her breasts the same as much as possible, but we could not guarantee symmetry nor could we guarantee a bra cup size.

Regarding the lateral fullness that she feels, this is, we believe, from her breast tissue and not from her implant. This could be improved slightly from narrowing of the breasts but could not be guaranteed to be completely resolved, as she does have natural breast tissue, which has natural movement. We discussed the risks of sensory changes, nipple necrosis, and permanent scars.

We also discussed that the shape of her breasts will be different without an implant. We showed her pictures of patients that have augmented breasts and patients with natural breasts who have undergone surgery, and we pointed out the main difference is the lack of superior fullness with a natural breast. This is a normal natural breast appearance to have most of the fullness at the bottom of the breast, but something that she would need to get used to.

From our standpoint, it does not do her any good to have this breast implant as she feels too large. We also do not feel it would be the right choice to do a breast reduction and leave an implant behind as to us this is counterintuitive and fraught with higher risk of complications in our opinion. The patient and I discussed that she always could have a breast implant placed again, if for some reason she was dissatisfied with this, but I think that this would be better for her in terms of being able to find bras that fit, clothes that fit, and be more proportional.

I also believe that this would give her the least maintenance required going forward because with an implant, she still will need to do some maintenance procedures in the future. The patient and I discussed that this is an operation that would take about three hours to perform under anesthesia. A drain may or may not be used, which would be removed the next day.

We discussed the risks of pain, infection, bleeding, damage to the neighboring structures, need for further operation, DVT, PE, as well as the other risks previously discussed. The patient also asked a lot about some submental fullness. I suggest she just treat that with weight loss. We also discussed that she should be at her goal weight prior to undergoing breast reduction, and if she were to gain weight or undergo menopause, it is possible her breast could increase in size again. While I cannot guarantee her that this operation will fulfill all of her goals, it would make her have a smaller breast more proportional for her, which I think is something that she would feel good with. The patient will meet with (XX) today to discuss scheduling.

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PAST MEDICAL HISTORY: Fairly significant for being diagnosed with D. fragilis and Blastocystis, and he was treated with antibiotics. Since that time, the patient has had a series of laboratory test and consulted a number of rheumatologists to diagnose the cause of joint pains that he had in his elbows and fingers. Six months ago, he consulted a rheumatologist who diagnosed him with Lyme’s disease. He has been placed on Celebrex and Ceftin for the treatment of the Lyme’s disease.

PRESENT MEDICAL HISTORY: Significant for Lyme’s disease. Also seen by Dr. John Doe for hamstring tendonitis. Two years ago, he had a stress fracture of his right tibia.

PODIATRY HISTORY: Remarkable for having a number of orthotics, some semi-rigid and some semi-flexible having a rearfoot post but none appeared to have a forefoot post on them. The shoe gear the patient regularly wears is running shoes for casual wear and school. The wear pattern on the running shoes appeared normal.

PODIATRY PHYSICAL EXAM:
VASCULAR:
DP: 3/4.
PT: 3/4.
PULSES: Capillary filing time is 2-3 seconds.
EDEMA: None and the toes and foot appeared warm.

NEUROLOGIC: Negative Tinel’s, vibratory grossly intact, and deep tendon reflex 3/5.

DERMATOLOGIC: Nonsignificant.

