SUBJECTIVE: The patient is here today with increasing symptoms of his asthma over the past week. He has had no fever. His chest is tighter and his Symbicort is not working. He is using his Ventolin inhaler more frequently.

His past medical history includes asthma, gastroesophageal reflux disease and allergies.

OBJECTIVE: Temperature is 98.4. HEENT: Unremarkable. Neck: Supple without adenopathy or thyromegaly. Lungs: Reveal diffuse wheezes bilaterally. Heart: Regular.

ASSESSMENT: Asthmatic bronchitis.

PLAN: The patient is given prednisone 50 mg to 0 mg taper. He is also given albuterol for nebulizer 4 times a day. We will cover him with antibiotic Zithromax 500 mg once a day for 5 days. The patient will follow up p.r.n. no improvement in his symptoms.

SOAP Note Example Medical Report #2

SUBJECTIVE: This (XX)-year-old patient of Dr. Jane Doe has had pain and a small amount of discharge in the right ear for the last 3 days. She teaches swim lessons and is in the pool all day. There has been no sore throat, cough, cold or coryza. She does not use Q-tips.

OBJECTIVE: Well woman in no obvious discomfort. Minimal irritation without erythema in the right ear canal. The left ear canal is normal. Both tympanic membranes are normal. The pharynx is perfectly clear.

ASSESSMENT: Early otitis externa.

PLAN: Cortisporin Otic solution 3 times a day. Return if not improved.

SOAP Note Example Medical Report #3

SUBJECTIVE: This (XX)-year-old patient of Dr. John Doe has chronic venous insufficiency. He occasionally wears support hose. Last night, he noticed that his left lower extremity was getting red. He has an area of skin breakdown, apparently an abrasion on the lateral margin. There has been no fever or chills. He was on cephalexin for 10 days last year for a similar problem.

OBJECTIVE: Thin gentleman in no apparent discomfort. Temperature is 98.6. The left lower extremity is red, minimal tenderness from knee to ankle.

ASSESSMENT: Cellulitis.

PLAN: We advised ceftriaxone 1 gram IV now. We will start cephalexin 500 mg 4 times a day. We have asked him to apply moist heat to lower extremity tomorrow. Return for reevaluation in the walk-in.

SOAP Note Example Medical Report #4

SUBJECTIVE: The patient is complaining of some intermittent dizziness off and on over the past 4 or 5 months. She was evaluated by somebody at work who thought she had benign positional vertigo and treated her with Antivert. It worked well, but when she stopped taking it, some of the symptoms recurred. She describes a dizzy feeling, primarily with putting her head back but not with any other movements. She has recently developed some tinnitus, which she described as a buzzing noise in her ear. Again, it is intermittent. Her hearing has been okay with no changes noted. She has not been unable to drive, and the symptoms have not interfered with her daily routine.

OBJECTIVE: Blood pressure 122/84, pulse 74 and regular, weight 142. Ears: Canals are clear. TMs are somewhat dull with absent light reflex. Throat: Clear. No exudate or erythema. No lateral banding. Neck: Supple. No increased adenopathy. Chest: Clear to P and A. No rales, rhonchi or wheezes.

ASSESSMENT: Benign positional vertigo.

PLAN: We have told her to use the Antivert on a p.r.n. basis. She also has serous otitis media, and we instructed her in pushing fluids and doing Valsalva. This may very well improve her dizziness somewhat. She also has some intermittent edema in her feet and says that her hands and feet are always cold. On exam, she does have a little purplish color to her distal feet and toes and they do feel cool.

SOAP Note Example Medical Report #5

SUBJECTIVE:  The patient is here today complaining of having had her period 3 times in the last 4 weeks. She said that they are not specifically heavier, but she has only 1 or 2 days where it is heavy and then the next day it is only a little brownish discharge. She normally has very regular period, and her period will last about 5 days with mild cramping. She denies any unprotected intercourse. She always uses protection. She denies any breast tenderness. She never had missed any either.

OBJECTIVE:  In terms of her exam today, her blood pressure was 114/66, which is about the same for her as before. Heart rate was 66. She weighs 136 pounds. Her temperature is 98.4. Her thyroid exam showed that she has normal thyroid. We could not feel for any masses. She does not have any upper extremity tremor either. Her lung examination was clear. Her cardiac examination showed regular heart sounds. She has no S3 or S4. Conjunctival exam is normal. Eye exam is EOMI and PERRLA. Abdominal examination showed a soft abdomen. She has no hepatomegaly. No splenomegaly.

