REPORT #: 1124.

OPERATIVE REPORT PATIENT NAME: MR #: DATE: SURGEON: ASSISTANT:

GASTROENTEROLOGY

Welton, James. 5032896 8-21-XXXX Alfred Binger, M.D. Charles Smith, M.D.

PRE OPERATIVE DIAGNOSIS Gall stone pancreatitis. POSTOPERATIVE DIAGNOSIS Gall stone pancreatitis. Rule out cirrhosis of liver. OPERATION: 1. Laparoscopic cholecystectomy. 2. Intraoperative cholangiogram. 3. Liver biopsy. ANESTHESIA: General. OPERATIVE PROCEDURE The patient was placed on the operating table in the supine position. After satisfactory induction of general anesthesia, the abdominal wall was prepped and draped in the usual sterile fashion. Pneumoperitoneum was instilled through a small infraumbilical incision and a Veress needle. The laparoscope was inserted. On inserting the laparoscope, the liver was found to be nodular and possibly cirrhotic. The operating trocars were now introduced under direct vision in the usual places. Dissection of the hepatoduodenal ligament was then commenced with identification of the cystic artery and the cystic duct. The cystic artery was divided between four clips. An attempt at cholangiography through the gallbladder was made by directly passing a needle into the gallbladder, instilling 20 cc of contrast material. This did not demonstrate anything other than the gallbladder. The area of the cystic duct was now dissected free and a clip placed on the proximal cystic duct. The cystic duct was opened and a cholangiogram catheter inserted in to the cystic duct. The cholangiogram was now shot which showed free flow of contrast material in to the common bile duct without any evidence of choledocholithiasis. The cholangiogram catheter was now removed and the distal cystic duct doubly clamped. The cystic duct was now divided. The gallbladder was now dissected out of the liver bed using Bovie cauterization for diathesis and hemostasis. Prior to removing the gallbladder, the bed and the hepatoduodenal ligament were inspected, and no bleeding was found. The reminder of the gallbladder was now removed under direct vision. The camera was placed into the upper abdomen and the gallbladder removed under direct vision through the infraumbilical port. A percutaneous liver biopsy was performed earlier in the procedure using a Tru-Cut needle under direct vision to the right lobe of the liver. No bleeding was found from this site later in the operation.

The abdomen was now copiously irrigated through the lateral ports. The ports were now removed under direct vision. Contd.report. #: 1124. (2) The skin incisions were closed with 4-0 Vicryl subcuticular suture. Steri-Strips were now applied to all wounds. Band-Aids were applied. The patient tolerated the procedure well and was taken to the recovery room in good condition. Signed Alfred Binger, M.D.

REPORT #: 1125.

PULMONOLOGY

DISCHARGE SUMMARY (PHYSICAL EXAMINATION SECTION) PATIENT NAME: ADMISSION DATE: DISCHARGE DATE: MR #: Charles Ingrid 5-3-XXXX 5-17-XXXX 7045692

PHYSICAL EXAMINATION GENERAL: The patient was alert, active, playful, and verbally appropriate for age. VITAL SIGNS: Blood pressure 80/45, pulse 92/min and regular, respirations 28 and regular, temperature 97 rectally. Weight 16.4 kg, which is in the 25 th percentile. Height 101.6 cm, which is within the 10th 25th percentile. SKIN: No lesions noted, no rash. HEENT: HEAD: Normocephalic. EARS: Tympanic membranes with good landmarks, positive light reflex, pearly white in color. EYES: Pupils are equal, round, and reactive to light and accommodation. Extraocular movement intact. Funduscopic: Discs have sharp margins, normal vessels. NOSE: Slightly hyperemic turbinates, no swelling. Mouth: Pink and moist, no hyperemia, no swollen glands. NECK: Supple, trachea is midline, no pulsations. CHEST: Thorax: AP diameter normal and symmetrical. LUNGS: Scattered rhonchi with good air entry, minimal expiratory wheezes. BACK: No CVA tenderness. CARDIAC: Heart with regular rate and rhythm, no murmurs. ABDOMEN: Slightly protuberant, soft, nontender, no organomegaly. Liver span is 4 cm in the midclavicular line. Positive bowel GENITALIA: Tanner stage I, circumcised, both testes are descended, no hernia. SPINE: No deformity. EXTREMITIES: Full range of motion, no edema, no cyanosis. Positive clubbing, minimal fingers and toes. NERVOUS SYSTEM: Cranial nerves II - XII are grossly intact. Reflexes are 2+ through out. Motor and sensory functions are grossly intact. Babinski is down-going. Signed Larissa M.Carron, M.D.