MUSCULOSKELETAL: Muscle strength was +5/5 with no pain on active or passive range of motion. On exam, there was no tenderness that could be elicited on exam of the medial and lateral aspect of the tibia or posterior malleoli. There was pain on palpation of the Achilles tendon approximately 2 inches proximal to the insertion in the watershed area, but there was no crepitus on exam and no fusiform swelling. Visual exam also revealed a dorsal and medial hyperostosis of the first metatarsal head. There was no pain on range of motion of the first MPJ, no crepitus. The dorsiflexion was 20 degrees and plantarflexion 10 degrees. The first ray appeared to be long and semi-rigid. There was a mild HAV. On stance, there was mild midtarsal joint sag along with the collapse of the longitudinal arch. There was no genu valgum or genu varum. The subtalar joint range of motion was normal. The neutral calcaneal stance was 4 degrees varus, resting was 3 degrees valgus, forefoot position was 4 degrees varus bilateral. Ankle dorsiflexion was –2 degrees knee straight and 10 degrees knee bent. Hip rotation was 70 degrees external and 10 degrees internal. Hamstring flexibility was 70 degrees bilateral and quadriceps 130 degrees. Leg length was equal. The knee exam showed no overt swelling or crepitus on range of motion. There was no instability of the knee, and there was pain on palpation of the anterior aspect of the patellar tendon at the site of the attachment of the plantar tendon. There was no pain elicited on exam of the medial aspect of the knee; although, the patient described having medial knee pain distal to the knee joint.

IMPRESSION:
1. A patient with Lyme’s disease but doubt that the patellar tendonitis is directly related to the Lyme’s disease since he has all the biomechanical components for patellar tendonitis.
2. Contracture of the gastroc.
3. Secondary Achilles tendonitis.
4. Contracture of the hamstring complex.
5. Ankle equinus.
6. Hallux limitus.

TREATMENT PLAN: The treatment provided for the patient today was discussion of findings with the patient and his mother, and we started him on aggressive calf stretching and hamstring flexibility program. He is to ice his knee twice a day and he is to wear some heel lift. We dispensed for about a week and then place in his orthotics again and see if they feel more comfortable. He is to return to the office in 2 weeks for podiatry followup at which time we may do a gait analysis and cast him for orthotics.

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PREOPERATIVE DIAGNOSIS: Ischemic colitis.

POSTOPERATIVE DIAGNOSIS: Ischemic colitis.

PROCEDURES PERFORMED: Right hemicolectomy.

SURGEON: John Doe, MD

ANESTHESIA: General.

COMPLICATIONS: None.

SPECIMENS: Right hemicolon.

INDICATIONS FOR PROCEDURE: This is a gentleman who just underwent a cardiac surgery and now has distended tender abdomen. CAT scan shows a thickened colon on the right side with possible ischemia. The patient is tender on exam. We recommended exploration. Risks, benefits and alternatives have been discussed with his family, who has consented for surgery.

DETAILS OF PROCEDURE: The patient was brought to the operating room and placed supine on the operating table. After undergoing general anesthesia, his abdomen was prepped and draped in surgical fashion using DuraPrep.

A vertical midline incision was made. Dissection was taken down to the fascia, which was incised with a Bovie, and the peritoneum was entered. The abdomen was explored. The right colon had been ischemic and was recovering. There were some punctate hemorrhages in the right side of the transverse colon consistent with possible embolic events.

The patient also had a very distended sigmoid. Based on our concerns about ischemic colitis, we elected to do right hemicolectomy mobilizing the right colon with a Bovie, transecting it to terminal ileum as well as transverse colon just proximal to the middle colic artery with a GIA stapler. Mesentery was taken with vascular loads and stapler.

Side-to-side functional end-to-end anastomosis was created. The anastomosis was then oversewn with 3-0 silk Lembert, left the mesenteric defect open because it was fairly large and wide and it had been difficult to close.

We ran the bowel in the peritoneum and began our closure with number 1 PDS used on the fascia and staples were used to close the skin. Dressing was applied. The patient was awakened and transferred to the PACU in satisfactory condition. The patient tolerated the procedure well.

Right Hemicolectomy Surgery Sample #2

PREOPERATIVE DIAGNOSIS: Cecal mass.

POSTOPERATIVE DIAGNOSIS: Hepatic flexure colonic mass.

PROCEDURE PERFORMED: Right hemicolectomy.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal.

SPECIMEN: Right colon.

COMPLICATIONS: None.

DRAINS: A 15-French round drain placed within the gallbladder bed fossa.

FINDINGS: Upon entry into the abdominal cavity, a hepatic flexure mass could be easily palpated. Visualization revealed that the mass had extended into the fundus of the gallbladder and also into the second portion of the duodenum.

