obi keyterms

abdominopelvic CT scan
abstain
adenofibroma
adnexa
Advil
amniotic fluid
ampicillin
Ancef
anorexic
anterior leaf of the broad ligament
apex
Apgar score
appendiceal abscess
autostapler
axilla
bimanual examination
bladder blade
blunt dissection
bowel gas
breast implant reconstruction
broad ligament
G-section
Candida
carcinoma in situ
cardinal ligament
cuadad
cephalad, cephalic
cervical os
cervical stump
cervicitis
Chlamydia enzyme test
CIN-3 (cervical intraepithelial neoplasia, grade 3)
Colace
Compazine
condyloma acuminatum
cryosurgery
cystadenoma
cystitis
cystocele
cystourethrocele
D&C (dilatation and curettage)
Darvocet-N 100
deciduoid reaction
DeLee trap
Demulen
descensus
diplococci
dysplasia
enterocele
epithelial cells
estrogen replacement therapy
exploratory laparotomy
exteriorized
extracellular
extubated
exudate
fallopian tube
fetal heart tones
fibrocystic disease, breasts
fibromyomata
finger cot
finger dissection
Flagyl
flank pain
Fleet enema
follicular cyst
forceps blade
forzen section diagnosis
fundal height
fundectomy
fundus of the uterus
Garnerella
gestation
giant cell formation
gonorrhea
gravida
herpes simplex
hypertrophic
hysterectomy clamp
induration
infundibulopelvic ligament
introitus
Jorgenson scissors
Kocher clamp
labium minus
large-cell carcinoma
leiomyomata
leukorrhea
linea alba
LMP (last menstrual period)
low cervical transverse
C-section
mammogram
mastitis
Mayo scissors
meconium
menarche
menometrorrhagia
Mighty-Vac vacuum extractor
multipara
myoma
nonstress test (pregnancy)
O'Connor-O'Sullivan retractor
ovarian cystadenoma
Pap smear
papilloma
para 3, 2-0-1-2
pedicle
pelvic inflammatory disease (PID)
pelvic relaxation
Pfannenstiel incision
placenta
postcoital
Premarin
pretibial edema
primipara
progesterone
Provera
reapproximated
rectocele
rectovaginal septum
rectus muscles
retorverted uterus
Rh negative
unsensitized
round ligament
rugous
salpingo-oophorectomy
secretory endometrium
Stadol
STD screen subcutaneous mastectomy
submucous
sulfa
suture
0 Dexon
chromiccontinuous
figure-of-8
imbricating
interlocking
locking
running
suture-ligated
TA-55 articulator
TA-55 Roticulator
TAH ( total abdominal hysterectomy)
tenaculum
Thayer-Martin test
toluidine O
toxemia
transceted
Trichomonas
tubal pregnancy
Tzanck smear
urethrovesical angle
uterine decensus
uterine gutter
uterine leiomyomata
vaginal cuff
vaginal vault
VBAC (vaginal birth after cesarean)
vector
vesicouterine reflection
vesicovaginal fistula
Vicodin
wet mount
zinc oxide ointment
Zovirax

Gastro keyterms

abdominal series
abscess
acid regurgitation
acute abdomen series
adenopathy
adherent
adhesions
air-contrast barium enema
air-fluid level
ANA ( antinuclear antibody)
anal sphincter
antacid
antibiotic
antireflux
AP diameter of chest
appendectomy
appendicitis
appendix
gangrenous
rectocecal
approximated
ASHD (anteriosclerotic heart disease)
atrophic gastritis
auscultation
bands
barium enema
belching
bethanechol
bile
bile reflux
biliary colic
bloating
bowel sounds
breath sounds
C. (Clostridium) difficile
cecum
cholecystitis
cholelithiasis
clamped
codeine
colon
ascending
descending
proximal
sigmoid
transverse
colonoscopy
constipation
COPD ( chronic obstructive pulmonary disease)
copious
Crohn disease
curvilinear incision
cystic artery
cystic duct
debris
dehydration
Demerol
diabetes mellitus
diarrhea
diet
BRAT
clear liquid
high-bulk
low-fat
difficulty swallowing
diffusely
discrete
dissection
blunt
finger
diverticulitis
diverticulosis
diveritculum, diveritcula
dorsal lithotomy position
duodenal bulb
duodenal ulcer
duodenitis
duodenum
dysfunction
dyspeptic
dysphagia
early satiety
electrocautery
electrocoagulated
electrophoresis
emergent
endoscopy
endotracheal
enteric-coated aspirin
epigastrium
Epstein-Barr (EB)
esophageal hyperkeratosis
esophagitis
excised
exercise-induced asthma
exploratory laparotomy
external muscular fascia
external oblique muscle
fascial defect
fecalith
fevers, chills, and sweats.
FEV1
filmy adhesions
full-thickness skin graft
fundus
gallbladder ultrasound
gallstones
gangrene
gangrenous appendicitis
gastric antrum
gastric contents
gastric mucosa
gastroduodenal
gastroenteritis
gastroscope
gastroscopy
general endotracheal anesthesia
GERD
Gram stain
grasper
guaiac-positive stool
gutter
Hasson retractor
Hasson trocar
hematemesis
Hemoccult card
hemorrhage
hemorrhoids
external
internal
hemostasis
hernia
hiatal
indirect
inguinal
sliding-type hiatal
herniorrhapy
hilar clip
hyaline casts
hyperactive
hypoactive
ileus
incision
indigestion
induced
inflammatory bowel disease
inflamed
infraumbilical incision
intraoperative
irritable bowel syndrome
jugular venous distention
Kocher clamp
KUB x-ray
laparoscopic cholecystectomy
lap pad (laparotomy)
left lower quadrant
left upper quadrant
left shift (on differential WBC count)
ligate, ligated
ligature
liver panel
long-standing
McBurney's point
mesoappendix
midepigastric
muscle layers
muscle-splitting technique
multisystem
nausea
necrosis, necrotic
NG ( nongastric) tube
normal saline
NSAID (nonsteroidal antiinflammatory drug)
obliquely
obstipated
Olympus GIF-K gastroscope
omentum
operative cholangiogram
operative field
organic disease
palpitations
paralytic
parrot scissors
paternal
pending
peptic ulcer disease
perforation
peripheral edema
peritoneal cavity
peritoneal fluid
peritonealized
periumbilical area
phlegm
pleural effusion
pleurisy
pneumoperitoneum
port
epigastric
lateral
umbilical
profuse
prothrombin time (PT, protime)
protrusion
purulent debris
pylorus
radiating
rebound constipation
rebound tenderness
rectum
referred tenderness
reflux
regurgitation
retrocecal
rheumatoid factor
rhythm
right lower quadrant
right upper quadrant
rugal folds
serum protein
sigmoidoscopy
sinus bradycardia
small bowel obstruction
small bowel series
sphincter
spillage
sponge and needle counts
Steri-strips
stoolculture
subcostal plane
substernal
superficial tenderness
supine
surgical clips
suture
0
2-0
3-0
catgut
dermal
interrupted
PDS
plain
Vicryl
Z-type
suture removal
symptomatic
tinkling bowel sounds
transit time
tympanitic
upper GI x-ray
upper GI with small bowel series
x3
viral gastroenteritis
vomiting

Clinic A 60026

Patient Name: Maroney, Lorraine
MRNo: 487867


Mrs. Maroney returns for followup of osteoarthritis of the knees. She has decided that she wants to have the right total knee replaced. This is booked with Dr. Ares in late July. She would like to have the left injected. She thinks the injections do help, but unfortunately, they do not last very long. She remains on naproxen in the form of Aleve 20 mg t.i.d.

PHYSICAL EXAM: Weight 182, blood pressure 120/74, pulse 72. She is a very pleasant elderly female in no acute distress. Her gait reveals that she limps on the right leg. The left has a range from 0-100 degrees with medial line tenderness and small effusions.. The right has a range from 0-100 degrees with medial line tenderness and a moderate-sized effusion.

IMPRESSION:
1. OA of the knees, severe on the right. She is going to go ahead and get a knee replacement. On the left side, I think it is reasonable to try another injection as surgery is not for six weeks. I have also told her that two weeks before the surgery, she should stop the Aleve. I have given her prescription for Darvocet-N 100. She can take up to one tablet t.i.d. p.r.n. for pain. If needed when she stops the naproxen. She tells me she has tolerated it well in the past. She was given her prescription for 50 times one refill.

PROCEDURE:After sterile prep, the left knee was injected with 2 cc of 1% Xylocaine and 40 mg of Depo-Medrol. She tolerated the procedure well.

2. At this point, I will have her see me p.r.n. She knows to make an appointment once her surgery and postop course are resolved.


