DISCHARGE DIAGNOSES:
1. (1)________, malignant, laryngeal primary.
2. Alcoholic liver disease.
3. History of alcohol abuse.
4. Chronic obstructive pulmonary disease.
5. (2)________.
6. Malnutrition.
PROCEDURES PERFORMED: Total laryngectomy with right (3) ________ neck dissection.
COMPLICATIONS: None.
HOSPITAL COURSE: The patient was admitted for a total laryngectomy and neck (4)________ for treatment of a laryngeal carcinoma. Preoperatively, this was thought to be a T4N0 transchorionic carcinoma. The procedure was performed without complication. Postoperatively the patient did relatively well and was without significant pulmonary complications, although she did have respiratory therapy treatment throughout her hospital course. She was noted to have a low hematocrit and received 2 units of packed red blood cells. She was also noted to have a low magnesium level, and this was treated with (5)________ magnesium. The drains were removed on the 3rd postoperative day. She was noted to have some redness and erythema of the neck skin and was (6)________ treated with ampicillin and gentamicin for a possible infection. Further signs of infection were not noted other than a low-grade fever. She did not develop any (7)________ and was noted to be feeling well at the time. The nasogastric tube was discontinued on the 11th postoperative day. A (8)________ swallow was obtained prior to discontinuing the nasogastric tube and no (9)________ of the neck was noted. The patient tolerated tube feedings relatively well while the nasogastric tube was in place and once the tube was removed, she tolerated oral feedings well.
DISPOSITION:
1. The patient was discharged home without complications or problems.
2. Her diet and activity level should be as tolerated.
DISCHARGE MEDICATIONS: Tylenol with codeine (10)________ 30 mL p.o. q.4 hours p.r.n. One pint was dispensed.
FOLLOWUP:
1. Followup will be in the ENT clinic for suture removal.
2. The patient will also be followed by Speech Therapy as an outpatient and will receive radiation therapy treatments approximately 1 month postoperatively.
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Q. 2) CLINIC NOTE
SUBJECTIVE: A 39-year-old female who complains of 1 week of left shoulder (1)__________. She was riding her motorcycle and doing a lot of work prior to the onset of this. She has tenderness in the muscles of her shoulder and has intermittent (2)__________ with discomfort into the hand. She has not dropped any objects. She does have (3)___________ and thought that she may be having a (4)__________, but was not sure. Patient is otherwise in the usual state of health.
OBJECTIVE: Musculoskeletal: Upper extremities have full range of motion, 5/5 muscle strength. (5)__________ is intact. (6)__________ reflex 2/4. There is tenderness over the left supraspinatus in the scapular area, with muscle spasm of the supraspinatus noted. The (7)__________ musculature is unremarkable. There are no skin changes noted. There is no tenderness of the (8)__________ bursa.
ASSESSMENT/PLAN: Left shoulder musculoskeletal pain with (9)__________. Skelaxin 20 mg 2 t.i.d. to q.i.d., 40. Continue with current Celebrex (10)__________. Warm moist heat. No lifting more than 10 pounds. If no improvement over the next 1 week, return for reevaluation.
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Q. 3) VISIT REASON: Follow up of (1)________. The patient was recently seen in the emergency room on 05/06 and was placed on (2)________ and prednisone because of right facial shingles. She still continues to have right facial pain with tenderness over the ear but no difficulty in hearing. The patient also complains of tenderness on the right side of the face, lip, and the right side of the neck. The patient occasionally gets chest discomfort and shortness of breath on (3)________. Currently she is not on any medication, but she does have a history of gastroesophageal (4)________ disease currently controlled with medication..
PHYSICAL EXAMINATION: Vital signs are stable. All systems are within normal limits.
IMPRESSION AND PLAN:
1. Follow up of shingles, currently stable. The patient has (5)________ (6)________ but do not want to pursue any medications at present. The patient was reassured that she will have pain possibly for 6 months to 2 years and will possibly consider (7)________ if the pain gets worse. Will follow up in 6 weeks for that.
2. Chest discomfort. An (8)________ was done today which showed normal sinus rhythm without any ST-T-wave changes.
3. Gastroesophageal reflux disease. Will continue on an antireflux diet and Pepcid AC p.r.n. Will follow up.
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Q. 4) SUBJECTIVE: The patient is here for followup of an infected (1)_________, which was removed. The (2)________ was removed last week, and the wound was noted to be erythematous with mild (3)________ discharge and warmth. Patient was placed on Keftab. Patient took her last Keftab today. She states the lesion is nontender. It has had no discharge or warmth. Patient also needs a refill of her Celexa today.