During the course of our blunt dissection, we were able to take off this area of tumor from the gallbladder bed and also from the second portion of the duodenum without injuring these structures. No other abdominal pathology was noted.

INDICATIONS FOR PROCEDURE: The patient is an (XX)-year-old male who presented to the emergency room complaining of abdominal pain and loss of appetite. On workup, his abdominal x-ray showed multiple dilated loops of small bowel and we then initially placed a nasogastric tube for decompression.

Upon questioning, the patient denied any change in his bowel habits or weight loss. Previously colonoscopy, multiple years ago, did not reveal any colonic pathology at that time and he reportedly had no family history of colon cancer. The patient also denied any history of diverticular disease.

Physical examination did not reveal any hernias, and he had a mildly tender abdomen that was quite distended. A CT of the abdomen and pelvis was then obtained, which did reveal a right-sided colonic lesion secondarily causing what looked to be a bowel obstruction. However, upon further review, the patient basically had a large bowel obstruction due to this right-sided colon lesion.

The patient was given IV fluid resuscitation, brought into the hospital and given antibiotics. The imaging findings were discussed with the patient and his family, and they were told that we would be preparing the patient for a right hemicolectomy the following day. All of the risks, benefits and alternatives to the procedure were described in detail to the patient and his family by the attending. Operative consent was signed and placed upon the chart.

DETAILS OF PROCEDURE: The patient was taken to the operating room and placed in supine position. Bilateral lower extremity athrombics were placed. A nasogastric tube along with a Foley catheter had already been placed the previous day. The patient’s abdomen was then sterilely prepped and draped in a standard surgical fashion.

A right paramedian incision was then made in a vertical fashion. The incision was extended from about 2 fingerbreadths below the costal margin to midway between the pubis and iliac crest. This incision was then deepened through the subcutaneous tissues with Bovie electrocautery. Peritoneal cavity was entered. A Bookwalter retractor device was then placed. The small bowel contents were then eviscerated. A moist towel was placed. A hepatic flexure mass was then easily palpated.

At this time, we went ahead and turned our attention at mobilizing the colon for future resection. Using electrocautery, the colon was then freed from its peritoneal attachments along the line of Toldt from the terminal ileum to just distal to the hepatic flexure. During the course of our dissection around the hepatic flexure, we noted that the tumor was eroding into a portion of the fundus of the gallbladder and also there was some tumor burden on the second portion of the duodenum. We were able to mobilize this with blunt dissection and there were no injuries noted to the duodenum or to the gallbladder fundus.

Once this was completed, the colon was then easily mobilized. Points of transection were then selected proximally and distally. The proximal resection was 5 cm from the ileocecal valve and our distal transection point was in the proximal one-third of the transverse colon. Once this was determined, the bowel was then divided with the linear cutting stapler in these two regions. The peritoneum overlying this area was then scored with electrocautery and the ileocolic artery was identified, doubly ligated with 2-0 silk sutures and transected. The main trunk to the middle colic was similarly identified and ligated. The remaining mesentery and all associated nodal tissue was then divided and swept down with the specimen.

The specimen was then removed and sent to pathology for examination. Hemostasis was checked in the operative field and shown to be intact. The two ends of the bowel were then checked and found to be viable with excellent blood supply present. At this time, we went ahead and proceeded with a staple anastomosis. The proximal and distal segments of the bowel were then brought into apposition and found to lie comfortably next to each other with no torsion.

Enterotomies were then made at the antimesenteric borders and then a linear cutting stapler was inserted and fired. Hemostasis was checked along the staple line within the lumen and shown to be intact. The enterotomies were then closed with a TA-60 stapler. The staple line was then reinforced with several interrupted 3-0 silk Lembert sutures. The anastomosis was checked and found to be intact and widely patent. The mesenteric defect was then closed with figure-of-eight 3-0 silk sutures. The abdominal cavity was then copiously irrigated with warm normal saline and hemostasis was checked.

