Some Stents Encountered in Medical Transcription Reports

11 mm trocar

5 mm trocar

AERO stent

Alimaxx-E stent

Aurora stent

bare-metal stent

Cypher drug-eluting stent

double-J stent

Express LD stent

Express stent

Genesis stent

Hasson trocar

Herculink Elite stent

Jostent stent

Liberte stent

Luminexx stent

Mini-Vision stent

Omnilink stent

Palmaz balloon expandable stent

Reston stent

SMART stent

suprapubic trocar

Taxus drug-eluting stent

umbilical trocar

Viabahn stent

Vision stent

Xact stent

Xience V drug-eluting stent

Zilver stent

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Carotid Endarterectomy Angioplasty MT Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Left carotid stenosis 80%.

POSTOPERATIVE DIAGNOSIS:
Left carotid stenosis 80%.

OPERATION PERFORMED:
Left carotid endarterectomy with Dacron patch angioplasty.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old male with a long-standing history of vascular disease. He had recent carotid imaging demonstrating severe stenosis bilaterally. He has had a previous right carotid endarterectomy. He was returned to the operating room today for left carotid endarterectomy for an 80% stenosis.

DESCRIPTION OF OPERATION:  The patient was placed in the supine position on the operating table following the induction of general endotracheal anesthesia. The left side of the neck was prepped and draped in the usual sterile fashion. The proposed incision site was infiltrated with 1% Xylocaine with epinephrine.

A skin incision was made with a scalpel along the anterior border of the left sternocleidomastoid muscle. Subcutaneous tissues and platysma were divided. The deep cervical fascia along the anterior border of the sternocleidomastoid muscle was divided. The common facial vein was ligated in continuity with 2-0 silk ties, clipped with Hemoclips, and divided. The common, internal, and external carotid arteries were dissected out and surrounded with vessel loops. Great care was taken to identify the vagus and hypoglossal nerves and to avoid injury to these structures.

Then, 8000 units of heparin was administered intravenously and allowed to circulate for 3 minutes. The internal carotid artery was then occluded followed by occlusion of the common and external carotid arteries. A #11 blade was used to make an arteriotomy in the common carotid artery. The arteriotomy was extended with Potts scissors through the bulb and up the internal carotid artery to a point beyond the distal extent of disease. A 3.0 x 4.0 Heyer-Schulte shunt was inserted and held in place with Javid shunt clamps. Shunt patency was confirmed with the Doppler.

Standard endarterectomy and carotid bifurcation were then performed using the Penfield. Eversion technique was used to facilitate endarterectomy in the external carotid artery. The distal endpoint feathered smoothly at the proximal internal carotid artery level. Any remaining loose atheromatous tissue was removed with plaque forceps. The surface of the artery was irrigated with copious amounts of heparinized saline. A Meadox Hemashield Finesse patch was obtained. The arteriotomy was closed as Dacron patch angioplasty using running 6-0 Prolene suture.

Just prior to completing the angioplasty, the shunt was removed and appropriate back bleeding and flushing maneuvers were performed. The angioplasty was then completed. Just prior to tying down the sutures, the external carotid artery was opened and allowed to backbleed to allow any air to escape from the vessel. The sutures were then tied down. The common carotid artery was opened. After several cardiac cycles, the internal carotid artery was opened. Doppler interrogation revealed normal signals in the common, internal, and external carotid arteries.

Heparin was then reversed with 50 mg of intravenous protamine. Hemostasis was meticulously achieved. The wound was irrigated with antibiotic solution. All vessel loops and retractors were removed. The platysma was closed with running 3-0 Vicryl suture. The skin was closed with a running 4-0 PDS subcuticular suture. Benzoin and Steri-Strips were applied. Sterile dressings placed over the incision. The patient was then awakened and extubated. He was noted to be neurologically intact. He was transferred to recovery room in stable condition.