Date Transcribed: <02/08/2006>
Time Start: <1:04>
Time End: <01:25>


LC = 24.25

clinic a 90014

Patient Name: Jews, Richard
MRNo: 556910


This is a 54-year-old patient I am seeing on behalf of Mr. Drexler, a physician’s assistant. The patient is here because of asymmetrical prostate. His current PSA is 0.8, all of his PSAs have been less than one. As we are talking, the patient denies any significant urinary symptoms. He states his stream might not be as strong as it was, but he could still write his name in the snow. He denies any nocturia, denies any frequency or urgency. He does narrate some problems with some erectile performance recently. He states that he did feel depressed when he will have problems on having an erection. However, when he self-stimulates he has no problems with attaining or maintaining an erection. He has been on a long-term relationship with his fiancée. He does not really have intentions of being married. He has been married in the past and was burnt. He does find that he is not as excited, but he is not interested in other people nor does he fantasize about other women. He does want to be with this person.

Today, we have discussed that this could be an issue related to low testosterone and libido. I will get a free and a total testosterone level on this patient. We have talked about the use of PDE5 inhibitors, but he states that he has been able to get erections without those without any difficulty and prove that he could. He does not feel that it is a problem with erectile functioning. I did talk about the role of sex therapist if he continues to have this problem and it is not related to testosterone.

The patient’s past medical history is significant for arthritis.

CURRENT MEDICATIONS: Motrin and Plaquenil.

ALLERGIES TO MEDICATIONS: None.

PAST SURGICAL HISTORY: Back surgery 2001 and 2002 for herniated L4-L5 disk. He does have another L3-L4 bulging disk.

SOCIAL HISTORY: The patient is engaged to long-term relationship. He smokes approximately four cigarettes a day. He uses alcohol once a week.

Family HISTORY: Not significant for any bladder, prostate, or renal cancers. His father died at the age of 89 with natural causes. Mother died at 84. She did have arthritis. He has a sister living and well. He states that his grandfather was an alcoholic as well as his father.

PAST UROLOGICAL HISTORY: None.

REVIEW OF SYSTEMS: Significant only for the chronic back pain. He does have some left toe numbness and left foot numbness which is the result of his L4-L5 disk herniation. He denies any fecal incontinence. He denies any urinary incontinence.

PHYSICAL EXAM: A male in no acute distress. Abdomen: Benign, no masses, organomegaly, or bruit. Prostate exam reveals a normal-sized prostate. Right lobe might be slightly larger than the left, but is not significant. The patient does clench down very tightly during a rectal exam, but the gland is free of any nodules or any areas of induration.

ASSESSMENT AND PLAN:
1. Mildly asymmetric prostate, a PSA of less than 1; minimal risk of cancer of the prostate with a PSA this low. No further evaluation is necessary at this time except for annual digital rectal exams.
2. Decreased libido. Free testosterone and testosterone level. I will contact the patient with the results. If abnormal, we will consider then treatment with exogenous testosterone. The patient is in agreement with this plan.



Date Transcribed: <02/10/2006
Time Start: <01:19>
Time End: <02:18>

LC = 51.4

clinic 60028

Patient Name: Weagle, Doris
MRNo: 637737


Doris is an 84-year-old patient of Dr. Nancy Phillip referred for evaluation of chronic worsening bilateral knee pain. She says that her knees have bothered her for about 30 years. She has been noticing much worsening discomfort for the last few months. She says they swell; it is hard to walk up and down stairs due to pain. She has given up shopping in large supermarkets because of the distance that has to be walked. She does have some nocturnal pain. Tylenol or using Bengay helps. She has not tried physical therapy or glucosamine. NSAIDs are avoided because of her chronic warfarin. She also complains that her ankles and feet hurt mostly around the stocking line where she tends to get swelling. Dr. Phillip recently gave her a diuretic which helps.

PAST MEDICAL HISTORY: Hypertension, A-fib.

REVIEW OF SYSTEMS: Her wrist occasionally ache. Few years ago, the left revealed degenerative disease.

FAMILY MEDICAL HISTORY: Her mother had arthritis in her legs.

PERSONAL/SOCIAL HISTORY: She is a retired office worker. She does not smoke and rarely drinks alcohol.

MEDICATIONS: Atenolol 25 mg q.d.; furosemide 20 mg q.d.; warfarin 2.5 mg Mondays, Wednesday, and Friday or as directed; lisinopril 10 mg q.d.; HCTZ as needed for edema; Digitek 0.125 mg per day.

PHYSICAL EXAM: Weight 169, blood pressure 154/72, pulse 96. She is a very pleasant elderly female in no acute distress.
CHEST: Clear.
CARDIAC EXAM: Normal first and second heart sound.
HANDS: Revealed Heberden’s nodes, but they are nontender. The base joint of both thumbs have marked flaccid motion. The wrists, elbows, and shoulders have full range without pain. Hips have good range. Knees have small effusions range from 0-100 degrees with slight crepitus. The area has minimal medial line tenderness. There are small effusions. The ankles and feet are edematous, but there is no loss of motion and the joints are nontender.

IMPRESSION: Complaints of bilateral knees pain and swelling. Most likely this represents osteoarthritis.

PLAN:
1. I have suggested that given her contraindication to NSAIDs due to the warfarin, then we try corticosteroid injections. If that is not effective, then we could try glucosamine here. In addition, I think it would be good to get x-rays to confirm her diagnosis. She is in agreement with this plan.

Procedure: After discussing the relative risks, benefits, and alternatives, each knee was injected with 2 cc of 1% Xylocaine and 40 mg of Depo-Medrol following sterile prep. She tolerated the procedure well.

2. Check bilateral standing knee x-rays today.
3. See me again in three months or sooner if needed.



Date Transcribed: <02/08/2006>
Time Start: <02:25>
Time End: <04:10>
Break 15 min
xc: Nancy Phillip, M.D.


LC = 41.77

clinic a 60024

Patient Name: Hollace, Ralph
MRNo: 215660

Mr. Hollace returns for followup of inflammatory arthritis and osteoarthritis of the hands. He also has severe lumbar spinal stenosis. He has been taking the Darvocet up to every six hours occasionally for the pain in his legs which is worse with standing. He finds that the arthritis in his hands is under good control. He thinks that the current medication program works well for that. This includes the following: Prednisone 2.5 mg q.o.d., hydroxychloroquine 200 mg every other day, propoxyphene with acetaminophen 3 per day.

He has also been taking Fosamax 70 mg once a week times six per day, two glasses of milk, and a multiple vitamin for prevention of bone loss while on prednisone. He wonders if he could get off the Fosamax.

Additional medicines:
1. Aspirin 325 mg q.d.
2. Digitek 0.25 mg q.d.
3. Ibuprofen 400 t.i.d.
4. Prednisone 2.5 q.o.d.
5. Lipitor 10 mg q.d.
6. Hydroxychloroquine 200 mg every other day.
7. Sulfamethoxazole 160 mg b.i.d.
8. Meclizine 2.5 mg q. p.r.n.
9. Propoxyphene 3 per day.
10. Metoprolol 50 mg b.i.d.
11. Fosamax 70 mg once a week.
12. Tums six.

PHYSICAL EXAM: Weight: 130, blood pressure 124/60, pulse 66. He is a delightful elderly male who walks slowly with a walker. Hands revealed Heberden’s and Bouchard’s nodes, but there is no active joint swelling. The wrists, elbows, and shoulders has full range without pain. Hips have good range without pain. Knees, ankles, and feet are nontender. Reflexes are absent at the knees, trace at the ankles.

IMPRESSION:
1. History of inflammatory arthritis. This remains stable. Plan is to continue the prednisone 2.5 q.o.d and Plaquenil 200 mg q.o.d.
2. Osteoarthritis of the hands and diffuse degenerative disk disease and OA of the lumbar spine. He will continue the ibuprofen 400 mg t.i.d. p.r.n.
3. Severe lumbar spinal stenosis. Unfortunately this is causing considerable alteration of his lifestyle. He has to use a walker. He cannot stand very long. He cannot walk very far. He is not been up and deemed to be a surgical. Consequently, there are no any other additional recommendations for this. I will see him again in six months.
Osteoporosis prevention while on prednisone. At this point, his dose is so low. I used 2.5 q.o.d. then I think he can stop the Fosamax. His bone density in the past revealed a normal bone density. The, the osteopenia even.



Date Transcribed: <02/07/2006>
Time Start: <03:15>
Time End: <04:45>

{END}
LC = 36.72

Clinic b 0029

Patient Name: Dube, Sarah
MRNo: 000665552
Date of Service: 06/15/2005

LABORATORY RESULTS:

I am in receipt of recent CT scan of sinuses showing a possible retention cyst or polyp in the left maxillary atrium. I spoke with her father; he is quite interested in having an evaluation by ENT to see if this is the source of her problems. She has not been doing the Rhinocort. I have encouraged him to get her to do it one spray twice a day in each nostril because if this is indeed a polyp, Rhinocort may assist in its reduction.


