Total Abdominal Hysterectomy RSO MT Sample Report

DATE OF OPERATION:  MM/DD/YYYY

SURGEON:  John Doe, MD

COMPLICATIONS: None.

DESCRIPTION OF OPERATION: The patient was taken to the operating room with IV running and transferred to the operating table, where she was placed in the dorsal supine position. General anesthesia was given. She was prepped and draped in the normal sterile fashion. The initial skin incision was made with a scalpel and carried down to the underlying layer of fascia. The fascia was incised in the midline. There were dense adhesions in the subcutaneous tissue. The fascia was then extended with the curved Mayo scissors. The superior aspect of the incision was grasped with Kocher clamps, elevated and the underlying rectus muscle was dissected off both bluntly and sharply.

Attention was turned to the inferior aspect of the incision, which in a similar fashion was grasped with Kocher clamps, elevated and underlying rectus muscle was dissected off both bluntly and sharply. The peritoneum was identified and entered bluntly and peritoneal incision extended inferiorly and superiorly with good visualization of the bladder. On examination of the pelvis, there was noted to be filmy adhesions surrounding the uterus, as well as dense bowel adhesions to the peritoneal wall. Prior to placing a retractor, the bowel was taken off the left lateral peritoneal wall.

Once this was safely taken down, the Bookwalter retractor was placed without difficulty. The bowel was packed away with moist laparotomy sponges, and on examination of the pelvis, the uterus could be visualized and was adhesed to the anterior peritoneal wall. These adhesions in the bladder were taken down sharply with Metzenbaum scissors. The uterus was clamped bilaterally with Kocher clamps for manipulation at the cornua. The round ligament was then transected, suture ligated on the left side. This was done in a similar fashion on the right side. Both ovaries were noted to be fairly well adhered to the peritoneal wall; therefore, decision was made to proceed with total abdominal hysterectomy and evaluate the ovaries for potential removal.

A window was made in the broad ligament and the tubo-ovarian ligaments were doubly clamped and suture ligated with 0 Vicryl suture bilaterally. Hemostasis was visualized. The uterine arteries were skeletonized bilaterally, clamped with Zeppelin clamps and suture ligated. Again, hemostasis was assured. The uterosacral ligaments were clamped on both sides, transected and suture ligated in similar fashion. The cervix and uterus were then amputated with the Jorgensen scissors. Vaginal cuff angles were closed with figure-of-eight 0 Vicryl suture and the remainder of the vaginal cuff was then closed with a series of interrupted 0 Vicryl sutures. Hemostasis was assured.

Attention was then turned to the ovaries. The right ovary was noted to have a cyst, which ruptured revealing clear cystic fluid on manipulation. The ureter was palpated and the IP ligament was then clamped and transected and the ovarian tissue on the right side was removed and sent to Pathology. The left ovary was then visualized and the left ureter palpated. However, the left ovary was noted to be very adherent to the peritoneal cavity and bowel, and due to the anticipated potential blood loss and complications to bowel, the decision was made to leave this ovary in place. The pelvis was then copiously irrigated. There was noted to be a small amount of bleeding at the site of the round ligament. Then, 2-0 Vicryl sutures was placed. Hemostasis was obtained. There was also noted to be a small amount of bleeding at the posterior cuff, which also was made hemostatic with 2-0 Vicryl suture.

All instruments were then removed. Seprafilm was placed to prevent further adhesions. All sponges, laps and needles were removed. The fascia was then reapproximated with 0 Vicryl suture, beginning at both sides and meeting at the midline. Subcutaneous tissue was reapproximated with 3-0 Vicryl suture and staples were placed as well as a sterile dressing. The patient tolerated the procedure well and was transferred to the recovery room in stable condition without complications.