REPORT #: 1126. OFFICE NOTE PATIENT NAME: Sandra Mahoney DATE OF VISIT: 4-18-XXXX

DERMATOLOGY

SUBJECTIVE: The patient is here for suture removal after excision of atypical compound nevus. OBJECTIVE: The incision appears clean with minimal reddening at the suture site. Sutures were removed without difficulty. PLAN: The patient was given samples of Steri-Strips and benzoin and advised to keep the lesion covered continuously for the next three weeks. Signed Gina Hollman, M.D.

REPORT #: 1129. CONSULTATION LETTER AUG 27, XXXX

GASTROENTEROLOGY

Sharon Strobe, MD Brookfield University Medical Center One University Place Fort Worth, TX 76104 RE: James Welton Dear Sharon: James Welton is a 34-year-old male who had eaten dinner and later complained of pain in his right side from the lower ribs to the hip and radiating around to the back. The pain gradually worsened, and he became nauseated and vomited many times during the evening. When the pain became severe, he was taken to the emergency room at Brookfield University Medical Center. On physical examination, Mr. Welton was found to be in acute distress and suffering from mild dehydration. His right abdomen was acutely tender on palpation. There were no palpable masses. Rectal examination was within normal limits. He was treated with Demerol 75 mg IM, an IV with D5W 0.45 NS was started, and he was admitted to the hospital for observation and further evaluation. During his hospitalization, an abdominal ultrasound revealed cholelithiasis, and a laparoscopic cholecystectomy was performed. He had an uneventful hospital course and was discharged three days postoperatively. He will return to my office in two weeks for follow-up. Thank you for referring this patient to me. Sincerely, Alfred Binger, M.D.

REPORT #: 1131. CONSULTATION LETTER DATE: NOVEMBER 29 XXXX Albert J. Eisner, M.D. Brookfield University Medical School One University Place Fort Worth, TX 76104-3223 RE: Lawrence Johnson, Jr., Dear Al:

OPHTHALMOLOGY

We rechecked Lawrence Johnson under anesthesia on November 21. It has been nine months since he completed his course of external beam radiation therapy as management of unilateral sporadic retinoblastoma in the left eye. On our exam today, our findings remain the same as on our prior exam in August. The tumor is completely regressed, and there is no evidence of viability. There are no new tumors in the left eye. The optic disc is healthy, and there are no signs of radiation retinopathy or papillopathy. The right eye is perfectly normal, with no evidence of retinoblastoma. Regarding the visual prognosis, because of the macular location of the regressed retinoblastoma, his visual prognosis is very guarded. We will try patching of the right eye in an attempt to stimulate any possible vision in the left eye. Thank you for allowing us to assist in his care. Very sincerely yours, Richard Sowers, M.D.

REPORT #: 1132. CONSULTATION LETTER

GASTROENTEROLOGY

AUGUST 12, XXXX Robert Smith, MD Fort Worth Medical Associates, PA 100 Leavenworth Boulevard Fort Worth, TX 76104 RE: Sara Johnson Dear Bob: Thank you for sending this very pleasant patient to our practice. Mrs. Johnson presented to my office with complaints of constipation, abdominal distension, and bloody stools of several weeks duration. She is a well-nourished female whose physical examination was generally within normal limits with the following exceptions: Abdomen was distended and firm with a palpable mass, approximately 3 x 5 cm, in left lower quadrant. Digital rectal exam was positive for a palpable, firm mass. Mrs. Johnson was admitted to Brookfield University Hospital for further evaluation, which consisted of an abdominal and pelvic CT scan, barium enema and sigmoidoscopy -- all positive for lesion within the colon and rectum. Surgery was performed with the colon resection. An infiltrating, moderately differentiated adenocarcinoma was found. The histologic information revealed the tumor classified as T3, N0, MX (Pathology report attached). All other submitted tissue showed no evidence of malignancy. Mrs. Johnson recuperated very well and is referred back to you for further treatment. Please keep me informed of her progress. Once again, thank you for this referral. Sincerely, Alfred Binger, M.D.