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Sleep Study Words / Terms for Medical Transcriptionists

apnea index


apnea-hypopnea index (AHI)


arousal index


CPAP trial


daytime sleepiness


delta waves


desaturation profile


Epworth sleepiness scale


insomnia


latency to REM sleep


latency to sleep onset


longest respiratory event


Mirage Vista mask


number of apneas and hypopneas


number of awakenings


O2 saturation


obstructive sleep apnea (OSA)


parasomnias


periodic leg movements


periodic limb movement (PLM)


polysomnogram


polysomnograph


REM latency


respiratory disturbance index (RDI)


sleep architecture


sleep efficiency


sleep parameters


slow wave sleep


snoring profile


stage I sleep


stage II sleep


stage III sleep


stage IV sleep


total number of REM events


total recording time


total sleep time


Medical Transcription Word Help

Brain MRI Medical Transcription Sample

HISTORY:  Asymmetric hearing loss.

MRI of the IACs was taken with and without contrast, thin sections, in coronal and axial images. Images through the whole head were also performed, both pre and postcontrast.

There is no evidence of an enhancing schwannoma or acoustic neuroma in the area of either internal auditory canal or the cerebellopontine angle. We do, however, see significant left mastoiditis and edema, which involves not only the mastoid air cells but the middle ear structures as well.

Today's examination also suggests two small white matter areas of demyelination on the FLAIR images in the gray-white matter junction of the right cerebral hemisphere involving the parietooccipital region, behind the posterior horn of the lateral ventricle and one in the superior aspect of the right parietal region. Both of these measure about 3 to 6 mm and do not enhance. These are most likely areas of demyelination and small vessel insult.

There is no abnormal enhancement noted, not only in the cerebellopontine angle and IAC regions but throughout the remainder of the head. Images through the whole head were also performed and do not show suspicious change.

There is a mild and diffuse amount of atrophy noted on the exam. Some mild enlargement of the ventricles is also seen, but it is quite minimal. The craniocervical junction on the lateral sagittal images is intact and does not present with a Chiari malformation.

IMPRESSION:
1. There is no evidence of a tumor, which enhances or nonenhancing in the internal auditory canal or cerebellopontine angle bilaterally.
2. No abnormal enhancement is noted throughout the exam.
3. There is abnormal presumed mucosal inflammation and edema suggested in the left mastoid air cells and including the left middle ear cavity suggestive of significant inflammation.
4. Two small areas of demyelination suggested in the right gray-white matter junction region of the superior parietal and then the parietooccipital region. These are most likely very small vessel insults. Again, they do not enhance.

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Lumbar Spine MRI Medical Transcription Sample

Routine images revealed the vertebral bodies to be of normal height and contour. No evidence of compression fractures or definite lytic or blastic change is seen.

At L5-S1, there is a very minimal bulge. There is some disk space narrowing. No significant neural foraminal or spinal canal disease is noted.

At L4-5, there is significant degenerative hypertrophy of the facets. Each of the synovial joint is filled with fluid and is hypertrophied. In addition, there is ligamentum flavum hypertrophy. More significantly is an area of soft tissue and probable degenerative cyst anterior to the right facet, which narrows the right recess and significantly narrows the right neural foramen and could easily affect the right crossing nerve root. The left neural foramen is also narrowed by this disease. It is most likely that this bilateral degenerative change of the facet joints and the accompanying probable cyst anterior, on the right, is accounting for the right radicular symptoms. Because there is a very small amount of isointense material seen near the area of the presumed facet cyst, it may be worthwhile to either follow this up in the future with a repeat MRI, perhaps with contrast and fat saturation, to make sure this area does not enhance, although felt unlikely to represent metastasis. This small area is not definitely all related to the degenerative process but may involve some granulation tissue due to chronic irritation or perhaps other disease.

At L3-4, there is a very mild left recess disk bulge. It produces only minimal narrowing of the inferior neural foramen. No spinal canal encroachment is noted. The right neural foramen is not significantly affected.

At L2-3, again, there is a very mild bulge to the left, and again, the right neural foramen appears widely patent.