Once this was completed, we then placed a 15-French round drain within the gallbladder bed fossa and exited in the right lower quadrant. The drain was anchored into place with a 3-0 silk suture. The peritoneum was then closed with a running stitch of 0 Vicryl. The fascia was then closed with a running 0 Prolene suture. The subcutaneous tissues were irrigated and reapproximated with running 3-0 Vicryl. The skin was reapproximated with skin staples. Iodoform wicks were placed intermittently between the staples also. Dry sterile dressing was placed and the JP drain was hooked to bulb suction. All instrument, sponge and needle counts were correct at the end of the case.

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TREATMENT:
1. Adriamycin and Cytoxan followed by weekly Taxotere, complete MM/DD/YYYY.
2. Taxotere 35 mg/meter squared weekly, initiated MM/DD/YYYY (3 cycles complete, truncated early secondary to intolerable side effects).
3. Currently Xeloda 2000 mg/meter squared p.o. b.i.d., 7 days on, 7 days, off every 2 weeks, initiated MM/DD/YYYY (4 cycles complete).
4. Evaluation/antibacterials, antifungals, antivirals with no localizing source.

The patient is a (XX)-year-old female with a history of metastatic breast cancer who presents today in followup. She was hospitalized on MM/DD/YY with cellulitis on her abdominal wall. Evaluation did not reveal a source of infection; however, the patient was given antibiotics, antifungals, and antivirals and has subsequently improved. She was discharged on MM/DD/YY. There was some question as to potential reaction to Xeloda, which was stopped 1 day early with her last cycle.

On 14-point review of systems today, the patient reports continued fatigue, slowing improving since hospitalization. Numbness and tingling in her upper and lower extremities is stable and unchanged. Nausea and vomiting; in fact, she had 1 emesis this morning while in the office waiting to be seen, indigestion and heartburn, new low back pain, as well as left hip pain that does radiate down her leg. It is not associated with increased paresthesias; however, she has initiated OxyContin 10 mg b.i.d. and does take 1 oxycodone for breakthrough approximately every other day. She does have shortness of breath with exertion, which is improving since hospitalization; however, remainder of review of systems without pertinent positives.

PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 176 pounds, stable. Blood pressure 122/78, pulse 74, respirations 20, temperature 98.6.
GENERAL: Alert and oriented x3, pleasant female in no acute distress, speaking in complete sentences without difficulty.
HEENT: Hair is short, regrowing. Pupils are equal, round, reactive to light. Sclerae anicteric. Oropharynx clear.
NECK: Supple.
LYMPHATICS: No cervical, axillary or inguinal lymphadenopathy.
LUNGS: Clear bilaterally to auscultation.
CARDIOVASCULAR: Regular rate and rhythm without murmur.
ABDOMEN: Soft, nontender, nondistended. Bowel sounds active x4 quadrants. No organomegaly. Right lower quadrant reddened area is marked with what appears to be decreasing of erythema and healing wound. Area is nonindurated, nondraining, and nontender. Does have less than 0.5 cm area to the left of the umbilicus, again appears to be healing.
EXTREMITIES: No clubbing, cyanosis or edema. The left lower shin biopsy site is healing with a small scabbed area. No induration or drainage.
NEUROLOGIC: Grossly nonfocal.

LABORATORY STUDIES: Laboratory studies from MM/DD/YY: WBCs 7.4, hemoglobin 11.8, hematocrit 37.4, platelet count 258,000. ANC 3.5. Total bilirubin 0.3, alkaline phosphatase 94, AST 22, ALT 6, LDH 492. Sodium 142, potassium 4.5. BUN 14, creatinine 1.01. CA15-3 is pending.

OTHER STUDIES: CT of the head without contrast from MM/DD/YY showed no intracranial abnormality. Small dense area of sclerosis occupies the left skull; could represent either sclerotic metastases or simply a bone island.

Transesophageal echocardiogram reveals ejection fraction of 55-60%, mild mitral and tricuspid regurgitation. No evidence of acute infectious endocarditis.