REPORT #: 1132. CONSULTATION LETTER

GASTROENTEROLOGY

AUGUST 12, XXXX Robert Smith, MD Fort Worth Medical Associates, PA 100 Leavenworth Boulevard Fort Worth, TX 76104 RE: Sara Johnson Dear Bob: Thank you for sending this very pleasant patient to our practice. Mrs. Johnson presented to my office with complaints of constipation, abdominal distension, and bloody stools of several weeks duration. She is a well-nourished female whose physical examination was generally within normal limits with the following exceptions: Abdomen was distended and firm with a palpable mass, approximately 3 x 5 cm, in left lower quadrant. Digital rectal exam was positive for a palpable, firm mass. Mrs. Johnson was admitted to Brookfield University Hospital for further evaluation, which consisted of an abdominal and pelvic CT scan, barium enema and sigmoidoscopy -- all positive for lesion within the colon and rectum. Surgery was performed with the colon resection. An infiltrating, moderately differentiated adenocarcinoma was found. The histologic information revealed the tumor classified as T3, N0, MX (Pathology report attached). All other submitted tissue showed no evidence of malignancy. Mrs. Johnson recuperated very well and is referred back to you for further treatment. Please keep me informed of her progress. Once again, thank you for this referral. Sincerely, Alfred Binger, M.D.

REPORT #: 1133.

GASTROENTEROLOGY

Listen for the following new term: Gastrografin enema. RADIOLOGY REPORT: NAME: MR #: DATE: SEX: ROOM #: Prince, Jonathan 7013409 9-1 -XXXX Male 206

REQUESTING PHYSICIAN: BARRY LEVEENE, MD. CLINICAL INFORMATION: CROHNS DISEASE. BARIUM ENEMA WITH AIR CONTRAST GASTROGRAFIN ENEMA The preliminary scout film shows a small amount of contrast in the appendix. There appears to be dilute contrast in a large rounded collection in the pelvis, possibly representing the patients known dilated small bowel. This is approximately 11 cm in diameter. There is mild dilatation of more proximal small bowel loops. A Gastrografin enema was performed without prior patient preparation. The barium flowed freely from rectum to cecum with reflux into the appendix as well as the terminal ileum. About 3 cm of the ileum appears to be of luminal caliber before there is opacification of a very narrowed, elongated segment measuring at least 10 to 15 cm in overall length. Only a minimal amount of contrast is seen swirling into markedly dilated small bowel proximal to this area of stricture. In addition, there is abnormal contour to the apex of the sigmoid colon, where it is adjacent to the terminal ileum. There appears to be some tethering of the right lateral wall of the sigmoid with a somewhat pointed configuration. No frank extravasation of contrast is seen in this area, nor do I feel there is any complete fistula formation to an adjacent small bowel loop. Adjacent inflammatory changes are likely, however. The rest of the colon is of normal caliber, and there are no other areas suspicious for fistula formation. IMPRESSION: Normal-caliber colon but tethering deformity at apex of sigmoid colon and area of adjacent terminal ileum is small.

John Kronin, M.D.