Lob/sde
Date Transcribed: 01/26/06
Time Start: 3:40
Time End: 4:04

clinic b 0028

Patient Name: Iman, Sharon
MRNo: 000817767
Date of Service: 06/15/2005

OFFICE VISIT

The patient is a 36-year-old white female who returns at the allergy department, after having last been seen on 12/06/2004. She has been spoken to several times in this process regarding her issues with allergies, allergic rhinitis, and allergic conjunctivitis. She was also seen on June 8, 2005 because she was received some chest tightness after immunotherapy. After that visit, it was decided that we will do a pulmonary function test and she would take Claritin prior to any injections. We also dropped her down a level.

CURRENT MEDICATIONS: She is now back on Advair 50/500 and Claritin. She has an EpiPen. She also has Patanol eye drops. She also takes ranitidine, Lorazepam, HCTZ, hydrocodone p.r.n., Celexa, and nasal saline.

REVIEW OF SYSTEMS:
The patient states she is not pregnant. She is followed for hypertension, GERD, depression, back pain, and obesity.

ALLERGIES: DOXYCYCLINE CAUSES DIFFICULTY BREATHING. SHE HAD AN ALLERGIC REACTION TO BEE STINGS, AND, THEREFORE, HAS AN EPIPEN.

SOCIAL HISTORY: Her grandmother is no longer smoking in the home. Home now has 2 dogs and no cats. She is now working in a restaurant that has a wood stove and she does find that at times it will irritate her.

PHYSICAL EXAMINATION:
The patient is alert in no apparent distress. Height 66 inches, weight 255 lbs., respirations 20. TMs: Within normal limits. Pupils: Equal and reactive to light. Conjunctivae: Slightly injected. Nasal septum midline, moderately boggy bilaterally, light pink, no heme bulge or obvious discharge noted. No frontal or maxillary sinus tenderness. Throat: Grossly clear. Teeth present. Oral mucosa: Pink and moist. Neck: Supple, no masses and nodes at present. Lungs: Clear to auscultation bilaterally with no rales, rhonchi or wheeze. Heart: Regular rate and rhythm, no gross murmur. No clubbing, cyanosis or edema noticed in extremities.

PRIOR ALLERGY TESTING:
Prick/intradermal positive for trees, dogs, weeds, rag, dust mites, feathers, grasses, cockroach, and mold.

LABORATORY:
Pulmonary function test: FEV 105%, FVC 102%, FEF 25-75 120% resulting in normal spirometry with medication.

ASSESSMENT:
1. Asthma.
2. Allergic rhinitis.
3. Allergic conjunctivitis.
4. Bee sting reaction.

PLAN:
1. Continue with Advair 500/50 one inhalation b.i.d.
2. Continue with Patanol eye drops.
3. Continue with Claritin OTC.
4. Advised not to replace any of the dogs when they are no longer with her. She has noticed she is better when she is not around dogs.
5. The patient has an albuterol inhaler, which she does use with an aerochamber.
6. She has a Peak flow with a height she said recently is 340. She will be on monitoring for her personal best. We have discussed that I would like her always above 80%. If she notices there is a decrease, I would like her to call me.
7. Continue to have an EpiPen available.
8. The patient is to return in 2 months for review of symptoms and medications. At that time, I will repeat the PFT. If she is doing well, I would like to decrease her Advair to get her to a lower dosage, but it is important she monitors herself closely.

Lob/sde
Date Transcribed: 01/26/06
Time Start: 11:15
Time End: 3:38
Break: 11:45-1:25

clinic b 0027

Patient Name: Supinar, Michelle
MRNO: 000562570
Date of service: 06/15/2005

OFFICE VISIT

The patient is a 36-year-old white female who returns to the allergy department after having last been seen on May 23, 2005 for allergic rhinitis. We tried Rhinocort Aqua; she is still trying to use it. We have also tried Clarinex. She says it makes her much too drowsy to even work. She has gotten dust mite-proof covers. Prior Prick testing showed her positive to trees, grasses, rag, weeds, cat, dust, dust mites, and cockroach. She was previously given printed materials regarding immunotherapy, which she had as a child. She returns today because of a question of food allergies and for testing.

REVIEW OF SYSTEMS: The patient states she is currently not pregnant.

ALLERGIES: Sensitivity to BENADRYL.

SOCIAL HISTORY: She drives a school bus. There are no pets. She does not smoke.

PHYSICAL EXAMINATION:
The patient is alert in no apparent distress. Height 63 inches, weight 145 lbs., blood pressure 94/60. TMs: Within normal limits. Pupils: Equal and reactive to light. Conjunctivae: Noninjected. Nose: Nasal septum is midline, moderately boggy bilaterally. A small amount of clear mucus drainage is seen, light pink, congestion noted. No frontal or maxillary sinus tenderness. Throat: Grossly clear. Teeth: Present. Oral mucosa: Pink and moist. Neck: Supple. No masses or nodes present. Lungs: Clear to auscultation bilaterally with no rales, rhonchi or wheeze. Heart: Regular rate and rhythm. No rubs or murmur. No clubbing, cyanosis or edema noticed in extremities. Tongue is pierced.

LABORATORY:
Prick testing to foods after informed consent per usual. After correlation with history, the patient is positive for whole milk, soy, peanut, shrimp, string beans, celery, peas, hazelnut, and black walnuts. She was negative for apple. Nectarine is not part of this, but she was also positive to almond, which is part of the family that nectarine is composed of. She does not eat almonds, so she has no history.

ASSESSMENT:
1. Allergic rhinitis.
2. Food allergies.


PLAN:
1. Avoidance of certain foods including legumes, milk, shellfish, peanuts, and tree nuts. She is able to eat cashews without difficulty.
2. Continue trying to use Rhinocort Aqua 1-2 sprays in each nostril q.d.
3. Trial of Zyrtec 10 mg 1 tab q.d., dispensing 30 with yearly refills.
4. The patient has decided she would like pursue immunotherapy for her seasonal allergies. She will return in 2-4 weeks for intradermals. I have advised her to call with any questions or concerns prior to that visit.

ADDENDUM: Her son gets bee sting shots her.


Lob/sde
Date Transcribed: 01/25/06-01/26/06
Time Start: 3:50
Time End: 4:40
Time Start: 9:45
Time End: 11:13

clinic b 0026

Patient Name: Hunt, Dalton
MRNo: 000857289
Date of Service: 06/15/2005

Telephone call/Laboratory Results:

I spoke with mother and relayed recent results of blood work. RAST testing all came back with negative results. Rheumatoid factor, antithyroid globulin, antibodies, and TSH: Within normal limits. CBC: Within normal limits except for minimal elevation of neutrophil percent and minimal depression of lymphocyte percent which would be inconsequential. His ANA came back positive with less than 1:40. I have recommended to mother that she does speak to his primary care for further evaluation of this, but then I expected that this was well within the normal range given his age and his sex. Mother will speak with Dr. Parker in approximately 3 days and I will be e-mailing him with the results of this laboratory report.


Lob/sde
Date Transcribed: 01/23/06
Time Start: 12:55
Time End: 1:30

clinic b 0127

Patient Name: Wobble, Vincent Jr.
MRNo: 401912

Follow-up OV requested by the patient for bilateral knee pain.

S: Mr. Wrobel is an 80-year-old male who had resolution of his right shoulder pain with the injections in November. His knees were feeling fine until several months ago. He now experiences bilateral ambulatory knee pain, right greater than the left. He notes mild swelling. He denies acute injury, fever, chills, rash, nocturnal pain, significant pain, stiffness, locking, and buckling. He would like to consider surgery.

MEDICATIONS: Antibiotics for H. pylori, propranolol, tetrazosin, amlodipine, felodipine, amiloride, KCl, fluvastatin, and iron pills.

ALLERGIES: NKDA.

O: BP 90/52, pulse 72, weight 194 lbs. The patient is a very pleasant obese white male who is A&O x3 and in NAD. Bilateral knees: Valgus deformity of the right; none on the left. He has small effusions bilaterally without redness, warmth, localized tenderness, and pain with full flexion to 210 degrees. Gait: Normal, nonantalgic.

IMPRESSION: Bilateral knee OA.

PLAN:
1. After sterile skin prep, 1.5 cc of 1% lidocaine were injected, and 11 cc of clear yellow fluid was removed from the left knee and 22 cc of clear yellow fluid was removed from the right knee, then 20 mg were suspended and 2 cc of 1% lidocaine were injected into each knee. The patient tolerated the procedures well without complications.
2. Refer to orthopedics to consider TKR.
3. Obtain bilateral standing knee x-rays before the orthopedics consult.
4. Follow up with me p.r.n.