CT of abdomen and pelvis without contrast reveals hepatic metastases are only subtly seen on this unenhanced CT. Comparison with prior examination for size changes was not possible because of difficulty in visualizing the lesion margins on current exam without contrast. Right lower abdominal wall cellulitis with infiltration of the subcutaneous fat down to the abdominal wall. No frank abscess or fluid collection.

Chest x-ray from MM/DD/YY reveals no acute pulmonary disease.

IMPRESSION:
1. Breast cancer, right, initially stage 2 (now metastatic to the liver and bone).
2. Previous tamoxifen.
3. Chemotherapy with Taxotere 35 mg/meter squared, initiated MM/DD/YY.
4. Shingles, currently resolved.
5. Depression/anxiety, stable on Celexa.
6. Currently Xeloda 2000 mg/meter squared in split doses, 7 days on, 7 days off, every 2 weeks.
7. Recent history of abdominal cellulitis.
8. New lower back and left hip pain.

DISCUSSION: We discussed our clinical findings along with the laboratory data and results of the scan with the patient. There was some question whether her recent infection was a reaction to Xeloda; however, this is not obviously clear. Tumor markers have been responding nicely.

The patient continues to heal regarding her infection; although, labs are stable today. Given her new hip pain, we will proceed with bone scan, have patient follow up in 1 week to discuss the results as well at that time a CA15-3 will be available for review. If patient continues to improve, we will plan on reinitiating Xeloda and monitoring carefully. The patient was agreeable with the above plan. The patient does have thrush on her tongue. She was given a prescription for nystatin 100,000 units/mL swish and spit 4 times daily x7 days or until resolved, 1 bottle with 1 refill.

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PREOPERATIVE DIAGNOSIS: Hydrocephalus.

POSTOPERATIVE DIAGNOSIS: Hydrocephalus.

OPERATION PERFORMED:
1. Left external ventricular drain removal.
2. Right ventriculoperitoneal shunt placement in 5 kg infant.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal.

INDICATION FOR PROCEDURE: The patient is a (XX)-year-old boy with a complex medical history who presented with a ventriculoperitoneal shunt failure. The patient has now had more than a week of negative cultures and appropriate antibiotics.

The risks, benefits and alternatives of surgery were discussed with the family. The risks including, but not limited to, bleeding, infection, injury to the brain, injury to the peritoneal contents, allergic reaction to anesthesia or even death were discussed.

No guarantees were made or implied. Despite the above, they desired to proceed with the left external ventricular drain removal and right ventriculoperitoneal shunt placement.

FINDINGS AND PROCEDURE: The patient was brought to the operative suite and underwent general endotracheal anesthesia. The left frontal incision was then prepped, the staples removed and the external ventricular drain stay stitches cut. The external ventricular drain was removed and the exit site as well as the insertion site was oversewn using 4-0 Vicryl Rapide.

Attention was then turned to the right side of the patient. He was prepped and draped in the usual sterile fashion and his previous right frontal incision was reopened with blunt and sharp dissection down to the existing bur hole. A curette was used to widen the bur hole and Kerrison punch was used to make it larger as well. Shunt passer was then passed from the right frontal region to the right lateral cervical region just above his ECMO cutdown site. The Micro Codman shunt single pressure of 70 mmHg had the Bactiseal peritoneal catheter tied to the proximal end and been appropriately flushed.

It was then passed through the shunt passer and the shunt passer was passed from the right lateral cervical region to the right upper quadrant and the shunt again was passed likewise. The distal 20-30 cm of peritoneal catheter were cut off and discarded.

The dura was incised using monopolar electrocautery and the ventricular catheter was passed into a depth of approximately 16.5 cm. It was easily passed into the lateral ventricle with spontaneous flow of moderate pressure CSF. The ventricular catheter was then appropriately attached to the Rickham reservoir and sewn in place using 2-0 Vicryl. The valve system was appropriately seated in the scalp tissue and spontaneous flow of clear CSF was appreciated through the distal end of the peritoneal catheter.