OBJECTIVE: Left posterior neck has an appropriately healing (4)________, which is status post EIC with suture removal. There is no erythema, edema, warmth, or discharge.
ASSESSMENT/PLAN:
1. Status post epidermal (5)__________ cyst removal with appropriately healing lesion. No specific treatment at this time.
2. Depression. Celexa 20 mg daily, 90, refill given. Follow up on p.r.n. basis.
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Q. 5) SOAP NOTE
SUBJECTIVE: Patient is here for followup of a left lower leg (1)__________ phlebitis. She was placed on aspirin therapy and an (2)__________ wrap at that time. The patient states that she has a long history of (3)__________ veins, which are painful, especially after standing for prolonged periods. She is inquiring as to whether or not she is a surgical candidate for this. Patient denies any chest pains, shortness of breath. She denies any warmth to the area and states that the acute tenderness she had over the (4) __________ is now resolved. The patient also has some TED hose with her today, which she wanted to see if the size is appropriate for her.
OBJECTIVE: Lower extremities: The left lower leg on the upper medial portion of the calf extending above the knee has significant varicose veins, which are very (5) __________. These are not painful to touch. There is no warmth or (6) __________associated with this. There is no (7) __________ firmness or clot noted. There are standard varicosities of both lower extremities, some of lesser and some of equal degree. The patients (8) __________ hose were placed on her and are the appropriate size for her.
ASSESSMENT/PLAN: Left lower extremity (9) __________, which are symptomatic and significant enough for surgical evaluation and, most likely, surgical treatment. The patient will continue with her (10) __________ therapy as previously directed. She may wear the TED hose and is referred to Surgery for definitive evaluation and treatment. Patient agrees with plan.
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Q. 6) SUBJECTIVE: The patient is here complaining of a (1)________ of her arthritic pain. She gets arthritic pain in her knees, ankle, back, and spine. She has a problem taking (2)________ secondary to GI upset. The patient has a history of rheumatoid arthritis, fibromyalgia, (3)________, and osteoarthritis. She is currently on Plaquenil. She had to self-discontinue her (4)________ secondary to GI upset. She also takes a Bayer aspirin each day. This is a longstanding problem, and the patient has no new acute changes.
OBJECTIVE: HEENT unremarkable. (5)________ Regular rate and rhythm without murmur. Lungs CTA. Extremities: No (6)________ edema. Musculoskeletal: No joint (7)________ or edema. There are no rheumatoid (8)________ noted.
ASSESSMENT/PLAN:
1. Rheumatoid arthritis, with (9)_______ pain. Patient is to continue with her Plaquenil. Will give trial of Arthrotec 50 mg daily to t.i.d. as her GI tract tolerates, 100, refill 1 prescription given.
2. Plaquenil use. Will check CBC and CMP today. Will also check (10)________, TSH, and lipid panel, as these are required at this time.
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Q. 7) CLINIC NOTE
SUBJECTIVE: Patient is a 72-year-old female with known osteoarthritis, rheumatoid arthritis. She says she fell October 29 and landed on her right buttock and hip while missing a step. She stated that she was looked at the time by a nurse who happened to be in the area. She felt okay and got up and moved about without any problems. Last week she had the onset of aching intermittently in the right anterior thigh up to the lateral aspect of the hip with activity. When she rests, it goes away. She has no coldness of the extremity, restriction of movement from her usual baseline, or (1)________. Patient is otherwise at her baseline state of health.
OBJECTIVE: Musculoskeletal: Back has full range of motion, with forward and backward bending, as well as sideward bending. Lower extremities have 5/5 muscle strength with 2/4 (2)________ reflex. Neurovascular is intact. There is no muscular tenderness at this time. Negative pelvic (3)________. Negative (4)________. No skin changes.
ASSESSMENT/PLAN: Musculoskeletal pain. Rule out fracture in patient with rheumatoid arthritis and osteoarthritis. Arthrotec 50 mg b.i.d. to t.i.d. to current (5)________. Rest and warm heat. Will follow up as dictated by x-ray and otherwise on a p.r.n. basis.