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Left Heart Catheterization Medical Transcription Procedure Sample

DESCRIPTION OF PROCEDURE: Informed consent was obtained from the patient prior to the procedure. The patient was prepped and draped in the usual sterile fashion. The right groin was anesthetized with 2% lidocaine. A 6 French sheath was introduced in the right femoral artery via modified Seldinger technique. A 6 French angled pigtail was used for left ventriculography and aortic valve pullback, and 6 French JL4 and JR4 catheters were used for selective coronary angiography. Multiple views were obtained.

FINDINGS: The coronary circulation was right dominant.

Left main artery: The vessel was long and large in caliber with minimal 10-20% narrowing.

Left anterior descending artery: The vessel was long and coursed in the interventricular groove towards the apex. The proximal vessel had a previously placed stent with 40-50% diffuse in-stent re-stenosis, which did not appear to be flow-limiting and was unchanged from the prior angiogram. Beyond the stent was an area of tortuosity followed by the mid vessel, which had a previous stent which was widely patent. Beyond the stent, in the later portion of the mid vessel, was an area of ectasia which was unchanged from the prior angiogram. The second diagonal branch arose from this area and had a 40-50% narrowing in its mid portion, which was unchanged from the prior angiogram. The distal portion of the left anterior descending in its course toward the apex had mild diffuse nonobstructive disease.

Left circumflex artery: The vessel had a previously placed stent in the mid vessel, which was widely patent. The second obtuse marginal branch was a medium to large caliber vessel which had 30% narrowing at its ostium and a focal 40-50% narrowing in the mid to distal portion, which was unchanged from the prior angiogram.

The third obtuse marginal branch had 30% diffuse narrowing.

Right coronary artery: The previously placed stent in the proximal and middle vessel had 20-30% diffuse mild in-stent re-stenosis. The distal vessel had 40-50% diffuse disease with a previously placed stent in the distal vessel widely patent. This was unchanged from the prior angiogram. An acute marginal branch arose from the mid vessel with an ostial 90% stenosis. This was a small caliber vessel, which was unchanged from the prior angiogram.

Left ventricle: Ejection fraction 65%. There were no wall motion abnormalities, mitral regurgitation, or aortic valve gradient. The left ventricular end diastolic pressure was 12.

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Direct Laryngoscopy Flexible Bronchoscopy Sample Report

DATE OF OPERATION:  MM/DD/YYYY

SURGEON:  John Doe, MD

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in supine position on the operating table. General anesthesia was induced and the patient was ventilated through an already intact tracheostomy tube.

Anterior commissure laryngoscope was first utilized. The patient was found to have a large amount of redundant soft tissue but no discrete mass or lesion in the oropharynx or hypopharynx. The large amount of soft tissue included lingual tonsillar hypertrophy, a large amount of postcricoid edema consistent with gastroesophageal reflux disease. True vocal folds showed a mild to moderate amount of Reinke's edema. There was a small amount of resolving ecchymosis along the posterior aspect of the right true vocal fold at the vocal process. No other significant trauma visible to the larynx.

Next, the bronchoscope was passed through the patient's oral cavity and through the true vocal folds. The immediate subglottis was visualized along with the entrance of the tracheostomy tube, which was seen to be well positioned within the trachea. There was no visible fixed obstruction at this level. At this point, the #6 extended length Shiley was removed and a #5 uncuffed extended length Shiley was placed into the already intact tracheotomy. Under visualization with the bronchoscope, it was seen to extend well into the trachea with good positioning. The bronchoscope and laryngoscope were then removed.

The bronchoscope was then placed through the tracheostomy tube and the trachea was visualized down to the larynx. There seemed to be no tracheomalacia and no masses or lesions down to the level of the carina. The new tracheostomy tube was then secured to the patient's neck and the patient was then awakened and taken to the postanesthesia care unit in stable condition.