With the assistance of anesthesia, getting a valve set up to 40, peritoneal trocar was passed in the peritoneal cavity. The distal end of the peritoneal catheter was then passed into the peritoneal cavity without difficulty.

Dr. Jane Doe had been on standby should entering the peritoneal cavity have caused any difficulty in this medically complicated patient with a history of a Nissen and G-tube.

The incisions were copiously irrigated with antibiotic irrigation and closed in anatomic layers using 4-0 Vicryl. The final layer of skin was closed using 4-0 Vicryl Rapide in the cranial incision and benzoin and Steri-Strips in the neck and abdominal incision.

The patient tolerated the left external ventricular drain removal and right ventriculoperitoneal shunt placement well and was sent to the PACU postoperatively.

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PREOPERATIVE DIAGNOSIS: Absent left breast status post mastectomy for cancer, previous infected implant.

POSTOPERATIVE DIAGNOSIS: Absent left breast status post mastectomy for cancer, previous infected implant.

SURGERY PERFORMED: Left breast reconstruction with placement of subpectoral implant and pocket adjustment (extensive capsular release).

SURGEON: John Doe, MD

ANESTHESIA: General anesthesia with LMA.

COMPLICATIONS: None apparent.

ESTIMATED BLOOD LOSS: Less than 50 mL.

DRAINS AND TUBES: A 7 mm Jackson-Pratt drain.

SPECIMEN: Removed expander, discarded. Left breast implant capsule for culture and sensitivity (aerobic, anaerobic, AFB and fungal).

IMPLANT: McGhan 363LF implant with 450 cc of saline added.

INDICATIONS FOR SURGERY: The patient is a (XX)-year-old female who is status post bilateral mastectomies for cancer, reconstructed with subpectoral expanders and implants. Unfortunately, the implant on the left side had clinical infection, although no positive cultures, and had to be removed.

The tissue has now settled down and now for replantation with the major concern being additional infection and also scar. Options considered including replacement of an expander or using a Mentor adjustable implant. However, concern would be that if we do not get adequate reconstruction, the scar tissue is going to be the major limiting factor and would need additional vital tissue, latissimus flap, to permit adequate reconstruction.

Given the risk of infection, we planned to irrigate with both Ancef and kanamycin as bacitracin was not available. In addition, given preoperative Timentin, and we will use Augmentin postoperatively. A drain will be placed.

DESCRIPTION OF SURGERY: The patient was taken to the operating room for left breast reconstruction and was placed in the supine position on the operating table whereupon all appropriate monitoring equipments were attached. At this point, general anesthesia with LMA was uneventfully introduced. Timentin was given intravenously.

The patient had been marked in the preoperative holding area in a sitting position as to the planned lines of the pocket creation and these marks of course were left in place. The entire operative site was then prepped with Betadine in the usual manner, and sterile drapes were applied in the usual fashion. With excellent illumination, including lighted breast retractor and loupe magnification, the left breast reconstruction was undertaken.

The previous left lateral incision just above the inframammary fold was used, and deeper dissection was done with a Bovie cautery device maintaining meticulous hemostasis at this point and throughout the entire procedure. There was some vigorous bleeding along some of the scar tissues, but it was easily controlled with the cautery.

We did dissect underneath the pectoralis and soon came to the previous pocket. This was then enlarged to the marks coming to the lateral border of the sternum, the inframammary fold, anterior axillary line, and then superiorly as well. The periphery being well open, the overlying scar tissue of the capsule was now opened with moldable “postage stamp” dissections until by palpation it was completely released to allow good expansion over the implant.

The pocket was again examined and a portion of the lateral pocket along the chest wall was excised, cut into small sections and sent for culture. No purulence, unhealthy tissue, masses or any other abnormalities were seen beyond the scar.

The #3-0 Vicryl sutures were placed along the capsular opening at the incision and left long to tie down over the implant once placed.