IMPRESSION:
1. At L4-5, we see bilateral neural foraminal narrowing but particularly on the right. This is due to the presence of a very mild disk bulge but more importantly due to significant facet hypertrophy and synovial fluid irritation within the facet joint itself and suggesting a small degenerative cyst directly of the synovium on the right. This produces posterior compression in the right recess area in addition to the mild disk bulge and would definitely affect the right crossing nerve root.
2. In the area that is believed most likely to represent a small degenerative cyst, presenting anterior to the right facet at L4-5, is a small area of isointense signal to bone. This is also isointense to soft tissue. Most likely, this is an area of bony granulation or degenerative change related to the facet degenerative change. However, as it is not of either high fluid signal or of definite cortical bone, I would recommend that this area be followed either by MRI or other modality in the future. This L4-5 level does present with a relative trilateral stenosis due to the disk and predominantly the facet degenerative changes just described. A mild element of ligamentum hypertrophy is also present.
3. There is mild left-sided narrowing of the inferior aspect of the neural foramen by bulges of the disk to the left at both L3-4 and L2-3. This is not felt significant in nature.
4. No definite metastases are seen to the vertebral bodies on this exam.

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Elbow MRI Medical Transcription Sample Report

RIGHT ELBOW MRI

DATE OF STUDY:  MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

INDICATIONS:  Trauma.  Unable to extend elbow.  Rule out tendon injury.

TECHNIQUE AND FINDINGS: These images are not optimal as the patient was in too much pain to lie still through the exam and was not able to extend arm or rotate appropriately. Some distinct findings can be described however.

There is high signal and either degenerative cystic changes through the proximal olecranon or incomplete fractures noted, which are directly opposite the trochlea. Near the medial epicondyle is some bony high signal debris indicating what may be some loose joint bodies in this trochlear ulnar joint space.

There is increased fluid in the radiocapitellar joint space. There is some degenerative flattening of the capitellum and very small cyst.

Just below the radial head of the proximal radius is a focal area of high signal. This would suggest either a contusion or a partial or incomplete fracture. No definite fracture line is noted on this exam to say that with certainty, and therefore, I would tend toward believing this is a bony contusion.

There is an old fracture of the coronoid process of the ulna, most likely related to a prominent spur. This does not displace significantly.

The biceps tendon and brachioradialis muscle and tendon are grossly intact. There is a very small amount of edema suggested of the brachioradialis muscle, directly adjacent to the capitellum, which may indicate a very small contusion or partial tear.

There is also some signal in the area of the ulnar nerve directly adjacent to the olecranon, which could indicate some inflammation or radicular change. Although there is some DJD noted of these bony structures, I do not see significant bony compromise of this area. The changes appear to be possibly due to trauma, as there is somewhat high signal indicating inflammation.

It is also noted that there is high signal in the superficial fatty tissues, particularly near the medial epicondyle area.

IMPRESSION:
1. There are some overall degenerative changes noted of the joint space, which may worsen any findings related to the recent trauma. There is some probable loose joint body between the trochlea and ulna in that more lateral trochlear ulnar joint space. The area of the proximal olecranon does suggest some focal high signal within it without displacement. This could be degenerative cyst or an incomplete fracture.
2. Mild flattening of the capitellum is noted and small subchondral cyst seen indicating some chronic degenerative change. Joint space fluid is noted at the radiocapitellar joint space. No radial head fracture is seen. However, there is some probable contusion of the proximal radius just distal to the radial head. This could represent an incomplete fracture but that is felt less likely.
3. The biceps tendon appears intact.
4. Very small strain of the brachioradialis muscle near the lateral epicondyle is suggested, may indicate a very small partial tear.
5. Some inflammation in the area of the ulnar nerve is noted, which could indicate some injury to this area.

MRI OF THE RIGHT ELBOW

DATE OF STUDY:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

INDICATION FOR STUDY:  Evaluated biceps tendon.  Lifting injury.