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Level III Selective Neck Dissection Medical Transcription Example Report

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in supine position on the operating room table. General anesthesia was then induced and the patient was intubated without complication. The patient was prepped and draped and pressure points were checked for right selective neck dissection. A hockey-stick incision was fashioned over the right side of the neck, after 6 mL of 2% lidocaine with 1:100,000 epinephrine was injected into an area overlying the natural skin crease. Subplatysmal flaps were elevated after the skin incision was made in a superior and inferior direction. Dissection was first performed along the anterior aspect of the sternocleidomastoid muscles. The fascia over this was grasped and, using Bovie electrocautery, this was dissected off the anterior and medial portion of the muscle reflecting the fascia and fat anteriorly. More superiorly, the spinal accessory nerve was identified and was seen to be superior to the area of dissection and this nerve was preserved. Dissection was carried further, inferiorly, until the cervical roots were identified. The dissection was carried over the cervical root, taking the fat, fascia, and lymph nodes in the level III, and reflecting them anteriorly. This was done anteriorly until the carotid artery was identified and preserved. At this point, attention was then turned to the superior aspect of the planned excision. Dissection was taken along the right submandibular gland, which was noted to be ptotic. The marginal mandibular nerve was identified and preserved. Dissection was carried more inferiorly until the digastric muscles were identified. This was reflected superiorly and the lingual nerve was identified and it was seen to be out of harm's way and left superiorly, and the fat and fascia was dissected and reflected inferiorly to go with the specimen. The hypoglossal nerve was traced posteriorly until the jugular vein was identified and this was preserved. Attention was then paid inferiorly. Dissection over the omohyoid muscle with reflection of fat, fascia, and lymph nodes superiorly revealed deep to the omohyoid muscle the inferior aspect of the jugular vein; this was identified and preserved. Attention was again paid to the deep aspect of the neck over the scalene muscles. The fat and fascia in this area along with the lymph nodes was reflected anteriorly with the specimen. This was dissected off the carotid artery and then the jugular vein, preserving all branches. The face nerve was also identified and preserved. Further dissection anteriorly freed the specimen entirely and that was then sent to for examination to rule out lymphoma. The patient's neck was then copiously irrigated with sterile salines. Small bleeding points were controlled using bipolar electrocautery. A #15 drain was placed through stab incision in the right aspect of the neck and hooked up to bulb suction. The platysmal layer was reapproximated using 4-0 Vicryl in a simple interrupted fashion and the skin was reapproximated using a single running Prolene 4-0. Steri-Strips were placed. Tegaderm and Telfa were placed over the patient's wound and the patient was then awoken, extubated, and taken to postanesthesia care unit.

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Right Shoulder Hemiarthroplasty Medical Transcription Operative Sample Report