ASSESSMENT AND PLAN:  This is a lady who is here today for menorrhagia. She is (XX) years old. Her symptoms might be related to perimenopause. However, we decided to check her CBC but also to check her thyroid. We explained to her that both hyper and hypothyroidism may cause her symptoms; although, she denies any change in her weight, any agitation or any fatigue. We will then follow up on her lab results, and we also discussed today perimenopausal symptoms.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Asian female who was admitted on MM/DD/YYYY for intensive inpatient rehabilitation evaluation after discharge from an outside hospital under Dr. John Doe and Dr. Jane Doe’s service on the same day.

She was initially admitted to the outside hospital after she tripped and fell in her shower. She was found to have a displaced right femoral neck fracture.

On MM/DD/YYYY, she underwent right hip hemiarthroplasty with a posterior approach by Dr. Jane Doe. The postoperative course was complicated by slow progress with limited mobility and exercise tolerance and endurance. She also developed postoperative anemia further limiting her endurance. She was recommended as a candidate for intensive inpatient rehabilitation evaluation and program.

PAST MEDICAL HISTORY: Significant for insulin-dependent diabetes mellitus, hypertension, hypercholesterolemia, and obesity.

PAST SURGICAL HISTORY: She has a history of hysterectomy.

FAMILY HISTORY: Essentially noncontributory.

PSYCHOSOCIAL AND FUNCTIONAL HISTORY: She is married and lives in a one-level house. She has been independent for mobility and self-care activities.

ALLERGIES: PENICILLIN.

REVIEW OF SYSTEMS: She has insulin-dependent diabetes mellitus, hypertension, hypercholesterolemia, and obesity as mentioned. Appetite fair. No BM since surgery. Has indwelling Foley catheter. Denies headache, nausea, vomiting, chest pain, shortness of breath or abdominal pain. Hip pain is moderate.

PHYSICAL EXAMINATION:
General: The patient is in fair spirits, has a stable affect, in no distress.
Vital Signs: Blood pressure 104/56, pulse 74, respirations 18, and temperature 98.4 degrees.
Heart: Regular rhythm without murmur.
Lungs: Clear to percussion and auscultation.
Abdomen: Soft and nontender. Bowel sounds are physiologic.
Pelvic: Examination is deferred.
Rectal: Examination is deferred.
Skin: No rashes or decubiti.
Neuromusculoskeletal: Mental Status Examination: The patient is awake, alert, and oriented x3. Memory and intellectual function intact. Affect and insight appropriate. Cranial nerves II through XII are intact. The active range of motion is full in both the upper and the left lower extremity with muscle strength at least fair to good. The right hip surgical incision is clean and dry and there are no staples. There is no sign of deep vein thrombosis in the legs. Peripheral circulation appears adequate in both lower and upper extremities. Sensory examination is unremarkable.

FUNCTIONAL STATUS: The patient has good mentation. She is well cooperative and motivated. Pain is moderate. Appetite fair. No BM since surgery. Has indwelling Foley catheter. She has stood at the side of bed requiring moderate assistance before coming to rehabilitation. Full mobility and activities of daily living evaluation is pending.

CODE STATUS: Full code.

CONDITION ON ADMISSION: Fair and stable.

IMPRESSION:
1. Impaired mobility and activities of daily living independence secondary to status post right hip hemiarthroplasty due to displaced femoral neck fracture from a fall. Weightbearing as tolerated.
2. Constipation.
3. Urinary retention.
4. Anemia.
5. Insulin-dependent diabetes mellitus.
6. Hypertension.
7. Hypercholesterolemia.
8. History of hysterectomy.
9. Obesity.
10. Allergic to penicillin.

REHABILITATION CARE PLAN

GOALS:
Short-term rehabilitation goals: To prevent injuries during the rehabilitation program, to obtain optimal pain control, to obtain optimal wound healing, to regain bladder and bowel regulation, to improve self-mobility and self-care independence and endurance.

Long-term rehabilitation goals: To regain mobility and self-care independence before returning home to family.

REHABILITATION POTENTIAL: Fair.

ESTIMATED LENGTH OF REHAB STAY: Ten to fourteen days.

PLAN:  Intensive inpatient rehabilitation evaluation and program as indicated. The patient will first be placed on an initial evaluation period of about 3 to 5 days before determining the potential for further rehabilitation program.

The initial evaluation will consist of rehabilitation nursing, physical therapy, occupational therapy, therapeutic recreation, and social service. The initial evaluation will be emphasized on mobility and activities of daily living, independence, safety and endurance, bladder and bowel, and the psychosocial aspect of function. Optimal medical management and consultation with Dr. Jane Doe and Dr. John Doe when indicated.

With further program, she will be discharged home when she achieves her maximum mobility and self-care independence with reasonable safety and endurance level.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: The patient is a (XX)-year-old female with history of COPD, myelodysplastic syndrome, transfusion dependent, who presented with left-sided chest pain and was admitted for further evaluation.