The pocket was copiously irrigated with saline plus Kantrex and Ancef after a 7 mm Jackson-Pratt drain had been placed through the previous stab wound laterally inferiorly and sutured to the skin with #3-0 Vicryl.

Re-inspection was unremarkable, no active bleeding.

The implant was prepared on the back table with all air evacuated and 50 cc of saline added. The implant was now put in position and inflated up to 500 cc, the volume of the right side, and then after about 2-1/2 minutes, it was backed down to 450 cc which had been the equalizing point earlier. That seemed to give a good volume match to the right side but again concern was related to the scar and how well the tissue will re-drape to allow good breast reconstruction.

The fill valve was removed and the seal placed. The #3-0 Vicryl sutures were tied down. Additionally, a #3-0 Vicryl was placed to the subcutaneous layer and then a subcuticular #4-0 Vicryl. Steri-Strips over Mastisol completed the closure.

The entire area was cleansed and dressed with ABDs and bra. No abnormalities were seen in the skin, except for scars.

The left breast reconstruction being done, anesthesia was also ended. The patient was then escorted to the recovery area having tolerated the procedure and the anesthesia in a satisfactory condition. Written instructions were provided. She already has a prescription for Augmentin and Lortab. Followup has been arranged for next week. The patient was specifically instructed to call if there are any questions or problems.

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SUBJECTIVE: The patient is a (XX)-year-old woman who returns for followup of rosacea and because of history of lichenoid keratosis. The patient reports that once every couple of months, the rosacea flares. She then started to use Noritate cream and sodium sulfacetamide, and within a month, she reports it has calmed down. The patient does not use the medications on a regular basis. Moderate sun exposure. She does use sunscreen for outdoor activities.

OBJECTIVE: The patient is alert and oriented x3. On examination of her face, neck, chest, abdomen, back, upper and lower extremities, hands, feet bilaterally, there are no worrisome pigmented lesions or other lesions worrisome for cutaneous malignancy. Face shows mild erythema on the forehead and cheeks.

ASSESSMENT: Mild rosacea, history of actinic keratosis.

PLAN: We discussed with the patient that she will see fewer flares of the rosacea if she uses the metronidazole 0.75% cream daily. The patient can increase to b.i.d. if it does flare. She can continue with the sodium sulfacetamide daily on a p.r.n. basis. Follow up in one year.

Dermatology SOAP Note Example 2

SUBJECTIVE: The patient is a (XX)-year-old woman who returns four weeks after beginning narrow-band UVB for chronic eczema. The patient’s eczema worsened significantly as she was tapering prednisone. She is now back to 20 mg prednisone daily; it had been tapered down to 7.5 mg. The patient is using clobetasol ointment on her skin. She does note that the itchiness has lessened, but she does not think the eczema has improved since she started phototherapy. She is presently on prednisone 20 mg daily, clobetasol ointment daily, hydroxyzine 10 mg q. 6 hours, betamethasone valerate lotion to the scalp, and desonide cream to the face p.r.n.

OBJECTIVE: The patient is alert and oriented x3. There are erythematous, slightly lichenified coalescing papules on the upper mid back, abdomen, proximal thighs, and arms. Face is clear.

ASSESSMENT: Chronic eczema.

PLAN: The patient will continue with the narrow-band UVB for an additional four weeks. We discussed with the patient if at that point she really has not had any improvement in her eczema, then it is unlikely that continuing phototherapy is going to be beneficial. We discussed with her again today that the phototherapy is not curative, but can have an additive benefit through other medications in managing the eczema. The patient voiced understanding of this, and she will continue with the narrow-band UVB three times weekly. Followup will be in four weeks.

Dermatology SOAP Note Example 3

SUBJECTIVE: The patient is a (XX)-year-old gentleman who returns for skin examination because of a history of basal cell carcinoma. He questions raised moles on his back, chest, legs; all of these are asymptomatic.