DESCRIPTION OF OPERATION: The patient was taken to the operating room, and after a scalene block was administered by the anesthesia team, the patient was positioned on the operating room table in a beach-chair position. Preoperative antibiotics were given. The right shoulder was prescrubbed with Betadine. Next, the right upper extremity, including the right base of the neck and shoulder, were prepped and draped in the usual sterile fashion. After bony palpation, a longitudinal skin incision was made over the anterior aspect of the right shoulder. The subcutaneous tissue was dissected and hemostasis was obtained with electrocautery. Dissection was carried down to the deltopectoral interval. The cephalic vein was identified, protected, and preserved throughout the case. A deep retractor was placed between the deltoid and pectoralis major to help with deep exposure. The clavipectoral fascia was then incised. Upon doing this, large gelatinous material was expressed from the joint as well as the biceps tendon and this was removed with suction. This was characteristic of rheumatoid arthritis. The tissue quality about the rotator cuff as well as the surrounding musculature was friable and diseased due to her rheumatoid arthritis. The subscapularis was then split leaving a 1 cm cuff. The medial edge was tagged with #2 FiberWire in a Mason-Allen fashion. This was used for repair at the end of the case. Humeral head was identified and had pannus covering as well as significant degenerative changes. The proximal humeral cut was then performed with an oscillating saw at 20 degrees of retroversion. This was sized and removed and sent to Pathology for further evaluation. The glenoid was then exposed and a complete labrectomy was performed. Significant erosive changes were seen throughout with no evidence of articular surface. With further inspection and manual palpation, it was felt that there was good contour with central wear. Because of this, it was felt that no formal glenoid plasty need be performed. With the deficient rotator cuff identified more proximally as well as posteriorly, it was felt that no formal glenoid component would be replaced. Attention was then returned back to the proximal humerus. This was reamed and broached to accommodate an 8 mm stem. Due to the patient's soft bone, it was felt that this would be cemented. The cement plug was placed and an 8 mm Mini Biomet stem was then cemented into place. After sizing, it was felt that extended articular surface head would be used to help articulate with the acromion. A 44 x 17 was trialed which demonstrated 50-50% of anterior-posterior translation, as well as 30% inferior translation. This was then tapped into position. The shoulder was reduced and liberally irrigated with bacitracin solution under power irrigation. The rest of the synovium was resected with Metzenbaum and Mayo scissors. The subscapularis was then repaired with #2 FiberWire. The shoulder could easily be externally rotated to 90 degrees and forward flexed to 180 degrees with no stress on the subscapularis repair. The wound was again liberally irrigated with bacitracin solution. Hemostasis was meticulously obtained with electrocautery. The deltopectoral interval was closed with 0 Vicryl in a simple interrupted fashion. The subcutaneous tissue was closed with 2-0 Vicryl in a simple interrupted fashion and skin was closed with 4-0 Monocryl in a running subcuticular pull-out stitch. All sponge and instrument counts proved to be correct and estimated blood loss was 250 mL. The wound was then cleaned and Steri-Stripped and dressed under the sterile field. A Polar Care ice machine and a shoulder immobilizer was placed to the right upper extremity. The patient was taken to the recovery room in a stable condition.

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Shoulder Arthroscopic Labral Repair Transcribed Operative Example

DESCRIPTION OF OPERATION: The patient was taken to the operating room, and after scalene block was administered by the anesthesia team, the patient was positioned on the operating room table in a sitting position. Preoperative antibiotics were given. The left shoulder was prescrubbed with Betadine. Next, the left upper extremity, including the left base of the neck and shoulder, were prepped and draped in the usual sterile fashion. After bony palpation, a posterior portal was created with a 15 scalpel blade and this was used for the arthroscope. The arthroscope was placed and a complete inventory of the left shoulder was performed. Under direct visualization, anterior-superior portal was created in a similar fashion and this was used for instrumentation and outflow. The superior labrum including the biceps anchor demonstrated no evidence of tears. There was a tear of the anterior-superior labrum starting at the 11 o'clock position and extending to the 9 o'clock position. There was significant fraying, which was debrided with the radiofrequency device and further demonstration of the personality of the tear demonstrated a complete tear off the glenoid rim. Irregularities of the glenoid rim was identified. It was felt by the operative team that it was of an acute nature, despite a one-year delay for surgery. This also incorporated the anchor of the middle glenohumeral ligament. The anterior-inferior, inferior, and rest of the posterior labrum were within normal limits. There was a negative drive-through sign. The axillary pouch showed no evidence of loose bodies. The articular surface of the glenoid fossa and humeral head were within normal limits. The rotator interval showed no defects. The superior glenohumeral ligament, middle glenohumeral ligament, and anterior band of the inferior glenohumeral ligament were within normal limits. The biceps was medialized, and there was no instability or fraying or neovascularization. The supraspinatus and posterior cuff were visualized, and there was no evidence of tears. Under direct visualization, an anterior-inferior portal was created in a similar fashion just superior to the intra-articular subscapularis and this was used for instrumentation. The rim of the glenoid was debrided with a 4.5 full radius shaver to bleeding bone. This was used to help further reparative process. A 3.0 Bio-FASTak suture anchor was then placed at the 10 o'clock position. Utilizing arthroscopic knot-tying techniques, a suture shuttle was performed and a labral repair was performed with #2 FiberWire in a simple half-hitch fashion. This now recreated the buttress with good labral fixation with probing. The arthroscope was then placed into the anterior-superior portal and visualization demonstrated good buttress with good fixation. It was felt by the operative team that an adequate arthroscopic labral repair had been performed. The instruments were removed, and the portal sites were closed with 4-0 nylon in a simple interrupted fashion. All sponge and instrument counts proved to be correct, and estimated blood loss was less than 5 mL. The wounds were then cleaned and dressed under the sterile field. A Polar Care ice machine and a shoulder immobilizer were placed to the left upper extremity. The patient was then taken to the recovery room in a stable condition.