TECHNIQUE AND FINDINGS: Multiplanar images of the right elbow were obtained without contrast.  Marrow signal within the bony structures is unremarkable.  There is no obvious fracture or dislocation.  There is no edema.  The biceps tendon is intact.  There are no large fluid collections.  Muscle bundles are preserved.  The tendons appear grossly unremarkable.

IMPRESSION:  Unremarkable MRI of the right elbow.

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Wrist and Hand MRI Medical Transcription Sample Report

Coronal and axial images were taken using different types of imaging sequencing.

There is no definite bone fracture noted. No focal edema noted, which is persistent. There is a very small amount of degenerative spurring seen at the distal end of the scaphoid but no definite scaphoid or navicular neck fracture is noted, nor is there edema or fractures noted elsewhere. No definite tendon rupture is seen.

The triangular fibrocartilage is intact. No significant joint effusion is noted within the wrist or at the radiocarpal regions.

There is a questionable injury to the area of the radioscaphoid interosseous ligament, which is not definitely visualized on this exam. Also, there is some small edema involving the lateral wrist, which would be approximately in the area of the extensor pollicis brevis location. It does not appear to be a complete tendon tear on this exam, but there could be some injury to that area. The greater and lesser multangulars and the first metacarpal bones are all intact. No chip fracture or definite joint effusion is seen in that area as well.

IMPRESSION:
1. Very small spurring is suggested of the distal end of the scaphoid but no evidence of a definite scaphoid or other bony fracture is noted.
2. Triangular fibrocartilage is intact.
3. Complete visualization of the radioscaphoid interosseous ligament is not seen on this exam and could indicate that this has been partially torn or injured. Also, a small amount of edema is suggested on the radial aspect of the wrist in the area of the expected extensor pollicis brevis tendon. I do not see evidence to suggest a complete tendon tear however.

RIGHT WRIST MRI WITHOUT CONTRAST

DATE OF STUDY:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

INDICATION FOR STUDY:  Evaluate right osteochondroma.

TECHNIQUE AND FINDINGS:  Routine imaging through the distal forearm and wrist was performed without contrast.

There is a focal bony protrusion extending from the distal radius in the volar and radial direction.  It would be consistent with a benign osteochondroma.  The margins are well defined and the substance is equal in signal intensity to the bone matrix of the distal radius.  It extends up to about 1.4 cm from the radius.  It extends out to the flexor carpi radialis and palmaris longus tendons.

On the coronal images, it projects and divides the flexor carpi radialis tendon to the radial aspect of this bony protuberance and the flexor digitorum superficialis tendon to the ulnar aspect.  It divides these tendons, which surround it in their longitudinal course.

We see no tears or indications of tendinitis.  There is a very small amount of edema suggested around the very tip of this osteochondroma.  Other etiologies of this lesion could be an exostosis, though felt less likely.

It does appear to present in a way that tug lesions appear in other parts of the body, but we do not see any attached tendons to suggest that etiology as well.  Most likely, it is a benign osteochondroma.

The remaining aspects of the radius are intact.  We see no lytic or blastic changes to the radius or the ulna.  This small bony protuberance does extend just under the skin and flexor carpi radialis tendon surface.

IMPRESSION:
1.  There is an approximately 1.4 cm bony extension from the distal radius oriented to the volar and radial aspect of the distal forearm.  This extends up to the flexor carpi radialis tendon and appears to divide it from the flexor digitorum superficialis tendon, projecting between these two structures.  A small amount of edema is suggested near the tip of this bony protuberance.  It is otherwise unremarkable in its signal intensity when compared to the remaining radius and bony structures.  The cortex is well maintained with some indistinctness directly at the tip beneath the tendon.
2.  No evidence of tendon rupture or tendinitis is noted.  There is no aggressive component noted to this bony irregularity.
3.  No other remarkable findings are seen.

MRI OF THE RIGHT WRIST

INDICATIONS FOR STUDY:  Fell on outstretched arm.  Evaluated for navicular fracture, radial side pain.