OBJECTIVE: The patient is alert and oriented x3. On examination of his face, neck, chest, abdomen, back, upper and lower extremities, hands, feet bilaterally, he has sebaceous hypertrophy diffusely on the dorsal and distal aspect of the nose. There are no inflammatory papules or pustules seen. There are multiple tan brown and gray stuck-on keratotic papules and plaques widely scattered on the back, chest, and legs; none with worrisome features.

ASSESSMENT: Multiple seborrheic keratoses. No sign of new basal cell carcinoma, rosacea with rhinophyma changes.

PLAN:
1. The patient wants to try stopping the tetracycline. We discussed with him the rosacea may have remitted. On the other hand, we discussed with him if he does start developing new areas of redness, pustules on the nose, would recommend resuming the tetracycline 500 mg p.o. b.i.d. He voiced understanding of this. He was given a written prescription, so can restart the medication if needed.
2. Reassurance regarding all of the other skin lesions he questions. Follow up again in one year because of a basal cell carcinoma.

Dermatology SOAP Note Example 4

SUBJECTIVE: The patient is a (XX)-year-old woman who returns for followup of hand eczema. She is very pleased with the improvement in her skin and has no other complaints regarding her skin today.

OBJECTIVE: The patient is alert and oriented x3. Palmar surface of right, greater than left hand, shows mildly erythematous, dry patches and similar changes on the dorsal surface of several of the fingers.

ASSESSMENT: Atopic eczema with component of chronic irritant contact dermatitis, improved.

PLAN:
1. Encouraged her to continue and increase moisturizer as her skin is still quite dry.
2. Continue with the mometasone ointment b.i.d. to the eczematous areas.
3. We discussed with her if it becomes severe, she can resume the clobetasol ointment, but not for longer than two weeks continuously. Followup is p.r.n.

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CHIEF COMPLAINT: Rash.

HISTORY OF PRESENT ILLNESS: This is a very pleasant (XX)-year-old who was brought to the emergency department today by mom. Apparently, the child developed a rash over the past few days.

Mom states that the child was with her dad. She is not sure if there were different laundry detergent use or soaps; although, he tends to use the same things they do, but she is concerned because the child has developed a rash on her buttocks as well as in the front trunk area.

She thinks it may be spreading to her neck as well. She states the child scratches here and there but not excessively. There has been no fever. No vomiting. No diarrhea. Child has been acting normal. Otherwise, no complaints of pain.

PAST MEDICAL HISTORY: Negative.

MEDICATIONS: None.

IMMUNIZATIONS: Up-to-date.

SOCIAL HISTORY: Here with mom.

REVIEW OF SYSTEMS: As noted in the HPI. The remainder 10 is negative unless otherwise stated.

PHYSICAL EXAMINATION:
GENERAL: Examination reveals a (XX)-year-old who is adorable. She is awake. She is alert. She is age appropriate. She appears in absolutely no distress. She is nontoxic in appearance.
VITAL SIGNS: She is afebrile.
HEENT: Head is normocephalic and atraumatic. Pupils are equal and reactive. Extraocular movements are intact. Nares patent. Throat is clear. TMs are intact.
NECK: Soft and supple.
LUNGS: Clear without wheezes.
HEART: Regular.
ABDOMEN: Soft.
SKIN: She has evidence of a maculopapular pinpoint rash that is noted on the buttocks, somewhat in the groin area. Mom states she sees it on the neck; I really do not see it there. She states she could feel it starting to form on her back. It seems to be in the distribution of her underwear. Mom states that she has not had pull-ups on in a few days as sometimes those can tend to give her a rash.

MEDICAL DECISION MAKING: At this point, I do not know the etiology of this rash. I told mom it does not appear consistent with scabies, bed bugs, cellulitis, MRSA, nothing to suggest chickenpox or roseola. She was using some Aquaphor, which I do not think could hurt. They can use some Benadryl if she is itching; otherwise, they would see the pediatrician. Nothing to suggest anything toxic. The patient is seen in collaboration with Dr. John Doe.

CLINICAL IMPRESSION: Rash.

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