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Question Answered step-by-step MRI REPORTEXAMINATION OF:CLINICAL SYMPTOMS:MYOCARDIAL PERFUSION IMAGING: CARDIOLITE HEART IMAGING: Myocardial perfusion imaging. Chest pain, shortness of breath. SPECT left ventricular myocardial perfusion imaging study was performed in this patient. 29.5 millicuries of technetium-99m sestamibi was injected intravenously at peak stress. The patient had a maximal heart rate of 88%.Evaluation of the qualitative image series shows the left ventricular myocardium to have a normal uptake of tracer. There is no evidence to suggest myocardial infarction or stress-induced ischemia.IMPRESSION: Normal Cardiolite heart imaging as described above.CPT Code(s): [A]ICD Code(s): [B], [C] QUESTION 2 PREOPERATIVE DIAGNOSIS: Glaucoma, severe stage, open angle, right eye.POSTOPERATIVE DIAGNOSIS: Same.OPERATION PERFORMED: Sequential cyclocryotherapy, right eye.INDICATION: This 74-year-old white female has an out-of-control glaucoma in her right eye. She is pseudophakic and has been allergic to multiple drops and has had one sequential therapy before that worked quite well and then she stopped taking her drops. It is obvious that despite the cyclocryotherapy, she will need to continue on the Pilocarpine.DESCRIPTION OF PROCEDURE: After the patient was placed on the OR table, she was given a retrobulbar anesthesia of Xylocaine 2% with 0.75% Marcaine and Wydase for a volume of 3.5 cc. After this, she was prepped and draped in the usual sterile fashion for ophthalmic surgery and a wire lid speculum was used to separate the lids of the right eye. 3.5 mm from the limbus was marked out with a marking pen in the superior temporal quadrant and the right inferior nasal quadrant of her eye. The cryoprobe was liquid nitrogen and nitrous oxide and was applied to −80 for a 5-second treatment in a freeze-thaw-freeze triple row of cryotherapy laid down in both the defined quadrants. There were no complications. Maxitrol ointment, Telfa, and two pads were applied and the patient sent to the Recovery Room.CPT Code(s): [A]ICD Code(s): [B] QUESTION 3 INDICATION: Prolonged fetal heart rate deceleration. (report delivery complicated by fetal heart rate)PROCEDURE: Vacuum-assisted vaginal delivery. (report delivery vacuum assisted)COMPLICATIONS: Shoulder dystocia, relieved with McRobert's maneuver. (report delivery complication due to shoulder presentation)PREAMBLE: The patient is a 33-year-old gravida 3, para 2, 38 week, 3 days gestation, admitted from the emergency department secondary to pelvic pain (not reported because the pain is part of delivery). The patient was quite uncomfortable and had artificial rupture of membranes followed by labor progression to full dilation. She then began pushing, and some prolonged fetal heart rate decelerations down to about 90 beats per minute were noted (supports delivery complicated by fetal heart rate). Because of this, a decision was made to proceed with vacuum extraction (supports delivery vacuum assisted) to assist in expediting delivery.PROCEDURE NOTE: Maternal bladder was emptied using straight catheter. Pelvic examination was carried out and the cervix was confirmed to be fully dilated. Fetal vertex was present at +1 station. The small kiwi cup vacuum (supports delivery vacuum assisted) was then applied to the fetal vertex. On the second pull, there was one pop off, but this was after good descent of the fetal head had been achieved. Baby then delivered and was a live-born male infant. There was moderate shoulder dystocia present (supports delivery complicated by shoulder presentation) and this was relieved with McRobert's maneuver. The baby was handed off to the NICU team and is currently in the NICU for further observation. Apgar's (a newborn maturity scoring method) are not available at this time. Cord blood gas is also pending. After an episiotomy, a second-degree perineal tear still occurred during delivery. This was repaired using 3-0 chromic in usual manner. The patient tolerated this procedure well. Estimated blood loss during delivery was 200 cc.CPT Code(s): [A]ICD Code(s): [B], [C], [D], [E]  QUESTION 4 PREOPERATIVE DIAGNOSIS: Morbid obesity.POSTOPERATIVE DIAGNOSIS: Same.PROCEDURES:1. Laparoscopic Roux-en-Y gastrointestinal bypass.2. Liver biopsy.ANESTHESIA: General.INDICATION: The patient is a 36-year-old female who presents with morbid obesity, with a current BMI of 46.0. She has gone to the seminars, and we have discussed laparoscopic Roux-en-Y gastrointestinal bypass along with the risk of surgery including bleeding, infection, leakage from the anastomoses, conversion to open procedure, postoperative