SOURCE OF INFORMATION: The patient is a poor historian, and history is obtained from nursing staff and previous medical record.

HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old Hispanic female with multiple comorbidities, including myelodysplastic syndrome resulting for pancytopenia and she is transfusion dependent. She has a history of GI bleeding secondary to AV malformation and history of hypertension for which she is taking multiple medications. She has a history of coronary artery disease, history of abdominal aortic aneurysm; she is status post repair. She has a history of intracranial hemorrhage in the past.

The patient was discharged from the hospital last week after being treated for fluid overload and congestive heart failure. During that time, the patient was treated with diuretics. Today, the patient came for regular blood transfusion, and after blood transfusion, she started to complain of left-sided chest pain and was admitted for further evaluation. Currently, the patient is complaining of chest pain and sharp tenderness localized to the left anterior chest wall. She denies any increasing shortness of breath. She denies any increasing cough, orthopnea or paroxysmal nocturnal dyspnea.

PAST MEDICAL HISTORY: As stated above, includes myelodysplastic syndrome, transfusion dependence, COPD, hypertension, gout, history of GI bleeding secondary to AV malformation, history of intracranial hemorrhage, history of renal insufficiency, history of coronary artery disease, and congestive heart failure. She is status post abdominal aortic aneurysm repair.

MEDICATIONS: List reviewed.

ALLERGIES: PENICILLIN.

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient smokes once in a while. Otherwise, she denies any use of alcohol.

REVIEW OF SYSTEMS: The patient is not a good historian. She denies any increasing shortness of breath, but she coughs once in a while. No orthopnea or paroxysmal nocturnal dyspnea. She is having chest pain as stated in the history of present illness.

PHYSICAL EXAMINATION:
GENERAL: The patient is an elderly lady, in distress secondary to pain localized to the left chest wall. Otherwise, not in cardiorespiratory distress.
VITAL SIGNS: Blood pressure 190/92, pulse rate 82 per minute, respiratory rate 20 per minute, saturating 97% on 2 liters, and temperature 99.2 degrees.
HEENT: Head is atraumatic. Pupils are equal and reactive bilaterally. Pink conjunctivae. Anicteric sclerae. Oropharyngeal examination significant for slight crowding.
NECK: Short.
CHEST: Symmetrical chest expansion. She had some rhonchi, mostly on the right side. She has localized tenderness over the sternum and the left anterior chest wall.
HEART: S1 and S2 are heard.
ABDOMEN: Obese but soft and nontender. No organomegaly.
EXTREMITIES: Did demonstrate edema bilaterally, pitting. No cyanosis or clubbing.
NEUROLOGIC: Alert and oriented x3. No focal deficit.

LABORATORY DATA: Pending.

DIAGNOSTIC DATA: Chest x-ray reviewed. There is no infiltrative process seen. The patient had a CAT scan of the chest done during last admission, which showed minimal effusion on the right side. She has some density localized to the left lower lobe, which was considered to be probable atelectasis. There was cardiomegaly suggested.

ASSESSMENT: The patient is a (XX)-year-old female with multiple comorbidities, including myelodysplastic syndrome, which is transfusion dependent, COPD, history of hypertension for which she has been on multiple medications, coronary artery disease, and congestive heart failure for which she was treated with aggressive diuresis during last admission. The patient now presented for blood transfusion and was admitted with left-sided chest pain. The chest pain seems to be musculoskeletal in origin, but we cannot rule out underlying ischemia. EKG done on presentation did not show any active ST-T change. Otherwise, she had history of chronic obstructive pulmonary disease, hypertension, gout, and prior history of gastrointestinal bleeding and intracranial hemorrhage. She had also history of renal insufficiency.

RECOMMENDATIONS:
1. Continue pain treatment with narcotic.
2. Blood pressure control.
3. Oxygen supplementation.
4. Bronchodilator therapy with DuoNeb.
5. Follow up with WBC and temperature. If she is going up, would start antibiotic therapy. Currently, chest x-ray does not show any significant infiltrate.
6. Would check cardiac enzymes and EKG. The patient would benefit from cardiology evaluation.
7. The patient would continue her regular home medication.
8. We will follow up closely and make appropriate recommendation based on clinical response. Overall, the patient’s prognosis is poor.

DATE OF CONSULTATION: MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Streptococcus sepsis.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old woman with end-stage renal disease, on chronic renal dialysis, who was found to have streptococcus, isolated from her blood culture. Streptococcus pyogenes and Streptococcus agalactiae were isolated from her blood culture. In the meantime, her left forearm graft has a draining wound. The patient was admitted today to have the graft removal. The patient was treated with intravenous vancomycin prior to this admission. She had no shortness of breath, and she does not have any back pain. The patient had a graft infection in the past.