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Laparoscopic Supracervical Hysterectomy Operative Transcription Example

OPERATION IN DETAIL: The patient was taken to the operating room and placed in the supine position on the operating room table. General anesthesia was administered. She was then placed in the dorsal lithotomy position where examination under anesthesia was performed. The patient was prepped and draped in the usual sterile fashion for laparoscopic surgery. A Foley catheter was inserted into the bladder. A weighted speculum was inserted into the vagina. The cervix was exposed with a Sims retractor and a Hulka clamp was inserted into the cervix and passed into the cervix for later manipulation of the uterus. The weighted speculum was withdrawn. The Hulka clamp was covered with a sterile drape. Clean operating gloves were donned and a stab incision was made just superior to the umbilicus. The Veress needle was inserted into the peritoneal cavity. Proper location was assessed by the hanging drop method. Pneumoperitoneum using 3 liters of CO2 was instilled with an opening pressure of 8 mmHg. The Veress needle was withdrawn. The incision was extended a bit to allow placement of the 5 mm laparoscopic sleeve and trocar. The trocar was withdrawn and the laparoscope was inserted allowing visualization of the pelvic cavity. The patient was placed in the Trendelenburg position to allow the intestines to fall back out of the pelvis. The ovaries on both sides were found to be normal in appearance. Additional trocars were placed to allow the hysterectomy to be begun. In the right lower quadrant, a 10 mm incision was made after transillumination to assure avoidance of blood vessels. A 10 mm sleeve and trocar were introduced under direct visualization through the scope. On the left side, after transilluminating, another incision was made and a 12 mm sleeve and trocar were introduced, again under direct visualization through the scope. A suprapubic incision was made and a 5 mm sleeve and trocar were introduced here. A suction-irrigation apparatus was introduced through the suprapubic port. A tenaculum was introduced through the right lower quadrant port. The harmonic ACE scalpel was placed through the left lower quadrant port. The tenaculum was used to grasp the fundus of the uterus to retract it laterally. The harmonic ACE was used to divide the left round ligament and the left utero-ovarian vessels and then used to take a bite through the broad ligament inferior to the round ligament. Some back-bleeding was encountered on the uterus. Attempts to control this with the harmonic ACE were not successful. Therefore, the LigaSure device was obtained and was used to cauterize the bleeding vessels on the uterus. The anterior leaf of the broad ligament was undermined and incised down to the level of the cervix. The instruments were then switched with the tenaculum being placed through the left lower quadrant and the harmonic ACE through the right lower quadrant port. The tenaculum was again used to grasp the fundus of the uterus for traction. The right round ligament was divided with the ACE and the fallopian tube and the utero-ovarian vessels again divided. The anterior leaf of the broad ligament was undermined and incised down to the level of the cervix. The bladder was then bluntly dissected off the cervix and lower uterine segment. The bladder was somewhat advanced because of prior cesarean section making this procedure somewhat difficult. Kitner devices were used to aid in this dissection. The Foley bulb was manipulated from outside to help in identifying the bladder itself. When the bladder had been dissected down sufficiently, the harmonic ACE was used to divide the remainder of the broad ligament and the uterine vessels on the right side. Again, there was some back-bleeding on the uterus, which was controlled with the LigaSure device. The instruments were again switched and the harmonic ACE was used to divide the remainder of the broad ligament and the uterine vessels on the left side. The uterus was excised from the cervix using the harmonic ACE, using a drill technique, drilling into the tissue with the active blade and then closing the jaws of the clamp and dividing the tissue. In this fashion, working from both the left and right sides, the uterus was excised from the cervix completely. All the pedicles were inspected for hemostasis. The pressure in the abdomen was lowered to 6 mmHg so that hemostasis could be assured. The pelvis was irrigated with the suction irrigator and hemostasis was found to be excellent. At this point, the sleeve in the left lower quadrant was removed. The morcellator was introduced. A tenaculum was introduced through the channel of the morcellator and used to grasp the uterus. The morcellator was kept high up out of the pelvis away from any possible contact with the intestines and the uterus was gradually morcellated by pulling it up into the shaft of the morcellator, where the rotating blade excised cores of myometrial tissue. When the entire uterus had been morcellated, the pelvis was again irrigated and any residual bits of myometrial tissue were removed. The morcellator was withdrawn. A sheet of Interceed gauze was placed through the right lower quadrant port and maneuvered into position over the cervical stump. It was moistened with saline to hold it in place. The left lower quadrant incision was then closed using a fascia closure device to place a 0-Vicryl suture through the fascia. The right lower quadrant port was closed in a similar fashion using the fascia closure device. The pneumoperitoneum was then allowed to escape. The remaining sleeves were withdrawn and the skin incisions were closed with interrupted subcuticular 4-0 Vicryl sutures. The incisions were wiped clean. Dry sterile dressings were applied. The patient was returned to the supine position. She was awakened from anesthesia without difficulty and transferred to the recovery room in good condition. The patient tolerated the procedure well.