Lob/sde
Date Transcribed: 01/25/06
Time Start: 11:35
Time End: 2:40
Break: 11:45-1:15

clinic b 0126

Patient Name: Gordon, Malcolm
MRNo: 136469

Primary rheumatologist is Dr. Heud. I am seeing the patient since he is on vacation.

Malcolm came in today for his methotrexate injection. The nurse brought his recent labs to me. He is slightly more anemic than previous labs several weeks ago. H&H is 12.2 and 37, and RDW is 16. He is on methotrexate 7.5 mg subcu q. week and no folic acid. He bought folic acid 400 mcg over-the-counter. I advised him to take 3 tablets a day and when he finishes that bottle, to fill the prescription given to him today of folic acid 1 mg q.d., #30 with a year’s refill. I will add on to his next drug monitoring labs a TIBC, iron, folate, and B12. I wanted to get stool guaiac but he does not want to do that nor does he want any rectal exams. “I’m too old for that.” I advised him to call me if he starts to feel dizzy or weak.

He does, on physical exam, have a slight bluish discoloration to his fingernails but the nail beds do blanch and they are warm. Lungs: Full, clear to percussion and auscultation. Cardiac: Normal S1, S2. No S3 or S4. No murmurs or rubs, RRR. Ankles: 1+ pitting edema. He denies abdominal pain, nausea, or vomiting. He is unable to state if there is melena due to his blindness.

Lob/sde
Date Transcribed: 01/24/06
Time Start: 1:00
Time End: 2:10

xc: ROBERT HEUD

clinic127

Patient Name: Wobble, Vincent Jr.
MRNo: 401912

Follow-up OV requested by the patient for bilateral knee pain.

S: Mr. Wobble is an 80-year-old male who had resolution of his right shoulder pain with the injections in November. His knees were feeling fine until several months ago. He now experiences bilateral ambulatory knee pain, right greater than the left. He notes mild swelling. He denies acute injury, fever, chills, rash, nocturnal pain, significant pain, stiffness, locking, and buckling. He would like to consider surgery.

MEDICATIONS: Antibiotics for H. pylori, propranolol, tetrazosin, amlodipine, felodipine, amiloride, KCl, fluvastatin, and iron pills.

ALLERGIES: NKDA.

O: BP 90/52, pulse 72, weight 194 lbs. The patient is a very pleasant obese white male who is A&O x3 and in NAD. Bilateral knees: Valgus deformity of the right; none on the left. He has small effusions bilaterally without redness, warmth, localized tenderness, and pain with full flexion to 210 degrees. Gait is normal, nonantalgic.

IMPRESSION: Bilateral knee OA.

PLAN:
1. After a sterile skin prep, 1.5 cc of 1% lidocaine were injected, and 11 cc of clear yellow fluid was removed from the left knee and 22 cc of clear yellow fluid was removed from the right knee, then 20 mg were suspended and 2 cc of 1% lidocaine were injected into each knee. The patient tolerated the procedures well without complications.
2. Refer to orthopedics to consider TKR.
3. Obtain bilateral standing knee x-rays before the orthopedics consult.
4. Follow up with me p.r.n.

clinic126

Patient Name: Gordon, Malcolm
MRNo: 136469

Primary rheumatologist is Dr. Heud. I am seeing the patient since he is on vacation.

The patient came in today for his methotrexate injection. The nurse brought his recent labs to me. He is slightly more anemic than previous labs several weeks ago. H&H is 12.2 and 37, and RDW is 16. He is on methotrexate 7.5 mg subcu q. week and no folic acid. He bought folic acid 400 mcg over-the-counter. I advised him to take three tablets a day and when he finishes that bottle, to fill the prescription given to him today of folic acid 1 mg q.d., #30 with a year’s refill. I will add on to his next drug monitoring labs a TRBC, iron, folate, and B12. I wanted to get stool guaiac but he does not want to do that nor does he want any rectal exams. “I am too old for that.” I advised him to call me if he starts to feel dizzy or weak.

He does, on physical exam, have a slight bluish discoloration to his fingernails but the nail beds do blanch and they are warm. LUNGS: Full, clear to percussion and auscultation. CARDIAC: Normal S1, S2. No S3 or S4, no murmurs, or rubs, RRR. ANKLE: 1+ pitting edema. ABDOMEN: He denies abdominal pain, nausea, or vomiting. He is unable to state if there is melena due to his blindness.


Ebc/sde
Date Transcribed: 01/25/06
Time Start: 2:42
Time End: 3:09

xc: Dr. Robert Heud

clinic125

Patient Name: Mulcany, Elizabeth
MRNo: 45602

Follow-up OV for right hip OA and greater trochanter bursitis.

S: History is obtained from her son since the patient has moderate dementia. He reports that his mother is limping while ambulating on flat surfaces. She does not climb stairs. He states that the injection in November only helped for two weeks. He denies acute injury, redness, warmth, swelling, rash, fever, chills, significant difficulty with other joints, nocturnal pain. Regular Tylenol 2 tablets b.i.d. is mildly effective.

MEDICATIONS: Cartia, Aricept, Lopressor, Maxzide, aspirin, Lipitor.

ALLERGY: CODEINE.

O: BP 130/62, pulse 64, current weight 165 lbs. Mrs. Mulcany is a delightful white female who is alert and in NAD. Right hip decreased internal and external rotation without pain. Moderate pain over the greater trochanter without redness, warmth, swelling, and rash. Left hip, knees, ankles, subtalar joints, and MCPs moved well and are negative for erythema, warmth, synovitis. Gait is normal, nonantalgic.

IMPRESSION: Right hip OA with greater trochanter bursitis.

PLAN:
1. After sterile skin prep, 80 mg of Depo-Medrol and 3 cc of 1% lidocaine were injected in the area of maximal tenderness near the right greater trochanter. The patient tolerated the procedure well without complications.
2. I advised her to increase the Tylenol to three times a day.
3. She will follow up with me in three months or sooner if needed.


Ebc/sde
Date Transcribed: 01/25/06
Time Start: 1:07
Time End: 1:58

clinic124

Patient Name: Rannikko, Marjorie
MRNo: 128179

Follow-up OV requested by the patient for bilateral CMC pain.

patient for bilateral CMC pain,
S: Mrs. Rannikko is a 74-year-old female who has known OA. Her pain became severe in April but fortunately it has slowly improved with rest and heat. The pain is now tolerable. Initially, the right CMC was swollen. She denies acute injury, redness, warmth, swelling, fever, chills, rash, paresthesias, locking, significant difficulty with other joints. The copper/magnetic bracelet is helpful. Despite the thumb splint, it caused too much pain. She is unable to take NSAIDs including COX-2 inhibitors due to history of peptic ulcer disease and GI upset. She has not tried glucosamine, and chondroitin sulfate full strength was ineffective after three months, so she discontinued it. She has not tried Tylenol or paraffin wax treatments. She is nervous about trying injections.

MEDICATIONS: Levothyroid, oxycodone (used for chronic low back pain), calcium, MVI, Zantac.

ALLERGIES: SULFA CAUSES HER RASH.

O: BP 126/62, pulse 80, weight 187 lbs. The patient is a delightful white female,who is A&O x3 and in NAD. Bilateral CMCs have marked squaring with crepitus and mild joint line tenderness on the left, none on the right. No redness, warmth, or synovitis. Wrists, MCPs, PIPs, DIPs are normal.

IMPRESSION: Right bilateral CMC OA.

PLAN:
1. Recommended Extra Strength Tylenol 1-2 tablets before aggravating activities p.r.n. Maximum dose 8 tablets a day.
2. She tried paraffin wax treatments many years ago and liked it, so she plans on buying a machine.
3. She will prefer to defer injection since the pain is tolerable. I certainly agree with this. However, she may want to consider them next fall/winter when the arthritis may be aggravated. Since she had difficulty obtaining this appointment, she would like to schedule an appointment. Since I will not be here at that time, I will have her schedule an appointment with Dr. Hosey in November. She was advised to cancel this appointment if she did not want the injections so that it could be used for someone else. She verbalized understanding.


Ebc/sde
Date Transcribed: 01/25/06
Time Start: 10:40
Time End: 11:19

clinic123

Patient Name: Torrey, Katie
MRNo: 838101

Follow-up OV for psoriatic arthritis:

S: Ms. Torrey is a 27-year-old female who reports significant improvement in her joint pain/swelling and stiffness with prednisone 10 mg q.o.d. and 7.5 mg q.o.d., and initiating sulfasalazine. She will reach the maximum dose of sulfasalazine on Saturday. She is sleeping better and able to function better in the morning. She feels slightly stiff after working and on rainy days. She reports some scalp psoriasis but no other rashes, fever, chills, nausea, vomiting, diarrhea, CP, or SOB.

