Problem 1: LOCATION: Nursing Home PATIENT: Thomas Weiss PHYSICIAN: Frank Gaul, M.D. HISTORY: Mr. Weiss is seen for a routine visit for Alzheimer’s. There is no code in place. The chart is reviewed along with the nursing notes. Advanced directives are in place. The graphic chart is also reviewed. The patient is experiencing no fevers, chills, chest pain or shortness of breath. Nurse states patient continues to be frequently delusional. EXAMINATION: This well-developed, well-nourished gentleman is sitting without distress. HEENT—normocephalic and atraumatic. Neck is supple. Lungs are clear to auscultation. Extremities show little to no edema. IMPRESSION: 1. Alzheimer dementia 2. Atypical psychosis with delusions PLAN: 1. As the patient is otherwise clinically stable; the rest of the treatment is without change.
Problem 2: The anesthesia service was performed by the CRNA with an anesthesiologist medically directing 2 concurrent cases. The patient’s physical status was a -P1. 2-4 OPERATIVE REPORT, INCISION AND DRAINAGE LOCATION: Outpatient, Hospital PATIENT: Gabby Brown PHYSICIAN: Loren White, M.D. ANESTHESIOLGIST: Janice E. Larson, M.D. PREOPERATIVE DIAGNOSIS: Right perineal abscess. POSTOPERATIVE DIAGNOSIS: Right perineal abscess x2. PROCEDURE: Incision and drainage of right perineal abscess. ANESTHESIA: General. ESTIMATED BLOOD LOSS: Less than 3 ml. COMPLICATIONS: None. INDICATIONS: This is a 14-year-old African-American female who has a 1-week history of a tender mass in right labial region. Per history, the mass has begun to bleed and drained over the past 24 hours. The patient was noted to be on Bactrim prior to admission. FINDINGS: as below DESCRIPTION OF PROCEDURE: After informed consent, we proceeded to the operating room. A general mask anesthesia was noted for the patient. A time out was made prior to the procedure beginning. The patient currently was receiving intravenous clindamycin. The prep was performed and sterile towels and drapes were placed over the perineum. A 1-cm stab incision was made near the edge of the right labia and into the buttocks region. Copious amount of purulence was noted with gentle expression of the cavity. The cavity was then irrigated with normal saline solution, approximately 80 ml. The cavity was then packed with quarter-inch iodoform gauze and covered by 4 x 4.
Problem 3: 3-8 OPERATIVE REPORT, STRESS TEST LOCATION: Outpatient, Hospital PATIENT: Kent Smith SURGEON: Marvin Elhart, M.D. INDICATION: Dyspnea on exertion. MEDICATIONS: Prevacid, aspirin, and Zoloft. PROCEDURE PERFORMED: Stress test INDICATIONS: This is a 47-year-old man who complained of some shortness of breath after working in his yard. He presents today for a stress test for evaluation of symptoms. The patient underwent the stress test according to the Bruce protocol. HEMODYNAMIC RESPONSE: Heart rate at rest is 99 and at peak is 167. Blood pressure is 130/80 and at peak is 164/60. During stress, the patient had no chest pain. The test was stopped because of fatigue. At baseline, the patient had normal sinus rhythm and no ST segment changes. At peak exercise, there was up-sloping ST segment changes but no ST depression noted. The patient exercised for a total of 7 minutes on the Bruce protocol achieving 10 METs. IMPRESSION & CONCLUSION: 1. Moderate exercise tolerance. 2. Good hemodynamic response to exercise. 3. No EKG evidence to suspect obstructive heart disease.
Problem 4: 4-14 OPERATIVE REPORT, SKIN TAG EXCISION LOCATION: Outpatient, Hospital PATIENT: DeAnna Hope SURGEON: Loren White, M.D. PREOPERATIVE DIAGNOSIS: Fibroepithelial skin tags of the neck Indications: DeAnna is a 58 year old woman who has multiple skin tags on her neck and requested to have them removed. She presents today for surgical removal of those skin tags. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: Excision of multiple skin tags of neck ANESTHESIA: General endotracheal, supplementing with 1% Xylocaine with 1:100,000 epinephrine, approximately 5 cc. SURGICAL FINDINGS: Fibroepithelial skin tags of the neck. PROCEDURE: The neck was prepped with Betadine scrub and solution and draped in a routine sterile fashion. Skin tags were removed by electrocautery. The bases of the skin tags were cauterized where appropriate. Antibiotic ointment and Band-Aids were applied. The multiple skin tags were submitted for permanent sections. The patient tolerated the procedure well and left the area in good condition. Pathology Report Later Indicated: Benign skin tags; total of 9.
Problem 5: 5-6 EMERGENCY DEPARTMENT SERVICES LOCATION: Hospital Emergency Department PATIENT: Shelly Porch PHYSICIAN: Paul Sutton, M.D. SUBJECTIVE: This patient is a 37-year-old female who reports she was feeling well until yesterday, when she developed some dizziness, which has persisted. She also feels like something is “sticking” in her throat. She is concerned that she may have a thyroid problem. She has a history of hypothyroidism for which she is on Synthroid 0.125 mg q.d. Her last TSH level was done three months ago, and at that time was normal at 0.57. OBJECTIVE: White female who appears to be in general good health. Her blood pressure is 118/82, Respiratory 20s, Afebrile. HEENT is unremarkable. Neck is supple. No masses. No palpable thyromegaly, nodules, or tenderness. TSH level is elevated at 11.77. ASSESSMENT: Hypothyroidism. PLAN: We will increase Synthroid to 0.15 mg q.d. Recommend follow-up TSH level in 3 months with her primary physician.

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