TECHNIQUE AND FINDINGS:  Multiplanar images were obtained without contrast.  In the distal radius, there is a large area of low attenuation on T1 that is high signal on STIR sequences suggestive of a bone bruise/contusion.  There is suggestion of a microfracture along the dorsal aspect of the distal radius on the sagittal images.  There may possibly be some minimal intra-articular involvement.  There is no displacement of fracture fragment.

There is a 5 mm area of low attenuation in the lunate that is round and is along the surface abutting the radius.  This may be a small cyst.  Alternatively, it could represent some focal contusion.

There is another area, 5 mm, in the base of the scaphoid that could be a cyst as it is low signal on T1 and high signal on STIR sequences.  Alternatively, this could be minimal contusion.

However, both of these lesions in the carpal bones are rather round and are more suggestive of cystic-type change.  There is no large fluid collection.

The scaphoid is intact and unremarkable.  Muscle bundles appear preserved.  Tendons are grossly unremarkable.

IMPRESSION:
1.  Large area of edema in the distal radius suggestive of contusion.  There is suggestion of some microfractures as there is a linear line along the dorsal aspect of the distal radius on the sagittal images.  This line may possibly involve the articular surface.  This is difficult to completely identify with certainty.  On the coronal images, the break in the cortex may be along the radial aspect of the distal radius.  Followup plain films may be of value to determine if there is callus formation.
2.  There are a couple of cystic areas in the scaphoid and lunate that probably represents cysts.  These less likely represent focal areas of contusion or edema.
3.  No large fluid collection.  Muscle bundles and tendons are grossly unremarkable.

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Urology Medical Transcription Consultation Sample

DATE OF CONSULTATION: XX/XX/XXXX

CONSULTING PHYSICIAN: John Doe, MD

REFERRING PHYSICIAN:  Jane Doe, MD

REASON FOR CONSULTATION: Hematuria.

BRIEF HISTORY: This is a (XX)-year-old male admitted now with chest pains. He has a history of hypertension and recurring chest pains. When I spoke with him, he says for at least 6 months, he has been bothered by a right-sided flank pain as well as microscopic hematuria. He denies any history of kidney stones, denies nocturia, denies urinary incontinence, denies nausea or vomiting, denies fevers.

PAST MEDICAL HISTORY: Hypertension and possible cardiac problems.

PAST SURGICAL HISTORY: Denied.

MEDICATIONS: He takes no medication on a daily basis.

ALLERGIES: UNKNOWN.

SOCIAL HISTORY: He is divorced. He does not smoke or drink.

FAMILY HISTORY: He says he has a son with kidney problems.

REVIEW OF SYSTEMS: Constitutional: No fevers. No weight loss. Cardiac: He was admitted with chest pains. Presently, he says he is not having any chest pains. Pulmonary: No cough or hemoptysis. Gastrointestinal: No nocturia. Positive for intermittent gross hematuria, right flank pain.

PHYSICAL EXAMINATION: General: Pleasant, middle-aged gentleman who is lying quietly in bed. Vital Signs: Temperature is 97.2, pulse is 58 and regular and blood pressure is 112/72. HEENT: Atraumatic and normocephalic. Extraocular muscles are intact. Sclerae are anicteric. Neck: Trachea midline, 2+ carotids, no bruits. Cardiac: Regular rate and rhythm. Chest: Both lung fields clear. Abdomen: Soft and nontender. There are no masses noted. Normoactive bowel sounds. Genitourinary: The bladder is not palpably distended. He complains of mild tenderness on percussion of the right flank. The phallus is a normal-appearing phallus. The foreskin retracts easily. Urethral meatus, normal caliber, normally placed. No lesions are noted. Scrotum, testes descended bilaterally, palpably normal. Digital rectal exam, no masses in the rectal vault. Prostate is about 25-30 grams. It is smooth and nontender. There is no blood on the gloved finger. Extremities: Full range of motion. No calf tenderness. No clubbing, cyanosis or edema is noted.