REPORT #: 1134. PATHOLOGY REPORT: PATIENT: RECORD #: SPECIMEN #: LOCATION: SEX: PHYSICIANS: PROCEDURE: PROCEDURE DATE: RECEIVE DATE:

GASTROENTEROLOGY

Prince, Jonathan 701340 S-4785-94 Inpatient Male Barry Laveene, MD: Nancy Sprans, MD. Colonoscopy 3/3 XXXX 3/3 XXXX

CLINICAL DIAGNOSIS: AN 18-YEAR-OLD MALE WITH CROHNS DISEASE, STATUS POST COLOSTOMY. CLINICAL HISTORY: AS ABOVE. GROSS DESCRIPTION: The specimen is received in formalin in six portions, A through G. Portion A is labeled 15 cm ileostomy and consists of multiple fragments of tan soft tissue, measuring in aggregate 0.4 x 0.3 x 0.1 cm, all taken in cassette A. Portion B is labeled 8 cm T1 and consists of one fragment of tan soft tissue, measuring 0.3 x 0.2 x 0.1 cm, all taken in cassette B. Portion C is labeled Sigmoid colon and consists of multiple fragments tan soft tissue, measuring in aggregate 0.5 x 0.3 x 0.2 cm, all taken in cassette C. Portion D is labeled 10 cm and consists of multiple fragments of tan soft tissue, measuring in aggregate 0.3 x 0.3 x 0.1 cm, all taken in cassette D. Portion E is labeled 10 cm and consists of one fragment of tan soft tissue, measuring 0.2 x 0. 2 x 0.1 cm, all taken in cassette E. Portion G is labeled mucous fistula and consists of multiple fragments of tan soft tissue, measuring in aggregate 0.2 x 0.2 x 0.1 cm, all taken in cassette G.

DIAGNOSIS (GROSS AND MICROSCOPIC) A. Biopsies of terminal ileum, 15 cm from ileostomy site, showing villous blunting and hyperemia with modest, nonspecific leukocytic inflammatory reaction, showing no granulomata or surface ulceration. B. Mucosal biopsies of terminal ileum, 8 cm. from ileostomy site demonstrating moderate to severe villous blunting with leukocytic inflammatory cell infiltration in lamina propria and epithelium, consistent with ileitis. No granulomata observed. Contd...report. #: 1134. (2) C. Mucosal biopsies, stated to be sigmoid colon, showing mucus and fragments of colonic mucosa with orderly mucous glands demonstrating lymphoid patch, but showing no active cryptitis or granuloma formation. D. Colonic mucosal biopsies, 20 cm. level, showing mature mucous glands with no evidence of active cryptitis or surface erosion. No granulomata identified. E. Colonic mucosal biopsy, 10-cm level, showing orderly mucous glands and intact surface epithelium, with no granuloma formation or cryptitis observed. F. Mucosal biopsy from mucous fistula showing colonic glands with moderate gland atrophy, showing intact surface epithelium with no ulceration or granuloma formation observed. Focal lymphoid patch. NOTE: It is not possible to validate any active degree of Crohns in the submitted material, although the sections from the terminal ileum demonstrated prominent reactive blunting.

NURI BANNO, M.D. PATHOLOGIST.

REPORT #: 1135. DISCHARGE SUMMARY NAME: MR #: ATTENDING PHYSICIAN: DATE OF ADMISSION: DATE OF DISCHARGE:

GASTROENTEROLOGY

Gonzales, Mary 1271106 Leslie Smith, MD 6-9-XXXX 6-23-XXXX

PRINCIPLE DIAGNOSES 1. Iron deficiency anemia. 2. Gastrointestinal bleed. 3. Coronary artery disease. 4. Hiatal hernia, mild gastritis, and diverticulosis. HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old Hispanic woman with a history of weakness, melena, and anemia requiring blood transfusions. She was admitted to the hospital with symptoms of chest pain and melena. She was found to have a decreased hematocrit to 24. HOSPITAL COURSE: The patient was admitted for enteroscopy and colonoscopy. She was transfused with packed red blood cells to a hematocrit of 36.5, which remained stable through out her hospitalization. Colonoscopy and enteroscopy revealed mild gastritis, hiatal hernia, diverticulosis, and hemorrhoids. There were no arteriovenous malformations visualized. Four days after her admission she had guaiac-negative stools. PROCEDURES PERFORMED 1. Enteroscopy on 6-21. Results showed hiatal hernia and non-specific gastritis.