MEDICATIONS: Flovent, albuterol, birth control pills, Claritin, sulindac 200 mg b.i.d., Nasarel, calcium with vitamin D 600 mg t.i.d., MVI, sulfasalazine 1000 mg q. a.m. and 500 q. p.m., prednisone 7.5 mg q.o.d. and 10 mg q.o.d., Plaquenil 200 mg q.d., and Ditropan.

ALLERGIES: BACTRIM AND PENICILLIN.

O: BP 98/62, pulse 60, weight 124 lbs. Ms. Torrey is a delightful white female who is A&O x3 and in NAD. HANDS: Mild synovitis of the bilateral second and right third MCPs, and bilateral second PIPs. Shoulders, elbows, wrists, all other MCPs, PIPs, DIPs, hips, knees, ankles, and patellar joints are normal. LUNGS: Full. Clear to percussion and auscultation. Cardiac: Normal S1, S2. No S3 or S4. No murmurs or rubs, RRR.

IMPRESSION: Psoriatic arthritis.

PLAN:
1. Continue sulindac 200 mg b.i.d. Prescription for #60 with 6 refills given.
2. She will increase the sulfasalazine this weekend to 1000 mg b.i.d. Prescription for 500 mg tablets, 2 tablets b.i.d. #120 with six refills given. With this medication, I advised her to wear at least 30 SPF sunscreen to prevent sunburns.
3. Continue prednisone 7.5 mg q.o.d. and 10 mg q.o.d. She will attempt to taper this if she starts to feel better. Prescription for 5 mg tablets #60 with 2 refills given.
4. Continue Plaquenil 200 mg q.d. She has enough medicine at home.
5. Obtain drug monitoring laboratories, CBC, ALT, AST, CR.
6. She will follow up with me in 8-10 weeks or sooner if needed.


Ebc/sde
Date Transcribed: 01/24/06
Time Start: 3:37
Time End: 4:21

xc: Dr. John Hosey.

clinic081

Patient Name: Rodriguez, Blanca
MRNo: 804031

FOLLOW-UP OFFICE VISIT

PROBLEMS:
1. Left trochanteric bursitis.
2. Iliopsoas bursitis.

SUBJECTIVE:
The patient returns with recurrence of left hip pain. She reports having had marked improvement but not resolution of the pain with an injection in the area of the greater trochanter at our initial appointment in December. She reports she has had injections done twice in the meantime, once by Dr. Sudae and once by Mr. Drexler. She reports each time, she had significant improvement by two weeks after the injection and recurrence within two months. She continues to report significant pain lying on the left side at night interfering with sleep.

OBJECTIVE:
The patient is a well-developed female in no apparent distress. Musculoskeletal examination: She has marked tenderness over the left greater trochanter. Hip mobility was not evaluated.

ASSESSMENT: Recurrent left trochanteric bursitis. The patient has past injections in the area on three separate occasions. It indicates that the trochanteric bursa area is the source of her symptoms. She has had recurrence in a short time each time she had an injection. Therapy had been recommended in December, but she reports she was never contacted about a specific date and time for therapy.

PLAN:
The nature of trochanteric bursitis was discussed with the patient. Limitation and frequency of injection was discussed. It was elected to inject at this time. After a sterile skin prep and ethyl chloride anesthesia, the left trochanteric bursa was injected with 40 mg of Depo-Medrol and 2 cc of 1% lidocaine. The patient tolerated the procedure without complications. I would consider repeat injection but not for at least three months. If she is markedly worse before that, I would consider trying a local anesthetic injection alone. She also will be rescheduled for physical therapy, and if she does not have a specific appointment date by the end of next week, it was recommended that she contact my office to further resolve the breakdown in communication. She was also given a prescription for Percocet 30 pills to be used one to two at bedtime on a p.r.n. basis.


Ebc/sde
Date Transcribed: 01/24/06
Time Start: 2:04
Time End: 3:34

xc: Dr. Sudae

clinic080

Name: Gervais, Hester
MRNo: 821326

FOLLOW-UP OFFICE VISIT

PROBLEMS:
1. Giant cell arteritis.
2. Osteoarthritis of the knees.

SUBJECTIVE:
The patient reports significant recurrence of pain in the left knee since her last injection three months ago. She also reports some new problem of pain in the left foot on the dorsomedial aspect. She reports that it has been present for several days to possibly much of the week. She had pain primarily with bearing weight on the left foot. She is not aware of any specific exciting activity or event. She does report having some swelling in the area. She has decreased her prednisone from 5 mg to 3 mg without an occurrence of headaches, cough, or aching in her shoulders or hips. She is currently on Celebrex 200 mg a day as well as the prednisone.

OBJECTIVE:
The patient is a well-developed, frail, elderly female, in a wheelchair. Musculoskeletal exam, she has moderate tenderness on palpation on the medial aspect of the midtarsal joint with no significant pain with range of motion in the tarsal joints. She has no tenderness at the posterior tibial tendon, the joint line of the ankle, or the Achilles tendon. She has minimal swelling with no redness or warmth. She has crepitus on range of motion of motion of both knees. Range of motion was not fully tested with the patient in the wheelchair. She has no effusions. She has minimal tenderness on the right and moderate tenderness on the left.

ASSESSMENT:
1. Osteoarthritis of the knees with exacerbation on the left knee.
2. New left foot pain. The patient may have some low-grade inflammation from gout crystal but do not have a definite gouty attack. She denies any previous history of gout. It is possible the symptoms are purely on a mechanical basis. They are not in the location where it is typical to develop a tendonitis.
3. Giant cell arteritis. The patient’s last notation was 4 mm/hr. She has tapered her prednisone from 5 to 3 mg without any significant exacerbation or recurrence of symptoms.

PLAN:
1. After discussing potential risks and benefits, she elected to inject the left knee joint only at this time. After a sterile skin prep and ethyl chloride skin anesthesia, the left knee joint was injected with 40 mg of Depo-Medrol and 2 cc of 1% lidocaine. The patient tolerated the procedure without complications.
2. Management for the left foot pain was discussed. She is already on an anti-inflammatory and has not considered a higher dose of Celebrex. She is also on some prednisone, and we are trying to eliminate the prednisone or at least keep it at the lowest possible dose. She will be started on colchicine 0.6 mg twice a day. If she has any cramps or diarrhea, she will discontinue the medication. If she has improvement in the foot over the next 1-3 weeks, she will continue the colchicine for about 5 days. After she feels like it is back to normal, then try discontinuing the colchicine. She was scheduled for follow-up appointment in three months. She will contact the office sooner if needed. She will continue the 3-mg prednisone dose through the month of July. Beginning of August, if things have been stable, she will try stopping the Celebrex and see if she is significantly worse without it. If she is worse, she would resume it.
3. She will try decreasing the prednisone from 3 mg to 2 mg in September.

Ebc/sde
Date Transcribed: 01/24/06
Time Start: 11:07
Time End: 1:59

xc: Dr. Javacar
{END}

Break: 11:45–In:12:59

clinic079

Patient Name: Twohy, James
MRNo: 1638840

FOLLOW-UP OFFICE VISIT

PROBLEM:
1. Gout.
2. Inflammatory arthropathy.

SUBJECTIVE:
The patient reports having had increased pain primarily in his elbow but also on his right knee with trying to taper prednisone to 1 mg a day. He reports he has gone back up to 5 mg and tried tapering back down several times and always has increased symptoms on the 1-mg dose. He has continued taking allopurinol 20 mg a day and 0.6 mg of colchicine once a day. He reports no problems tolerating the medications.

OBJECTIVE:
The patient is a well-developed male in no apparent distress. Musculoskeletal Exam: He has mild swelling of second and third MCP and wrist on the left. No definite swelling on the right. He has no swelling or tenderness at the joint line of the elbows. He has palpable nodules in the olecranon bursa bilaterally, larger and more firm on the left with no redness or tenderness on palpation. He has no tenderness on palpation on the shoulders, knees or ankles. He has decreased range of motion to the right ankle. He reports that right ankle also has increased pain with lower prednisone dose and improved pain with a higher dose.

ASSESSMENT:
1. Inflammatory arthropathy.
2. Gout. The patient does not have any typical acute gouty flare-ups. I suspect the increased symptom involved with the prednisone is chronic inflammatory synovitis independent of gout.

PLAN:
The patient will continue the colchicine and allopurinol. He will continue with 3 mg of prednisone for at least three months and as much as six months. At some point at three or six months, he will try decreasing to two a day and if he is able to go for months without any obvious increase in pain symptoms, he will try to stay at the lowest possible baseline. He did have a bone density study done on day of the visit, which showed normal bone density in the spine and hip including a normal bone density in the femoral neck.