IMPRESSION: The patient is a (XX)-year-old gentleman with right flank pain, intermittent gross hematuria. No history of tobacco use. He needs a full hematuria workup.

PLAN:
1. CT scan of the abdomen and pelvis with and without contrast.
2. Urine cytology.

Neurology Medical Transcription Consult Sample Report

DATE OF CONSULTATION:  XX/XX/XXXX

CONSULTANT:  John Doe, MD

REFERRING PHYSICIAN:  Jane Doe, MD

HISTORY OF PRESENT ILLNESS:  This (XX)-year-old female was admitted to the hospital last night for speech difficulties. Her husband reported that they were traveling. Her husband noted that she was not acting right for about 2 hours. She was unable to talk clearly and seemed to be confused. There was no complete loss of consciousness or any tonic-clonic seizure activity. There was no nausea or vomiting. No focal neurological symptoms reported. She was brought to the emergency room. Blood pressure was 225/115 with pulse 78 per minute.

CT of the head without contrast was reported as negative for any acute focal lesions. The patient was admitted for further management and started on heparin drip. This morning, she was still unable to give any history.

PAST MEDICAL HISTORY:
1.  Hypertension.
2.  Cardiac disease.
3.  History of shingles.
4.  No history of any transient ischemic attack, cerebrovascular accident or seizures.

MEDICATIONS:
1.  Vasotec.
2.  Zocor.
3.  Protonix.

ALLERGIES: SHE HAS NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY: No history of any smoking or alcohol abuse.

FAMILY HISTORY: Noncontributory.

PHYSICAL EXAMINATION: General: The patient is a well-built, elderly female, not in acute distress. Vital Signs: As noted on the chart. HEENT: Examination unremarkable. Neck: Supple. No signs of meningeal irritation. No carotid bruit. Heart: S1 and S2 normal. No murmur, gallop or rub. Lungs: Clear. Neurologic: She is alert but she has expressive and sensory aphasia. She does not follow commands appropriately. She tries to utter words. At times, a few words are intelligible. Naming and repetition is impaired. Pupils are 3 mm, round and reactive to light. Extraocular movements appear to be full. No nystagmus. Mild right facial weakness noted, but facial movements could not be evaluated as the patient is unable to follow commands. Motor examination reveals normal muscle bulk and tone. She appeared to be moving all extremities spontaneously; however, on examination, there is mild weakness on the right side. Strength is probably 4/5 on the right. Sensory examination could not be evaluated accurately. Generalized hyporeflexia. Plantar response is upgoing on the right, downgoing on the left. Rest of the neurological examination could not be performed.

LABORATORY DATA: On admission, WBC 6100, H and H 14.2 and 44.4 and platelets 226,000. Baseline PT and PTT were normal. Chemistry profile showed sodium 135 and glucose 196. On admission, BUN was 25 and creatinine was 1.2. Liver profile was normal. Lipase was elevated at 509.

CT of the head without contrast is as discussed above.

IMPRESSION:
1. Aphasia, expressive and also sensory component, possible mild right hemiparesis, most likely suggestive of left hemispheric cerebrovascular accident, carotid artery disease versus cardioembolic.
2. Hypertension and diabetes risk factors.

RECOMMENDATIONS: I agree with present workup and management. Repeat CT of the head without contrast tomorrow. Carotid Dopplers and echocardiograms were ordered. We will continue to monitor the patient closely.

Thank you, Dr. Doe, for the consult. I will follow the case with you.

Gastroenterology Consultation MT Sample Report            Neuro Critical Care Consultation Sample Report

Neuropsychology Consultation MT Sample Report            Hematology / Oncology Consult Sample

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Vaginal Hysterectomy Cystocele Rectocele Repair Sample

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1. Uterine prolapse.
2. Cystocele.
3. Rectocele.

POSTOPERATIVE DIAGNOSES:
1. Uterine prolapse.
2. Cystocele.
3. Rectocele.

OPERATIONS PERFORMED:
1. Vaginal hysterectomy.
2. Cystocele and rectocele repair.