stenoses of the anastomoses, or bowel obstruction. She understands and wishes to proceed.PROCEDURE: The patient was brought to the operating room and placed under general anesthesia. A Foley catheter and orogastric tubes were inserted. She was prepped and draped sterilely with Betadine solution. A supraumbilical incision was made with a #15 blade, and dissection was carried down through the subcutaneous tissues bluntly. The patient had an incisional hernia from an old trocar port site. We placed our operative trocar into the abdomen, insufflated the abdomen. There was no damage to the underlying viscera. Under direct vision, we then placed two, midclavicular line, 12-millimeter ports that were just lateral and above the umbilical port. There was a right upper quadrant 12-millimeter port in the anterior axillary line and a left upper quadrant 5-millimeter port in the anterior axillary line. These were all placed under direct vision with no damage to the bowel. The patient had some adhesions of her gastrohepatic ligament to the liver. We took these down using the harmonic scalpel. Before continuing, a needle specimen was obtained from the liver, appropriately marked for pathologic evaluation. We then entered the retrogastric space and placed our taut catheter behind the stomach. We then flipped the omentum up over the top of itself. We elevated the transverse colon and opened the transverse colon where we could see the drain. We identified the ligament of Treitz and fired an Endo-GIA stapler across the bowel, down from the ligament of Treitz. We fired an additional load across the mesentery. We then counted out 100 centimeters of bowel and then performed a stapled side-to-side functional end-to-end anastomosis by opening the bowel on the proximal and distal sides with the harmonic scalpel, firing two loads of the Endo-GIA stapler and closing the anastomosis with an Endo-GIA fired staple line. This gave us a nice anastomosis. We closed the mesenteric defect here with an Ethibond suture and fixed with Laparoties. We then sutured the proximal end to the catheter and flipped the mesentery back down. We then brought the bowel and the catheter up in retrogastric fashion. Next, we identified the angle of His. We opened the angle of His, and we fired five loads of the Endo-GIA stapler across the stomach. We had blown up the 20-cc balloon and had about a 20-cc pouch. Once we had completely transected the stomach, we went above and placed the Bioenteric catheter within the gastric pouch. We passed the snare through it. We made a separate stab incision in the upper abdomen and passed the wire through. We then fed the anvil end of the CEA-21 stapler down through the back of the pharynx down through the esophagus and brought out through our gastric pouch. We then enlarged the left midclavicular line, abdominal port, and placed the CEA-25 stapler through here. We opened the staple line on the bowel that we had brought up after we had removed the taut catheter and placed the CEA stapler into the bowel, brought the spike through, connected the two ends of the CEA, closed it, and fired it. This gave us a nice 21-millimeter circular anastomosis. We completed the anastomosis with the Endo-GIA stapler. We imbricated the staple line with two Ethibond sutures, placed a wad of fat over the last to adhere the fat near our staple line. We tested the anastomosis with air with the bowel clamped, and there was no evidence of a leak. We then placed Hemaseel over this anastomosis, and then once again mobilized the mesentery. We then closed the mesenteric defect where the small bowel had gone in retrogastric fashion with the Ethicon Endo-suture. We once again placed Hemaseel on our small anastomosis. We placed 10 flat Jackson-Pratt drains near our GJ anastomosis, which came on out the left side. We removed the trocar ports under direct vision. We then extended our umbilical incision and reduced the umbilical hernia. We closed the fascial defect with interrupted 0 Prolene sutures. We anesthetized the wounds at all areas with a total of 60 cc of 0.50% Sensorcaine with epinephrine solution. We secured the drains in place with 0 silk sutures and then closed the skin with 3-0 Prolene sutures. Steri-Strips and sterile Band-Aids were applied.All sponge and needle counts were correct. We left the taut catheter and a Penrose drain in the left midclavicular line incision. All sponge and needle counts were correct. She tolerated this well and was taken to recovery in stable condition.CPT Code(s): [A], [B]ICD Code(s): [C], [D], [E]        Health Science Science Nursing BUSN 2375 Share QuestionEmailCopy link Comments (0)