PAST MEDICAL HISTORY:
1. Chronic renal failure.
2. Hypertension.
3. Sepsis from a graft infection.
4. Status post PermCath insertion and subsequent removal, status post right arm AV graft surgery and status post left arm AV graft surgery.

ALLERGIES: NKDA.

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient does not smoke and does not consume alcohol.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.6, pulse 82, respiratory rate 20, blood pressure 184/118. O2 saturation is 99%. She weighs 48.8 kilograms.
GENERAL APPEARANCE: A young woman sitting upright, comfortable.
HEENT: The patient had facial edema but no cellulitis.
NECK: Supple.
LUNGS: Trace crackles at the base.
HEART: Regular rate and rhythm with a 1 to 2/6 systolic murmur.
ABDOMEN: Soft and nontender.
EXTREMITIES: The patient had an AV graft on her right arm, which is not functional. She had an AV graft on the left forearm, and there is a boil along the graft with some purulent drainage.
NEUROLOGIC: The patient is awake and alert. She moved all four extremities spontaneously.

DIAGNOSTIC DATA: Blood culture grew Streptococcus pyogenes and Streptococcus agalactiae. Hemoglobin 11.8, sodium 130, potassium 37.8.

IMPRESSION:
1. Polymicrobial sepsis, probably secondary to a left forearm arteriovenous graft infection.
2. Left arm arteriovenous graft infection.
3. End-stage renal disease, on chronic renal dialysis.
4. Hypertension.

RECOMMENDATIONS:
1. Continue intravenous cefazolin 1 gram IV after the graft removal. The patient may need four weeks of IV antibiotics.
2. Echocardiogram.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female with a history of progressive lower extremity weakness and chronic lower back pain, which has been going on for several weeks. The patient later began to develop pain in her lower extremities, left side greater than the right, and her condition progressed with numbness in her left lower extremity. The patient failed conservative treatment, and she was brought to an outside hospital where she underwent a multilevel lumbar laminectomy from L2 through L5.

The patient tolerated the surgery well, but postoperatively, she was still impaired with her self-care and mobility skills with limited ambulation and numbness in her lower extremities. It was felt that she would benefit from acute rehabilitation. She was then transferred here for continuation of her care and spinal rehabilitation program.

PAST MEDICAL HISTORY: As in HPI plus cancer of the breast, status post lumpectomy and removal of axillary nodes on the right.

SOCIAL HISTORY: The patient lives in a one-story home with no stairs or steps. She was previously independent with her activities of daily living and mobility skills. She does not smoke or chew tobacco or drink alcoholic beverages.

REVIEW OF SYSTEMS: The patient denies any nausea, vomiting, headache, diarrhea, constipation, fits, pains, seizures, psychiatric disorders or bowel or bladder dysfunction.

PHYSICAL EXAMINATION:
GENERAL: The patient is a well-developed, well-nourished female in no apparent distress.
VITAL SIGNS: Temperature 96.4 degrees, pulse 70, respirations 18, and blood pressure 146/62.
HEENT: Normocephalic. She has full ocular range of motion. Pupils are equal and reactive to light and accommodation.
NECK: Supple to palpation.
LUNGS: Clear to auscultation with diminished breath sounds.
HEART: S1 and S2 are present with no carotid bruits auscultated.
EXTREMITIES: Peripheral pulses are intact and good capillary return. Skin was essentially normal in regards to color, tone, and circulation. Lower extremities have no edema and Homans’ sign is absent.
BACK: Examination of the back shows spinal wound healing well without any sign of infection or skin breakdown and minimal serosanguineous drainage from the dressing.
PELVIC: Refused and would prefer to have this done with her PCP upon discharge.
RECTAL: Refused and would prefer to have this done with her PCP upon discharge.
BREASTS: Refused and would prefer to have this done with her PCP upon discharge.

FUNCTIONAL EVALUATION: The patient required minimal to moderate assistance with her self-care and mobility skills, and she is able to ambulate short distances with the use of a front-wheel walker and was limited secondary to resurgence of her back pain.

IMPRESSION:
1.  Spinal stenosis, status post multilevel decompressive lumbar laminectomy.
2.  Lumbar myelopathy.
3.  History of breast cancer.

REHABILITATION GOALS: The patient being at a modified independent level with her activities of daily living and mobility skills.

ESTIMATED LENGTH OF STAY: Four to six days before returning to home.