SURGEON: Jane Doe, MD

ANESTHESIA: General.

TECHNIQUE: As soon as adequate general anesthesia was administered, the patient was put in dorsal lithotomy position and the perineal and lower abdominal area were prepped and draped. The labial folds were stitched out of the way and a heavyweight posterior vaginal speculum was inserted. Lahey clamps were placed in the anterior and posterior lips of the cervix and the cervix was drawn anteriorly. Diluted solution of Marcaine with epinephrine was injected into the upper part of the cervix along the mucocutaneous junction for hemostasis and also for hydrodissection. Circumferential incision was then made above the cervix and the anterior and posterior vaginal mucosa. The cul-de-sac was then entered, and the uterosacral ligaments on either side were clamped, divided and ligated.

The anterior vaginal mucosa was then dissected fully, anteriorly. The space between the vagina and bladder was entered. A small retractor was placed underneath the bladder, and the lower part of the cardinal ligaments on either side were clamped, divided and ligated. Then, the upper parts of the cardinal ligaments were clamped, divided and ligated. The uterine vessels on either side were clamped, divided and ligated. The proximal ends of the mesosalpinx and the mesovarian on either side were clamped, divided and doubly ligated. The uterus was then removed, and the peritoneum was closed by running pursestring suture of chromic #2-0 starting from the anterior parietal peritoneum, going to the sides, running it posteriorly, going to the sides again, and tying it anteriorly. This closed the pelvic peritoneum.

The cystocele was then repaired by pulling down on the anterior vaginal mucosa. A superficial vertical incision was made along the anterior vaginal mucosa. The bladder was then sharply separated from the vaginal mucosa until the endopelvic fascia was reached and the base of the bladder was reached. At this point, Dr. John Doe came to do sling bladder suspension.

After he tied all the sutures, I then imbricated the posterior cystocele bulge with interrupted sutures of #2-0 chromic material and excess vaginal mucosa was removed, and the anterior vaginal mucosa was approximated in the midline with interrupted sutures of #1 chromic suture material.

The rectocele was then repaired by making an incision across the introitus. Then, tunneling and cutting into the posterior vaginal mucosa was done until the apex of the rectocele bulge was reached. At this point, the rectum was separated from the posterior vaginal mucosa, and the rectal bulge imbricated in the midline with interrupted sutures of #2-0 chromic material. Levator ani muscles on either side were approximated in the midline with interrupted Vicryl #1. Excess posterior vaginal mucosa was excised, and the vaginal episiotomy was repaired by approximating the posterior vaginal mucosa with interrupted sutures of Vicryl #0 suture material. Packing was left in the vaginal canal, and an indwelling Foley catheter was left in place. Estimated blood loss was about 300 mL. The patient tolerated the procedure well. A suprapubic tube and an indwelling Foley catheter were left in place.

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Cervical dysplasia, persistent, status post cold knife cone.

POSTOPERATIVE DIAGNOSIS:  Cervical dysplasia, persistent, status post cold knife cone.

OPERATION PERFORMED:  Total vaginal hysterectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

SPECIMEN:  Uterus and cervix.

ESTIMATED BLOOD LOSS:  300 mL.