2. Colonoscopy on 6-22. Notable for moderate sigmoid diverticulosis, but an otherwise normal colonoscopy to the terminal ileum. DISCHARGE MEDICATIONS: 1. Prilosec 20 mg p.o.q.d. 2. Accupril 20 mg p.o.q.d. 3. Xanax 0.25 mg p.o.t.i.d. p.r.n., for anxiety. DIET: The patient was instructed to follow a high-fiber, low-salt diet. PHYSICAL ACTIVITY: As tolerated. FOLLOW-UP CARE: The patient will make an appointment with Dr. Smith. We recommend a possible upper gastrointestinal series with a small bowel follow-through in the future in order to evaluate the small bowel for possible tumors. James Chen, M.D.

REPORT #: 1173. PATHOLOGY REPORT: PATIENT NAME: MR #: SPECIMEN #: ROOM #: SEX: DATE OF BIRTH: PHYSICIAN: PROCEDURE: PROCEDURE DATE:

GASTROENTEROLOGY

Johnson, Sara 7904532. 30240. 91. Female. 11/4/43. Bringer, A. ABDOMINAL RESECTION. 8/10/XXXX

CLINICAL DIAGNOSIS: Carcinoma of rectum. CLINICAL HISTORY: UNSTATED. GROSS DESCRIPTION: The specimen is received in three portions. Portion one is stated to be colon and consist of portion of large intestine, measuring 28.0 cm in length, and 6.0 cm in greatest diameter. The serosal surface is reddish tan, smooth, and glistening with attached epiploic adipose tissue. The mucosal surface is tan- red, smooth, and glistening with normal folds. At 0.5 cm from one surgical margin, there is a flat, fungating, ulcerated mass which occupies more than two-thirds of the circumference of the lumen and measures 6.5 x 3.5 cm in greatest diameter. Grossly, the tumor invades the serosal surface in the central portion. The surgical margin close to the tumor is inked. Representative sections of the tumor are submitted in three cassettes. Cassette-A contains the surgical margin close to the tumor submitted in CM;

surgical margin far from tumor submitted in FM; random sections in R; nodes close to tumor submitted in CN; nodes far from tumor submitted in FN. Portion two is stated to be proximal ring and consists of a ring of tan-pink soft tissue, measuring 1.5 x 1.4 x 0.5 cm, which has attached staples. The stapled portion of the specimen is removed, and the remainder of the specimen is submitted in cassette-B. Portion three is stated to be distal ring and consists of a fragment of pinkish tan, soft tissue, measuring 2.3 x 1.4 x 0.3 cm, and has some attached staples. The stapled portion is removed, and the remainder of the specimen is submitted in cassette-C. DIAGNOSIS: (GROSS AND MICROSCOPIC) A. Colon resection infiltrating, moderately differentiated adenocarcinoma with transmural invasion and into pericolonic fat. No tumor seen in proximal and distal margins of resection. Nine lymph nodes isolated, no tumor seen. Based on the available histologic information, the tumor is classified as T3, N0, MX. B. Proximal ring, segment segment of large bowel with no evidence of malignancy. C. Distal ring, segment segment of large bowel with no evidence of malignancy. SIGNED: PATHOLOGIST: NURI BANO, M.D. REPORT #: 1175. PROCEDURE REPORT: PATIENT NAME: David Dronen DATE: 6-11-XXXX PROCEDURE: FLEXIBLE SIGMOIDOSCOPY. The patient gives a questionable history of colonic polyps. He states that he was told that he had polyps, but it is unclear with his somewhat rambling history whether this was a rectal or colon abnormality. He denies that anything was ever done in this regard. A review of the chart indicates that he had Hepatitis A, and he has a mild elevation of his GGT noted on the labs drawn a few days ago. Hepatitis A profile was ordered to be certain that this was a past infection. Screening sigmoidoscopy was performed to 45 cm without difficulty, but was stopped because the patient complained of some cramping. There was spasm in the colon at this level. No polyps were seen. No bleeding sources were found. The patient tolerated the procedure fairly well. RECOMMENDATIONS 1. Hepatitis A profile - sent. 2. Repeat liver profile - sent. 3. Barium enema - to be rescheduled.

GASTROENTEROLOGY

The patient will follow up in approximately two weeks to discuss results.

Leslie Smith, M.D.