PLAN: The patient is scheduled to undergo a course of physical and occupational therapy, dietary, and rehabilitation nursing with the goal of the patient being at a modified independent level with her activities of daily living and mobility skills. Physical therapy team will work with the patient on general mobilization skills, upper and lower body strengthening, pre-gait and gait training activities, and balance and coordination skills. Occupational therapy team will work with the patient on feeding, grooming, upper and lower body dressing skills, toilet-to-tub/shower transfers with and without the use of adaptive equipment. Dietary team will work with the patient on appropriate diet. Rehabilitation nursing team will work with the patient on bowel and bladder management program and appropriate taking of medications. All team members will be utilizing appropriate spinal precautions. Medical team will monitor the patient’s pain level and wound and will adjust therapies and medications as needed.

Reviewed key steps in coordinating the vocal system with avoidance of laryngeal strain. The patient is able to independently identify that an initiating breath, relaxed open throat positioning, and forward resonance are optimal in promoting her best voice.

Reviewed /m/-onset words. The patient was 70% accurate with these, given cueing to slow her initiating breath and produce relaxed voice.

A frank discussion was held with the patient that although she has good conceptual and structured practice and grasp on given local techniques, carryover will be limited due to her restricted practice schedule. She understands that continued outpatient therapy is not indicated if she is unable to rehearse the techniques to promote voicing.

At this time, we will break from voice therapy. She was given comprehensive home program for continued rehearsal. She will complete physical therapy and attempt to return to voice exercises as she is able. Given her sound understanding of overall voice problem, her success through therapy is quite good, but this will only occur with structured home practice.

She will follow up in one month’s time. If she is unable to comply with voice therapy rehearsal at that time she will defer further intervention as her schedule permits this. She knows that she can contact us with any questions in the interim.

Sample #2

The patient was seen today for first session of voice therapy, targeting strengthening and bulking of the vocal folds in the presence of bilateral vocal fold bowing with hyperfunctional voice use. No specific changes or questions since initial evaluation.

Introduced isometric exercises for strengthening and bulking of the vocal folds. He is performing these appropriately and will do 20 x 3 times per day, pushing palms together with each production to help build strength.

Introduced neck stretches in the form of head turns, head tilts, and head rolls. These will be done immediately after isometric exercises.

Introduced laryngeal massage. The patient was able to independently find the thyrohyoid space and will do this for 3 to 5 minutes after neck stretches at each practice session.

The patient is provided with list of vocally abusive behaviors with alternative recommendations. He will review and follow up with any specific questions.

The patient will continue with program as outlined above for homework. At next week’s session, we will review hard glottal attack with likely movement towards varying phoneme level and initial instruction in diaphragmatic breathing.

Sample #3

The patient was seen today for his second session of voice therapy optimizing functional voice use in the presence of suspected hyperfunctional voice disorder.

He reports that he has incorporated neck stretches and laryngeal massage. This week, he came down with cold. He is wondering if laryngeal massage caused his congested symptoms, which it did not. He is continuing with given exercises, performing them with good technique.

Introduced diaphragmatic breathing. The patient easily transitioned to diaphragmatic breath pattern, requiring only slight cueing to relax the shoulders slightly. Otherwise, he was able to breathe without any specific breath hold, increased tension, or shallow breaths.

Introduced humming to optimize oral resonance. Given cueing, the patient was able to identify forward vibration of voice via kinesthetic feedback. He was also able to demonstrate through negative practice laryngeal tone focus and conceptualized the difference between this and forward resonance.

He will continue with exercises as outlined above. At next week’s session, will work further with partially occluded vocal tract exercises and move towards /m/ and /n/ onset syllables at the CV and CVC level.

REASON FOR VISIT: Hair loss.

HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old female, who comes in today with the above concern. She reports that over the past 6 months, she has noticed some thinning of her hair. Specifically, she noticed that it comes out in clumps from the root. At first, the patient thought this was perhaps due to coloring her hair and had discussed this with her hair stylist. However, she notes that she has been using the same process for many years, and it was reported to her that typically chemical damage would result in breakage as opposed to hair coming off at the root.

The patient also notes that approximately 6 months ago, she began on lamotrigine, which was prescribed for control of her bipolar disease. She reports that this has been extremely helpful in terms of her mood. However, she had done some reading online and thought this might be contributing to her hair loss. Review indicates that alopecia is a very rarely reported side effect of this medication. However, the patient states that she would continue on this medication.

The patient also admits that she has been under a lot of stress over the past year and acknowledges that this may be playing a role. The patient denies any fatigue, headaches, dizziness, weakness, shortness of breath, chest pain, gastrointestinal upset, or muscle pain and notes that otherwise she has been feeling very well. She is a bit overdue for her routine studies. The patient states that she needs to schedule an appointment with her gynecologist and also would like to have her mammogram arranged.