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Subtotal Abdominal Hysterectomy and Cystoscopy with Bilateral Ureteral Stent Placement Operative Transcription Example

OPERATION IN DETAIL: The patient was taken to the operating room where she was placed under general anesthesia and prepped and draped in the dorsal lithotomy position. Cystoscopy and bilateral ureteral stents were placed. The patient was then placed in the supine position and again reprepped and draped. A transverse incision was made through the skin with a scalpel and carried through to the underlying layer of fascia with a Bovie. The Bovie was nicked in the midline and this incision was extended laterally using the Bovie. The inferior epigastric vessels were visualized at the lateral edges of the rectus abdominis muscle bilaterally and these were doubly clamped, cut, and suture ligated with 3-0 Vicryl free ties. The rectus muscles were then separated in the midline and transected using the Bovie. The peritoneum was then identified and tented up with pickups and entered sharply with Metzenbaum scissors. This incision was extended laterally using the Bovie. Pelvic washings were then obtained at this time. The uterus was palpated and noted to be about 21-week size and with large fundal fibroid and large fibroid in the right lower uterine segment. An O'Connor-O'Sullivan self-retaining retractor was placed in the abdomen and the upper abdomen explored, noting normal liver and kidneys bilaterally. The bowel was then packed away with moist laparotomy sponges and the round ligament identified on the right side, doubly clamped with Mayo clamps, cut, and then suture ligated with 1 chromic. The utero-ovarian ligament was then isolated and the ureter with stent palpated on the right side as well. The utero-ovarian ligament on the right side was doubly clamped, cut, and suture ligated with 1 chromic. The bladder flap was then created on the right, followed by identical procedure on the left side, where the round ligament was isolated, doubly clamped, cut, and suture ligated with 1 chromic. The utero-ovarian ligament in the left was identified, doubly clamped, cut, and suture ligated. The ureter with stent on the left was also palpated and identified. The bladder flap was created on the left to meet the vesicouterine peritoneal flap on the right. The bladder was pushed down with a sponge stick. The large fibroid in the right lower uterine segment was then removed at this time, first by using the Bovie to free the overlying tissues. The fibroid was then grasped with a Lahey clamp and truncated in space using a Bovie. The uterine arteries were then skeletonized bilaterally and doubly clamped, cut, and suture ligated with 1 chromic. The cardinal ligaments bilaterally were then clamped, cut, and suture ligated with 1 chromic as well. It was noted at this point that the patient did have some endometriosis in the cul-de-sac causing the colon to be adhesed in the posterior cul-de-sac near the lower edge of the cervix. At this point, a subtotal hysterectomy was decided to be performed. The uterus was then truncated above the level of the cervix and sent off to pathology. The inferior aspect of the lower uterine segment and cervix was then reapproximated with figure-of-eight stitches of 0-Vicryl. Excellent hemostasis was obtained. The abdomen was then irrigated and small oozing coagulated with Bovie. Again, bilateral ureters were identified and followed up from the bifurcation of the internal iliacs to the bladder. CoSeal was then sprayed over the site of the cervical closure, over the adnexa bilaterally and the posterior cul-de-sac. Once laparotomy sponges and self-retaining retractors were removed and the peritoneum reapproximated with 3-0 Vicryl, the fascia was then reapproximated with 0-PDS in running fashion. The subcutaneous layer was irrigated and reapproximated with 3-0 Vicryl. The skin was closed with 4-0 Monocryl in a subcuticular stitch and Benzoin and Steri-Strips were placed over the incision site. The bilateral ureteral stents were then removed at this time. The patient tolerated the procedure well. Sponge, lap, needle, instrument counts were correct x2.