Ebc/sde
Date Transcribed: 01/23/06
Time Start: 2:39
Time End: 10:40

xc: Dr. Cooks
{END}

Cont.: 9:30am

clinic028

Patient Name: Iman, Sharon
MRNo: 000817767
Date of Service: 06/15/2005

OFFICE VISIT

The patient is a 36-year-old white female who returns to the allergy department after having last been seen on 12/06/2004. She has been spoken to several times in this process regarding her issues with allergies, allergic rhinitis, and allergic conjunctivitis. She was also seen on June 8, 2005 because she has received some chest tightness after immunotherapy. After that visit, it was decided that we will do a pulmonary function test and she will take Claritin prior to any injections. We also dropped her down a level.

CURRENT MEDICATIONS: She is now back on Advair 50/500 and Claritin. She has an Epipen. She also has Patanol eye drops. She also takes ranitidine, lorazepam, HCTZ, hydrocodone p.r.n., Celexa, and nasal saline.

REVIEW OF SYSTEMS: The patient said she is not pregnant. She is followed for hypertension, GERD, depression, back pain, and obesity.

ALLERGIES: DOXYCYCLINE CAUSES DIFFICULTY BREATHING. SHE HAD AN ALLERGIC REACTION TO BEE STINGS AND, THEREFORE, HAS AN EPIPEN.

SOCIAL HISTORY: Her grandmother is no longer smoking in the home. The home now has two dogs and no cats. She is now working in a restaurant that has a wood stove. And she does find that at times it will irritate her.

PHYSICAL EXAMINATION: The patient is alert in no apparent distress. Height 66 inches, weight 255 lbs. Respirations 20. TM is within normal limits. Pupils are equal, and reactive to light. Conjunctiva is slightly injected. Nasal septum midline, moderately boggy bilaterally, light pink, no heme bulge or obvious discharge noted. No frontal or maxillary sinus tenderness. Throat is grossly clear. Teeth present. Oral mucosa: Pink and moist. NECK: Supple, no masses and nodes present. LUNGS: Clear to auscultation bilaterally with no rales, rhonchi or wheeze. HEART: Regular rate and rhythm. No gross murmur. No clubbing, cyanosis or edema noticed in extremities.

PRIOR ALLERGY TESTING: Prick/intradermal positive for trees, dogs, wheat, ragweeds, dust mites, feathers, grasses, cockroach, and mold.

LABORATORY: Pulmonary function tests FEV 105%, FVC 102%, FEF 25-75 120% resulting in normal spirometry with medication.

ASSESSMENT:
1. Asthma.
2. Allergic rhinitis.
3. Allergic conjunctivitis.
4. Bee sting reaction.

PLAN:
1. Continue with Advair 500/50 one inhalation b.i.d.
2. Continue with Patanol eye drops.
3. Continue with Claritin OTC.
4. Advised not to replace any of the dogs when they are no longer with her. She has noticed she is better when she is not around dogs.
5. The patient has an albuterol inhaler, which she does use with an aerochamber.
6. She has a Peak flow with a height she said recently is 340. She will be on monitoring for her personal best. We have discussed that I would like her always above 80%. If she notices there is a decrease, I would like her to call me.
7. Continue to have an EpiPen available.
8. The patient is to return in two months for review of symptoms and medications. At that time, I will repeat the PFT. If she is doing well, I would like to decrease her Advair to get her to a lower dosage, but it is important she monitors herself closely.



Ebc/sde
Date Transcribed: 01/26/05
Time Start: 3:48
Time End: 4:34

cllinic026

Patient Name: Hunt, Dalton
MRNo: 000857289
Date of Service: 06/15/2005

TELEPHONE CALL/LABORATORY RESULTS:

I spoke with mother and related recent results of blood work. RAST testing all came back with negative results. Rheumatoid factor, antithyroid globulin, antibodies, and TSH are within normal limits. CBC is within normal limits except for minimal elevation of neutrophil percent and minimal depression of lymphocyte percent, which would be inconsequential. His ANA came back positive with less than 1:40. I have recommended to mother that she does speak to his primary care for further evaluation of this, but then I expected that this was well within the normal range given his age and his sex. The mother will speak with Dr. Parker in approximately three days and I will be e-mailing him with the results of this laboratory report.


Ebc/sde
Date Transcribed: 01/26/06
Time Start: 11:25
Time End: 11:40

clinic025

Patient Name: Gilger, Emmanuel
MRNo: 001565544
Date of Service: 06/15/2005

TELEPHONE CALL

The patient had called to state that her hives were not controlled. She is currently taking loratidine, ranitidine, and Benadryl. She has stopped the Benadryl and takes doxepin 25 mg one to four tablets a day, dispensing 120 to CVS in Park Ave. In speaking with the patient, I explained the purpose behind the doxepin. If this does not control the hives, she will call.


ebc
Date Transcribed: 01/26/06
Time Start: 10:45
Time End: 10:54

Operative 22

THE OAKS SURGERY CENTER
40740 California Oaks Rd.
Murrieta, CA 92562

OPERATIVE REPORT

PATIENT NAME: DETASQUALE, LEWISDEPASQUALE, LUIS
PATIENT ID#: 13761
DATE OF OPERATION: 01/13/2006
SURGEON: Chris Alexander, M.D.
ASSISTANT: None.
ANESTHESIA: General.

PREOPERATIVE DIAGNOSIS:
Osteoarthritis, left elbow.

POSTOPERATIVE DIAGNOSES:
1. Osteoarthritis, left elbow.
2. Plus a sSubluxating annular ligaments, left elbow.

PROCEDURES PERFORMED:
1. Left elbow arhtroscopic partial debridement, annular ligament, and c.
2. Chondro plasty, radial head.
3. Osteophytectomy, coronoid process.
24. Open left elbow annular ligament reconstruction. .

ESTIMATED BLOOD LOSS:
Minimal.

FINDINGS:
There is a palpable snapping mass at the lateral elbow with flexion-extension maneuvers and pronation-supination. Arthroscopically, there is a prominent annular ligament edge would which subluxates end ofinto the radial radiocapitellar joint space. There is great threegrade 3 changes on the radial head and there is an osteo_____1.27phytic rigde ridge on the coronoid process. The trochlear cartilage is in good condition. The capitellar cartilage in good condition. Upon open procedure laterally, it is clear that the annular ligament snaps back and forth into the radial radiocapitellar joint from its own anatomic location around the radial neck

TOURNIQUET TIME: It is
33 minutes.

COMPLICATIONS:
None.

DRAINS:
None.

DETAILED DESCRIPTION OF PROCEDUREINTRODUCTION:
The patient is a 73-year-old male, who is complaining of snapping and pain in his left elbow from an injury, July of last year.

SUMMARY:
He is placed in a supine position under a general anesthetic. at tThe left upper extremity. S is sterilely, prepped, and draped within an overheard boom used to suspend the left upper extremity with the elbow at about 90 degrees of flexion. Arthroscopy is performed through medial and lateral portals to examine the anterior aspect of the left elbow joint. Findings are described. Chondro plasty of the radial head is completed, osteophytectomy on a coronoid process is completed, and a partial debridement of the edge of the annular ligament was performed. An open procedure was then performed through a lateral incision over the elbow about 4 cm in length. Dissection is carried out down to the extensor conjoint tendon was usedwhich is divided longitudinally to both expose the annular ligament and radio-capitellar joint space. The annular ligament clearly snaps back and forth into the radio- capitellar space from the radial neck area. A reconstruction of the ligament was then completed so that the ligament no longer would snap back into the radio-capitellar space. The ligament was tightened by incising partially on the lateral aspect transversally transversely through the ligament and then, imbricating the ligament so that there is a greater hoop stress around the radial neck. T thus, not allowing the ligament to slip over the larger diameter radial head. Elbow range of emotion is full. P, pronation-supination are full. T, and thehe snapping phenomenon has been eliminated after reconstruction. The reconstructive reconstructed ligament was repaired with #0 _____4.49Ethibond. The conjoint tendon was repaired with #0 Vicryl and the subcutaneous tissue with 2-0 Vicryl. The skin was monochrome forwith Monocryl 4-0 subcuticular closure followed by Steri-Strips, Marcaine injection, dry gauze, soft roll, and an ace wrap. The patient is placed in a _____5.11sling and transferred out of the operating room in good condition.



___________________________
CHRIS ALEXANDER, M.D.

CA:ebc/sde

Date Transcribed: 01/23/2006
Time Start: 10:40
Time End: 1:00

Break 11:45- In: 12:45

Operative 19

THE OAKS SURGERY CENTER
40740 California Oaks Rd.
Murrieta, CA 92562

OPERATIVE REPORT

PATIENT NAME: AGUILAR, LUIS
PATIENT ID#: 13763
DATE OF OPERATION: 01/13/2006
SURGEON: Richard Rouhe, M.D.
ASSISTANT: Dr. Burrows
ANESTHESIA: General.
ANESTHESIOLOGIST: Dr. Jackson.