CURRENT MEDICATIONS: Lamotrigine.

ALLERGIES: None known.

PHYSICAL EXAMINATION:
VITAL SIGNS: Revealed a blood pressure of 104/72, pulse 72, oxygen saturation 97% on room air.
GENERAL: The patient is alert, oriented, pleasant and friendly. She is in no acute physical distress.
HEENT: NCAT. Scalp appears healthy without lesion. Hair is rather brittle. Pull test does reveal that multiple hairs do come out with root bulb intact. There are no patches of alopecia noted. Conjunctiva without pallor. Oropharynx benign.
NECK: Supple. No lymphadenopathy. No thyromegaly.
CHEST: Lung sounds clear to auscultation.
CARDIOVASCULAR: Regular rate and rhythm.
ABDOMEN: Soft, nontender. No guarding, rebound, masses.
EXTREMITIES: Without edema.

ASSESSMENT AND PLAN: The patient is a (XX)-year-old female with approximately 6-month history of mild hair loss. We discussed various causes for this, including iron deficiency anemia, thyroid disorder, stress, or possibly the new medication. We will check some routine labs to rule out a metabolic cause for her hair loss.

I, otherwise, advised her to discuss this with the physician who prescribed her this medication, though she states that she would ultimately like to stay on lamotrigine even if this were proven to be the cause of her symptoms, which would likely be difficult. We will communicate regarding results of her labs once available, and she will return for followup with me in approximately 3 months to reevaluate, being sure to see her gynecologist in the interim for her preventative studies.

We will also help her arrange her mammogram at today’s visit and follow up according to the result. The patient is agreeable with this plan.

PREOPERATIVE DIAGNOSIS: Bilateral carotid artery stenosis.

POSTOPERATIVE DIAGNOSIS: Bilateral carotid artery stenosis.

PROCEDURE PERFORMED: Thoracic arch angiography and selective angiography of right innominate artery and bilateral carotid arteries.

SURGEON: John Doe, MD

ANESTHESIA: Local anesthesia with IV sedation.

DESCRIPTION OF PROCEDURE: The patient was brought to the angio suite and was placed in the supine position. The patient received IV sedation. Both groins were prepped and draped in the usual sterile manner. Xylocaine 1% was infiltrated into the right groin over the skin and subcutaneous tissues and local anesthesia was obtained.

Then, a percutaneous stick was made with an 18-gauge needle into the right common femoral artery. Once the blood flow was seen, we introduced a 0.035 J wire. This was advanced all the way into the thoracic arch. We then placed a 5-French sheath. A 5-French pigtail catheter was threaded over the guidewire. This was placed in the proximal thoracic arch and then we did arch injection and arch angiography.

The pigtail catheter was removed, and we used a JB-2 catheter to select the right innominate artery and injection was made here. We selected the right carotid artery, and multiple injections were made and carotid angiography films were obtained. The JB-2 catheter was pulled back, and we accessed the left common carotid artery and selective left carotid angiography was accomplished in several views.

At the end of the procedure, the JB-2 catheter and the sheath were removed, and we held pressure in the right groin until hemostasis was obtained. The patient was transferred out of the angio suite in a stable condition.

ANGIOGRAPHY FINDINGS: The thoracic arch appears to be widely patent without any stenosis. Right innominate artery as well as subclavian arteries are widely patent. Right vertebral artery is tortuous, but there is no obvious stenosis seen at its origin. The right common carotid artery is normally patent.

At the origin of the right internal carotid artery, there is plaque formation causing 50-60% stenosis. The distal right internal carotid artery is fairly smooth and patent. The left common carotid artery has mild plaque formation at its origin from the thoracic arch without any stenosis.

There is plaque formation at the left carotid bifurcation extending into the internal carotid artery causing 40% stenosis. The plaque appears to be somewhat irregular.

FINAL IMPRESSION:
1.  There is plaque formation at the right carotid bifurcation extending into the internal carotid artery causing 50-60% stenosis.
2.  There is plaque formation at the left carotid bifurcation extending into the left internal carotid artery causing 40% stenosis.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old who presented to the emergency room yesterday with the above episode. The patient has been seen in the hospital several times this year for various medical problems. His problems include 18 years of advanced Parkinson’s disease and an idiopathic peripheral neuropathy. He also has cardiac history. Investigations regarding his peripheral neuropathy showed no treatable cause of neuropathy found. Overall, the patient has no true dysesthesias but has some numbness in his feet and at times weakness in all four limbs.

The patient’s Parkinson’s disease is advanced, and he is on Sinemet and Mirapex. In addition to this, he has spasms of muscle in his neck causing him to hold intermittent dystonic postures of his neck. This does not affect his chewing, swallowing or breathing, according to the patient. He has had this on and off for many years. He has never tried any Botox injections to the neck. He is seen for further neurologic evaluation.