FINDINGS:  Examination under anesthesia was within normal limits. Cervix was poorly visualized secondary to previous cold knife cone.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room where general anesthesia was administered. She was prepped and draped and placed in dorsal lithotomy position for vaginal hysterectomy. The bladder was partially emptied. The cervix was grasped with tenaculum both anteriorly and posteriorly, and delineation of the cervix was made digitally given poor visualization. At this point in time, 5 mL of Pitressin 20:20 was injected, and the scalpel was used to make a circumferential incision. Afterwards, the anterior portion of the cervical fascia was pushed cephalad, and the anterior perineum was entered without difficulty. Posteriorly, Mayo scissors were used to enter the posterior perineum and a suture was used to tag this. At this point in time, Heaney clamps were used to grasp the uterosacral ligaments. These were cut, followed by suture ligature. Another set of clamps were used to grasp the uterine vessels and two more clamps were used until the uteroovarian ligaments were able to be grasped with double Heaney clamps, cut, followed by free tie and suture ligature.  At this point in time, evaluation of the vesical pedicles confirmed hemostasis. There was bleeding noted along the right lateral wall, which was made hemostatic with a figure-of-eight. The perineum was then identified and tied in a pursestring closure. Identification of the uterosacral ligaments was made and extra reinforcing sutures were placed and were approximated together. At this point in time, no bleeding was noted along the vaginal cuff end. The vaginal cuff was approximated with interrupted sutures transversely. There was no bleeding noted at the end of the case. Foley catheter was inserted with clear urine, and the vagina was packed with Estrace vaginal cream. The patient tolerated the procedure well without complications. She was transferred to recovery in stable condition. All counts were correct. Repeat CBC tonight and in the a.m. will be performed.

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Miscellaneous Terms For Medical Transcriptionists

0.045 K-wire

0.12 forceps and Westcott scissors

21-French cystoscope

Allen forceps

AM-35 drill bit

ArthroCare

Betadine-impregnated Vi-Drape

bone mill

Caspar distraction

Chelsea-Eaton

Cholangiocath

chromotubation

ConstaVac

constrained polyethylene liner

continuous bladder irrigation (CBI)

cortical apposition

cricoid

curved stylette

decidual tissue

delta wing keel

DePuy cement

dilators and sleeves

dobutamine dual isotope

Dorsey irrigator

double gloves and total exhaust suits

Duraloc

end-colostomy

Endoclip

Endoloops

environment laminar flow suite

erysipelas-type reaction

floor of prostatic urethra

fluted guide rod

fundal pressure

Gore-Tex graft

graded Hegar

Hasson trocar

hepatocystic triangle

Iglesias electrotome

image intensifier

instrumental examination, prophylaxis fluoride treatment

Interceed

iodine-impregnated surgical drape

kocherized

laminar flow room

LigaSure

lug holes

mallet blows

Maxitrol ointment, patch and shield

microdrop of Dermabond

Morse taper stem

nasooropharynx suctioned with the bulb syringe

NeoProbe

nitrous oxide, oxygen and halothane induction

Novofil

NuBlade

Optiview

Ortho-T product

peristalsing

piperacillin and piperacillin/tazobactam

pool-sucker

posterior lumbar interbody fusion procedure (PLIF)

posts were drilled

powder-free sterile gloves

Pratt dilators

Rainbow retractors

Reston foam

sacral ala

SCD hose

Seprafilm

Skeeter drill

SonoSurg

sports bra

stasis ulcer

steal syndrome

sternal dynamics

Stryker scope

supernatant fat

T-handle chuck

thimble

Tisseel

tumescent solution

valsalved

Verbrugge

white line of Toldt

Williams frame table

Alternative Medicine Words for Medical Transcriptionists

Here are a few alternative medicine terms you wouldn't find in your normal drug references,

acidophilus
aloe vera
aniseed
Australian tea tree oil
benzoin
bioflavonoids
black cohosh
blackberry
blue cohosh
boric acid
cactus
calcium
cat's claw bark
cayenne
chicory
cinnamon
clove
cod liver oil
coenzyme Q10 or CoQ10
colloidal silver
coriander
cranberry
fennel
fish oil
flaxseed oil
folic acid
garlic
gentian root
ginger
Ginkgo biloba
ginseng
glucosamine sulfate
green tea
hawthorn
homocysteine
iron
juniper oil
kava kava
lactobacillus
L-arginine
L-carnitine
lemongrass
L-lysine
magnesium
malic acid
mannitol
melatonin
milk thistle
motherwort
mugwort
neti pot
nutmeg
omega-3
omega-6
oregano
patchouli
phosphorus
potassium
psyllium
raspberry
red clover
rosemary
safflower
saffron
sage
saw palmetto
selenium
senna
sodium
tea tree oil
turmeric
yoga
zinc
zinc lozenges