PREOPERATIVE DIAGNOSIS:
1. Internal derangement, the right knee.
2. ACL disruption.
3. Meniscal tears.

DETAILED DESCRIPTION OF PROCEDURE:
Once the patient was anesthetized under general anesthetic, the tourniquet was applied to the proximal thigh of the right leg. The right leg was elevated and exsanguinated with an ACE bandage and the tourniquet inflated to anesthetic level. The leg was then placed on a leg holder, prepped, draped, and arthroscopy is carried out in the usual fashion. At arthroscopy, first, the medial compartment was visualized. There is noted to be a macerated tear of the posterior horn. Grades 1 and 2 chondromalacia of the medial femoral condyle but no subchondral bone noted. The lateral compartment was visualized. Then, there was a small radial tear of the membranous margin of the lateral meniscus but generally the meniscus was intact as well as the medial condyle. The ACL appeared to be intact, but the knee had a very positive drawer and Lachman test. I introduced the turbo trimmer and debrided the tissue around the ACL up to its femoral attachment and checked out the PCL. The PCL was intact. There was a significant laxity of the ACL by using the probe. We proceeded with ACL reconstruction. Once the macerated horn of the medial meniscus was resected and the medial from the condyle was smoothed with a turbo reamer. Then, I removed the arthroscopic instruments and we proceeded with the harvesting of the patellar tendon graft with a linear incision anteriorly on the knee. Dissection down to the subcutaneous tissue to the patellar tendon was done. The peritenon was then incised and the patellar tendon was exposed beneath the peritenon. The margins of the patellar were identified and then, a 1 x 3 cm bone plug was harvested from the patella, and a 1-cm strip of patellar tendon through the center portion of the tendon down to the tibial tuberosity. A 1 x 3 cm bone graft from the tibial portion of the tibial attachment of the patellar tendon was then harvested. While the graft was being prepared on the back table by the assistant, arthroscopy was carried outfurther debriding the medial meniscus and the medial femoral condyle. Then, doing debridement of the deficient ACL tendon using the bulk and the turbo trimmer and using a bur for the notchplasty of the medial side of the lateral femoral condyle. Once the knee was prepared, instrumentation was then inserted. The graft was ready and we then, introduced the guide pin for the tibial tunnel. Once the guide pin was in place, the reaming of the tibial tendon was done with an 11-mm reamer. Once that was completed, then the knee was debrided of the debris from the reamings, then the over-the-top guide was then placed on the femoral side, 7 mm over the top guide. Then, the beef needle was used to introduce into the femoral side from the femoral tunnel. And once it exited the anterior aspect of the thigh, the reaming of the femoral side was done with a 10-mm reamer. We have 11-tibial and 10-femoral tunnel. Once that was debrided, the notchplasty was done. The graft was then introduced and just prior to fittiing the graft, the guide pin for the BioScrew was introduced. Once in place, the graft was fitted. The Bioscrew then entrapped the femoral fragment into position. Once the screw was fitted, tension on the tibial side of the graft was done and there was no motion of the femoral side, in other words, it was sufficiently fixed. The knee was then extended and tension placed on a tibial graft, then the Bioscrew was introduced through over -guide pin and fixing the tibial graft and placed the knee at about 15 degrees flexion. Just prior to fixing with the screw, we brought attention on the tibial side, the probe was introduced. The tibial graft is noted to have a sufficient tension, and so once the tibial graft was fitted, the knee was checked again. Pictures were taken. Then drawer and Lachman tests were negative now. At this point, the knee was thoroughly irrigated and the instrumentation was removed and the wound was closed using 2-0 Vicryl on the peritenon in a continuous fashion, 2-0 Vicryl subcutaneously, and staples on the skin. Sterile dressing was applied and placed in a knee brace, so the knees have 30 degrees extension mark and as well as a 90 degrees flexion mark. Then the patient was then taken to recovery room for postoperative care. The patient tolerated the procedure well. No complications were encountered nor anticipated. The prognosis is is good.



___________________________
RICHARD ROUHE, M.D.

RSB:ebc/sde

Date Transcribed: 01/20/2006
Time Start: 11:00
Time End: 10:32

Break:12:02p- In: 1:20p
Go out: 1:51p – In: 2:14p
Started: 9:07am

Operative 15

THE OAKS SURGERY CENTER
40740 California Oaks Rd.
Murrieta, CA 92562

OPERATIVE REPORT

PATIENT NAME: JENCHIS, VICTOR
PATIENT ID#: 13767
DATE OF OPERATION: 01/13/2006
SURGEON: Chris Alexander, M.D.
ASSISTANT: None.
ANESTHESIA: General.

PREOPERATIVE DIAGNOSIS:
Left ankle distal fibular fracture.

POSTOPERATIVE DIAGNOSIS:
Left ankle distal fibular fracture.

PROCEDURES PERFORMED:
Open reduction and internal fixation, left distal fibular fracture.

ESTIMATED BLOOD LOSS:
Minimal.

FINDINGS:
The distal fibula is fractured in an oblique fashion and displaced lateral and proximalward. There are some fibrous connections at the fracture site. It was able to be reduced to an anatomic position. Fixation is stable.

DISPOSITION:TOURNIQUET TIME:
Tourniquet time is aAbout 45 minutes.

COMPLICATIONS:
None.

DRAINS:
None.

DETAILED DESCRIPTION OF PROCEDUREINTRODUCTION:
The patient is a 28-year-old male, complaining of left ankle pain after falling off of a ladder about 2-1/2 weeks ago.

SUMMARY:
He is placed supine on an operating room table under general anesthetic with the left lower extremities extremity sterilely prepped and draped. A tourniquet on a the thigh turned up to 275 mm Hg. An incision was made longitudinally across the lateral aspect of the distal fibula exposing the distal fibular periosteal tissues which are incised to expose the fracture site. The fibrous connection had to be taken down using curettes and the fracture fragments were then reduced. A 5-hole semitubular plate was fixated across the fracture. A serum C-arm was used to image the hardware and reduction was found to be acceptable. The wound was then irrigated, closing closed witha 2-0 Vicryl for the subcutaneous layer and staples for the skin. _____2.22Xeroform form, dry gauze, and a posterior spleen splint is applied. The patient has beenis then transferred out of the operating room in good condition.



___________________________
CHRIS ALEXANDER, M.D.

CA:ebc/sde

Date Transcribed: 01/19/2006
Time Start: 11:46
Time End: 2:35

Break: 12:06pm In: 2:04p

operativ 10

THE OAKS SURGERY CENTER
40740 California Oaks Rd.
Murrieta, CA 92562

OPERATIVE REPORT

PATIENT NAME: RENDALE, CLAREN BICK KLAARENBEEK, RENDELL
PATIENT ID#: 13764
DATE OF OPERATION: 01/13/2006
SURGEON: Hedrick Keding, M.D.
ASSISTANT: Jackson, M.D.
ANESTHESIA: General.

PREOPERATIVE DIAGNOSIS:
Impingement syndrome--rule out rotator cuff tear, left shoulder.

POSTOPERATIVE DIAGNOSES:
Impingement syndrome, plus partial rotator cuff tear.

PROCEDURES PERFORMED:
1. Open subacromial decompression.
2. Rotator cuff repair.

DETAILED DESCRIPTION OF PROCEDURE:
Once the patient was anesthetized, he is placed in a beach-chair bizchair position, t. Then, a bolster underneath the left shoulder. , Tthe left upper extremity shoulder was then prepped and draped and an incision was made from over the AC joint to the disk of the tip of the acromion and distally 2 cm. Dissection down to subcutaneous tissue to the acromion was done with the cutting curette Aaron Bovie. Self-retaining retractors were put them in placed leaving with control initially by injecting the intended incision by works of Marcaine and epinephrine. And then once the incision was made, the bleeding was controlled with coagulated Bovie. Once the acromion was identified, it was further delineated subperiosteallytowards the _____1.23 using the cutting curette Aaron Bovie to detach the deltoid proximally and posteriorly around the tip of the acromion. Once that was established, the deltoid first will be very thickened, that was excised and the subacromial space, then they are evaluated and there was noted to be some partial tears of the rotator cuff , not through and through but there was small acromion abrasive type of abrasive thinning of the _____supraspinatus tendon1.57 and then the acromion. _____ An oscillating saw was 2.02 than we used to do a partial acromionectomy. The cuff surface of this _____2.07 was then smoothed with a power ____rasp2.10. Then, the shoulder joint was evaluated. The archenteric rotator cuff was evaluated and no through and through tears noted but there was some abrasive tears as mentionedinfection. So, there were some linear areas. There wereand some of the real _____thin2.35 redundant tissue was excised and then, this area of excision once repaired but I did not incised it through and through into the articular surface. It was more superficial, so I have superficial repair of the partially torn rotator cuff. Once that was accomplished, the wound was then closed we would return _____2.59 approximating the deltoid over the acromion from the posterior andto the anterior aspect of #1 Vicryl ruptured suture. The deltoid fascia of the tip of the acromion was approximated with #1 Vicryl continuous suture and then, the subcutaneous tissues were closed with 2-0 Vicryl subcutaneously and the skin approximated with 3-0 Nnylon of subcuticularsubticular suture. That would have then injected with Marcaine and epinephrine and the sterile dressings was appliedas the _____3.29 of the pipe, and once the sterile dressing was appliedof the pipe, he was placed in an ____arm sling3.34 plane and takes him to the recovery room for appropriate medication demonstrations.