MEDICATIONS: Mirapex 1 mg five times a day and Sinemet 25/100 mg one and half tablets five times per day. He is on Neurontin 200 mg t.i.d. for his peripheral neuropathy.

ALLERGIES: NKDA.

SOCIAL HISTORY: The patient does not smoke or drink. No illicit drug use.

FAMILY HISTORY: Negative for neurologic disease.

CARDIAC HISTORY: The patient has a history of high blood pressure and open heart surgery.

REVIEW OF SYSTEMS: Reveals no chewing, swallowing or breathing difficulties. Vision and hearing are normal. He is not short of breath. He has had no fevers, confusion, seizures, falls or head injuries.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 182/90. This is somewhat labile as he had a blood pressure of 152/80 last night. Pulse 90 and respirations 20. Weight is 182 pounds and stable.
GENERAL APPEARANCE: The patient is in no apparent distress. The patient is a well-developed and well-nourished male with frequent dystonic side-to-side movements of the head with spasming of the platysma muscles bilaterally. He has some facial grimacing as well as facial dystonia as well.

The patient’s signs of parkinsonism include slowness of speech, but he has no hoarseness or whispering voice. He has masked facial expression, mild cogwheeling in the upper extremities, but no increase in tone. He has no resting tremor, and he has a difficult time initiating movement overall.

The patient actually has good strength in all three limbs, including right arm and bilateral lower extremities; although, he did have shoulder surgery on the left, which limits his range of motion and strength there. He has no fasciculations or atrophy in the intrinsic hand muscles, forearms or lower extremities. Sensory examination is intact in all primary modalities, expect over the feet where he has diminished sensation to light touch and vibration consistent with a leg-dependent symmetric peripheral neuropathy. Reflexes are intact in the upper extremities, absent in lower extremities with downgoing toes. There is no sensory level. There are no signs of myelopathy overall. He does have chronic alopecia over the extensor surface of the legs consistent with peripheral neuropathy. Cerebellar exam is normal. Gait is not tested.

Laboratories have been reviewed today showing normal CPK 91 and a slightly high ESR of 14.

IMPRESSION: The patient is a (XX)-year-old with severe Parkinson’s disease and probably overlying cervical dystonia and facial dystonia causing spasms of muscle. He also has an idiopathic polyneuropathy with negative workup this year.

RECOMMENDATIONS: We agree with the rehab inpatient consult, and he will likely need a course of rehab. He should keep his Sinemet and Mirapex as well as Neurontin the same. He states he is not really in pain at this point. We do not suspect a new process, but we think most of his spasms in muscles is either due to overlying cervical dystonia, which is a movement disorder, which can be seen with other movement disorder such as Parkinson’s disease.

We would refer to Dr. Jane Doe. She should be asked to consult for his Parkinson’s disease and management. Potentially, she can also refer the patient for Botox injections, which we think would at least help some of the spasms in muscle, in his neck, and would be safe to do if the patient agrees. The patient states he is interested in this at this point; however, we do not do this. The patient states he is not happy with his visits to the neurologist downtown and would like to change. We think Dr. Jane Doe would be an excellent reference for him as well as potentially do Botox injections to help his muscle spasms in his neck.

For now, we will not change any of his treatment, but would look for treatable cause of neuropathy in about three or four months as this should be done on a yearly basis. This includes a hemoglobin A1c, thyroid studies, B12, folate, homocystine, ESR, ANA panel, Sjogren antibodies, and a serum protein electrophoresis. He may go to rehab when medically stable and should see Dr. Jane Doe over there.

PREOPERATIVE DIAGNOSES:
1. Infrarenal abdominal aortic aneurysm.
2. Mild common iliac artery aneurysms bilaterally.

POSTOPERATIVE DIAGNOSES:
1. Infrarenal abdominal aortic aneurysm.
2. Mild common iliac artery aneurysm bilaterally.

OPERATION PERFORMED: Aortobifemoral bypass with 18 x 9 mm Gore-Tex graft.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, PA-C

ANESTHESIA: General endotracheal.

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS: 550 mL cell saver, all of which was returned.

IV FLUIDS: 4.5 liters of crystalloid and 1 unit cell saver.

URINE OUTPUT: 125 mL.

DISPOSITION: The patient tolerated the procedure well and was stable to PACU with Doppler DP and PT signals bilaterally.

OPERATIVE FINDINGS:
1. Large amount of posterior plaque, left common femoral artery.
2. Bilateral common iliac artery aneurysms, left greater than right.