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Q. 8) SOAP NOTE
SUBJECTIVE: The patient is here for followup from the emergency room. She had swelling of her large toe with purple discoloration and progressive pain, which started 3 days ago. She went to the emergency room and was thought to have (1)________. An x-ray was done and was normal. ESR was 60, and a (2)________ was 7.6. The patient was placed on Vioxx, as well as some Percocet, according to patient. She has not taken the (3)________. She has taken the Vioxx 12.5 mg b.i.d. She has had some decreased tenderness and decrease in the discoloration. The toe is still quite painful. The patient is otherwise without any complaints. She states that she is tolerating the Vioxx, with only minimal GI distress. Patient has difficulty taking (4)________.
OBJECTIVE: Extremities: Right large toe has tenderness, with mild (5)________ and some mild purplish discoloration. There is no (6)________. Neurovascular is otherwise intact.
ASSESSMENT/PLAN: Resolving (7)________ arthritic attack. Continue with Vioxx 12.5 mg b.i.d. until pain free. Patient may increase to 25 mg b.i.d. if her stomach tolerates this. She is to not use the foot as much as possible and limit all (8)________. She may use warm moist soaks. Will recheck (9)________ today and reevaluate in 1 week and (10)________. Patient agrees with plan. The patient will return to work in 1 week. Work note given.
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Q. 9) LUMBAR MRI
HISTORY: Low back pain radiating into the right leg.
INTERPRETATION: The patient has a normal appearance of the (1)________ and the upper lumbar disk levels are well-maintained down to L2-L3. The L3-L4 area shows mild degenerative disk signal with only very slight narrowing. There is a small amount of posterior (2)________ at the L3-L4 interspace which combines with (3)________ and ligamentum (4) ________ hypertrophy to cause a mild degree of central spinal stenosis and lateral recess narrowing.
The L4-L5 area shows moderate narrowing and more focal disk (5) ________ that begins in the midline at the disk space and then just below the disk level extends eccentrically toward the right side. On the T1 axial images, we can see displacement and obscurity of the fat plane around the right L5 nerve root as it branches off. Although the (6) ________ images are not dramatic, I believe as they come over toward the right side that there is a disk herniation that is extending down over the lip of the L4-L5 interspace toward the right side. The L5-S1 area also shows moderate degenerative disk narrowing and a midline central disk protrusion causing approximately a 3 mm (7) ________ defect on the (8) ________ sac in the midline. This L5-S1 disk protrusion could be affecting the S1 or S2 roots as they begin to branch off, but I do not see any localization toward the right at this level. There is some degenerative facet disease at both L4-L5 and L5-S1, but no central spinal stenosis at these levels. The right L4-L5 foramen is compromised by the posterolateral disk herniation and facet change.
IMPRESSION: Mild degenerative disk changes at L3-L4 and a moderate degree of central spinal stenosis at this level, some posterior spurring and facet and ligamentum flavum changes. Focal disk herniation at the L4-L5 level that is eccentric toward the right side and extends a short way below the L4-L5 disk to elevate and obscure nerve roots around the right L5 root as it branches off. There is a mild right L4-L5 (9) ________ narrowing from the posterolateral disk protrusion and facet change, but no definite compromise of the right L4 root.
A central 3 mm disk (10) ________ at the L5-S1 level causing mild mass effect on the thecal sac and S1 roots as they branch off.
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Q. 10) Dear Doctor:
As per previous notes, Mr. Patient 2183 was found to have an invasive B2 (1) ________ cell carcinoma of the bladder on (2) ________ and TUR bladder tumor. Random biopsies showed no evidence of carcinoma (3) ________. However, since the tumor is invasive, we feel that this 52year-old male would be best with his bladder removed.
We discussed the alternatives, including radiation therapy alone; radiation therapy plus (4) ________; or radiation therapy, chemotherapy, and radical (5) ________ with urinary (6) ________. After presenting the statistics to the patient, it was decided by the patient to go ahead with a combination of chemotherapy, radiation therapy, and radical cystectomy with diversion. We will contact his oncologist, who will give 2 or 3 courses a month apart of MVAC therapy, followed 2 weeks thereafter by radiation therapy, 2000 (7) ________ over 5 days, to the bladder. Two weeks after completion of radiation therapy, a radical cystectomy will be performed and diversion at the same sitting.
In addition, we discussed the various forms of urinary diversion, including the production of a (8) _________ versus a continent (9) ________ versus the standard (10) ________ loop. The patient, after discussion, decided to go ahead with the standard ileal loop since he desires the minimal complication rates. Continent urostomies and neobladders have complication rates as high as 25 to 50, requiring repeat surgery, and the patient is not willing to run those risks. We will inform you of his followup.
Sincerely,
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