___________________________
Hedrick Keding, M.D.

HK:ebc/jmm

Date Transcribed: 01/19/2006
Time Start: 09:20
Time End: 11:42

0-8 ops

THE OAKS SURGERY CENTER
40740 California Oaks Rd.
Murrieta, CA 92562

OPERATIVE REPORT

PATIENT NAME: FISCHER, ERIN
PATIENT ID#: 13766
DATE OF OPERATION: 01/13/2006
SURGEON: Chris Alexander, M.D.
ASSISTANT: None.
ANESTHESIA: General.

PREOPERATIVE DIAGNOSIS:
Left knee medial meniscus tear.

POSTOPERATIVE DIAGNOSIS:
Left knee plica/synovial impingement lesion, patellofemoral joint.

PROCEDURE PERFORMED:
Left knee arthroscopy plica excision.

FINDINGS:
There is a large mass of tissue that is easily displaceable between the patellar and the femoral sulcus with the knee extended. The remainder of the knee joint surfaces and meniscal tissues are found to be entirely normal. The anterior cruciate ligament is intact. There is possibly some partial injury to the proximal portion of the ligament where it appears somewhat thinned, but Lachman and pivot shift testing are negative. The PCL is intact.

TOURNIQUET TIME: About 25 minutes.

COMPLICATIONS:
None.


DRAINS:
None.

DETAILED DESCRIPTION OF PROCEDURE:
The patient is an 18-year-old female who is complaining of popping and pain in her left knee from a gymnastic tumbling injury about 7 months ago. Symptoms have not improved.

In summary, placed in a supine position under general anesthetic. The left lower extremities sterile prepped and draped. A tourniquet on the thigh turned up to 275 mm Hg. Arthroscopy is performed through anteromedial, anterolateral, and superomedial portals. The internal notches are examined initially where the cruciate ligaments are carefully probed. She has findings as described. The patellofemoral compartment is that described of cartilage surfaces are in good condition. There is a large prominent synovial mass based off of the retropatellar fat pad and it is displaceable in the patellofemoral joint. Examination of the medial lower compartments reveals entirely normal appearing cartilage surfaces and meniscus tissues. Probing of the condyles was carried out carefully to look for any OCD lesions, none were identified. The patellofemoral joint was then viewed through this superomedial portal and a debridement of the synovial mass was carried out through the anteromedial portal using a shaver tip. Finally, the knee is irrigated and drained through a large _____a large IV cannula.. Instrumentation is removed. Wounds are repaired with Steri-Strips, Marcaine injection, dry gauze, soft roll, and the knee is wrapped from the toes to the thigh. The patient was transferred out of the operating room in good condition.



___________________________
CHRIS ALEXANDER, M.D.

CA:ebc/jmm

Date Transcribed: 01/18/2006
Time Start: 1:00
Time End: 3.01

Go out 2:07p – in: 2:10p

05 Ops

THE OAKS SURGERY CENTER
40740 California Oaks Rd.
Murrieta, CA 92562

OPERATIVE REPORT

PATIENT NAME: FISCHER, ERIN
PATIENT ID#: 13766
DATE OF OPERATION: 01/13/2006
SURGEON: Chris Alexander, M.D.
ASSISTANT: None.
ANESTHESIA: General.

PREOPERATIVE DIAGNOSIS:
Left knee medial meniscus tear.

POSTOPERATIVE DIAGNOSIS:
Left knee plica/synovial impingement lesion, patellofemoral joint.

PROCEDURE PERFORMED:
Left knee arthroscopy plica excision.

FINDINGS:
There is a large mass of tissue that is easily displaceable between the patellar and the femoral sulcus with the knee extended. The remainder of the knee joint surfaces and meniscal tissues are found to be entirely normal. The anterior cruciate ligament is intact. There is possibly some partial injury to the proximal portion of the ligament where it appears somewhat thinned, but Lachman and pivot shift testing are negative. The PCL is intact.

TOURNIQUET TIME: About 25 minutes.

COMPLICATIONS:
None.


DRAINS:
None.

DETAILED DESCRIPTION OF PROCEDURE:
The patient is an 18-year-old female who is complaining of popping and pain in her left knee from a gymnastic tumbling injury about 7 months ago. Symptoms have not improved.

In summary, placed in a supine position under general anesthetic. The left lower extremities sterile prepped and draped. A tourniquet on the thigh turned up to 275 mm Hg. Arthroscopy is performed through anteromedial, anterolateral, and superomedial portals. The internal notches are examined initially where the cruciate ligaments are carefully probed. She has findings as described. The patellofemoral compartment is that described of cartilage surfaces are in good condition. There is a large prominent synovial mass based off of the retropatellar fat pad and it is displaceable in the patellofemoral joint. Examination of the medial lower compartments reveals entirely normal appearing cartilage surfaces and meniscus tissues. Probing of the condyles was carried out carefully to look for any OCD lesions, none were identified. The patellofemoral joint was then viewed through this superomedial portal and a debridement of the synovial mass was carried out through the anteromedial portal using a shaver tip. Finally, the knee is irrigated and drained through a large _____a large IV cannula.. Instrumentation is removed. Wounds are repaired with Steri-Strips, Marcaine injection, dry gauze, soft roll, and the knee is wrapped from the toes to the thigh. The patient was transferred out of the operating room in good condition.



___________________________
CHRIS ALEXANDER, M.D.

CA:ebc/jmm

Date Transcribed: 01/18/2006
Time Start: 1:00
Time End: 3.01

Go out 2:07p – in: 2:10p

148993

Patient Name: McCarthy, Susan
MRNo: 148993


The patient is seen in consultation as requested by Dr. Metkos.

CHIEF COMPLAINT:
The triggering of the right second finger.

HISTORY OF PRESENT ILLNESS:
Ms. McCarthy is a 46-year-old female who reports developing aching in all the fingers in both hands about six weeks ago. She was still on naproxen at that time. She reports the ache in her fingers has resolved, and she has stopped the naproxen. But she has developed triggering of the right second finger. She reports having used a splint that she obtained, I believe at a pharmacy, for about three nights and finds it helpful. She does do some repetitive activities with the hands primarily doing keyboard work on the family landscaping business. She occasionally does some of the light landscaping work.

PAST MEDICAL HISTORY:
1. Status post breast cancer diagnosed five years ago. She is coming to the end of her course of tamoxifen.
2. Status post one pregnancy with normal delivery.
3. Status post tonsillectomy.
4. Status post surgery for ovarian cysts.

PERSONAL AND SOCIAL HISTORY:
The patient reports having adverse reactions to penicillin and sulfa, both of which cause her rashes. She does not smoke or use alcohol regularly.

CURRENT MEDICATIONS:
Tamoxifen, calcium, multivitamin, and vitamin E.

PHYSICAL EXAMINATION:
GENERAL: The patient is a well-developed femalenormal in no apparent distress.
MUSCULOSKELETAL EXAMINATION: She has minimal hypertrophy of the several DIP joints but no tenderness. She has no swelling or tenderness in the PIPs, MCPs, or wrists. She has a palpable nodule with moderate tenderness in the flexor tendon of the right second finger.

ASSESSMENT:
Right second flexor tendinitis with trigger finger. Teh patient does not have any significant ongoing symptoms in the joints. She has findings for minimal osteoarthritis in some DIPs and no definite synovitis on exam.In May, she had a negative lime titer, normalnormal TSH, normal sedimentation rate,normal CPK. It is possible the patient has had some inflammatory joint symptoms recently, but no definite findings on exam at this time and no lab abnormalities to suggest an inflammatory disease process.

PLAN:
The nature of flexor tendonitis was discussed. Management options were discussed and elected to inject at this time. After a sterile skin prep and ethyl chloride skin anesthesia, the right second flexor tendon was injected at the site of the A1 pulley with 10 mg of Depo-Medrol and 0.25 cc of 1% lidocaine. The patient tolerated the procedure. No complications. She will contact to the office for followup if she has any significant ongoing problem.


Ebc/sde
Date Transcribed: 01/23/06
Time Start: 1:20
Time End: 2:35

xc: Dr. Metkos
{END}