INDICATIONS FOR OPERATION: The patient is a (XX)-year-old gentleman with an infrarenal abdominal aortic aneurysm measuring approximately 4.5 cm. He also has iliac artery aneurysms. It was discussed with the patient operative intervention, open versus endovascular approach. It was discussed that we thought that he was a better candidate for open aneurysmorrhaphy due to iliac artery aneurysm as well as ulcerated plaque, particularly on the left side. Risks, indications, and technique of the operative intervention, aortobifemoral bypass, were discussed with the patient. The patient understood and was agreeable for the aortobifemoral bypass.

DESCRIPTION OF OPERATION: The patient was brought to the operating room and was identified as the patient. He had an epidural catheter placed and was placed supine on the operating room table. General anesthesia was induced. Central venous access and arterial line were placed. He was prepped and draped in the normal sterile fashion. Bilateral inguinal incisions were made and dissection down to the level of the common, superficial, and deep femoral arteries was performed. There was thickened intima throughout the right femoral system. On the left, however, there was a large, thick plaque posteriorly in the common femoral artery. Wet Ray-Tec sponges were then laid into these wounds, and each of the vessels, common superficial and deep femoral, were controlled with Silastic vessel loops.

Standard midline incision was made and entry into the abdominal cavity was performed. NG tube was noted to be in appropriate position. Liver was palpated with no abnormalities. There were some adhesions to the gallbladder and these were allowed to remain in place. Bowel showed no focal areas of abnormality. The retroperitoneum was then exposed and the duodenum was reflected to the right side. The small bowel was all packed to the right side of the abdomen. A Bookwalter retractor was used to retract the tissue.

Retroperitoneum was dissected. The inferior neck was dissected for an appropriate length. This was dissected circumferentially. Umbilical tape was placed around it. The iliac arteries were then dissected down to the level of the aneurysmal changes. Vessel loops were then used to tunnel from retroperitoneum to the femoral regions and umbilical tapes were placed through these areas. The patient then received 5000 units of intravenous heparin and appropriate circulation time was allowed. The iliac arteries were ligated using #1 Prolene ties x2 on each side at the level of the aneurysms. The aortic neck was then clamped using a Subramanian clamp. Aneurysm was opened and all mural thrombus was removed. There was a single lumbar vessel, which was oversewn.

An 18 x 9 mm Gore-Tex graft had already been selected. The tube portion was cut to the appropriate length, and anastomosis was performed using a CV3 stitch beginning at the posterior aspect of the wall and run circumferentially. It was tied. The graft limbs were clamped and then the anastomotic area was inspected. The anastomosis was hemostatic. The graft limbs were then clamped proximally, and graft limbs were tunneled appropriately. The right side was then clamped in common, superficial, and deep femoral arteries. Femoral arteriotomy was made with an 11 blade followed by angled Potts scissors.

The anastomosis was performed after graftotomy was made using a CV5 Gore-Tex stitch. This was begun at the heel and run circumferentially. Upon completion, the areas were back-bled with nominal back-bleeding from superficial femoral artery, better back-bleeding from the profunda femoris and common femoral arteries. The anastomosis was completed. The graft was de-aired prior to completing the anastomosis. The pelvic clamp was released followed by release of the graft clamp, and hemostasis was adequately achieved. The profunda femoris and then the superficial femoral artery were all released. The bleeding was controlled with Surgicel.

Anastomosis on the left was performed in a similar fashion. There was markedly thickened plaque over the posterior wall. The superficial femoral and deep femoral arteries were of better overall quality, softer with less plaque. Again, prior to release of the clamp, there was nominal back-bleeding from the superficial femoral artery and reasonable back-bleeding from the profunda femoris as well as the common femoral artery. The graft was de-aired. The anastomosis was irrigated and then completed. As opposed to the right side where there was nearly a 30 mmHg drop after opening of the limb, there was only about approximately 10-15 mm pressure drop after opening the left limb.

The areas were inspected. Single repair suture was used for hemostasis. The wounds were irrigated. The patient had Doppler DP and PT signals bilaterally with the left stronger than that of the right. The wounds were irrigated. The abdominal cavity was again inspected. The retroperitoneum was closed in two layers using 2-0 Vicryl in a running fashion to reapproximate the aortic wall as well as the retroperitoneum. Then, the abdominal cavity was again irrigated and then a #1 looped PDS suture was used to repair the abdominal wall. The groins were repaired in layers using 2-0 Vicryl for deep, 3-0 Vicryl for superficial fascia, and then 4-0 Vicryl subcuticular stitch for skin closures. A 4-0 Vicryl stitch was also used for skin closure of the abdominal wound. Appropriate dressings were applied. The patient was extubated on the operating table and transferred to the PACU in stable condition with Doppler DP and PT signals at his feet.