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Penetrating Keratoplasty Operative Transcription Sample Report

OPERATION IN DETAIL: After informed consent was obtained, the patient was brought to the operating room and laid on the table in the supine position. The patient was then administered general anesthesia by the anesthesia service and was intubated. The patient was then prepped and draped in the usual sterile fashion for surgery on the right eye. A Schott lid speculum was inserted. The patient's corneal diameter was measured with a corneal caliber and found to be 12.3 mm horizontally by 11.8 mm vertically. There was significant corneal ectasia with central subepithelial and stromal scarring. Healon and a corneal shield were placed on the cornea. A scleral fixation ring was chosen and sutured with eight interrupted 5-0 Dacron sutures, with partial thickness scleral bites. The cornea was examined again, and the optical axis was marked with a sterile marking pen and the tips of a forceps. The patient's pupil was noted to be slightly nasal. The host cornea was marked by applying brief gentle pressure with an 8.0 mm trephine. The mark was repositioned until satisfactory centering was achieved. A 12-prong radial marker was marked with a sterile marker, and the cornea was marked to assist in donor-host suture symmetry and alignment. The donor cornea was trephined with an 8.0 mm trephine after being placed in a donor corneal punch that had been marked with a marker in the punch holes. The cornea was placed in the punch endothelial side up. The donor rim was sent for culture on a culture plate. The donor button was covered with Healon and OptiSeal and placed aside. Next, the host cornea was trephined with an 8.0 mm trephine until the anterior chamber was entered. Miochol was injected through the initial opening to constrict the pupil and protect the lens. The edge of the trephine recipient cornea was lifted with an ionized and 0.12 forceps and corneal scissors were used to excise the recipient button, leaving a slightly beveled edge. The cornea was noted to be extremely floppy, indicating a very thick cornea. Vannas scissors were used to trim a tag of remaining tissue superonasally. The anterior chamber, remaining recipient corneal rim and sclera out to the fixation ring were coated with Healon. The donor tissue was lifted from the corneal punch with a spatula and transferred onto the recipient bed atop the viscoelastic. The four interrupted 10-0 nylon cardinal sutures were placed first. These were left intentionally loose. Twelve additional radial interrupted 10-0 nylon sutures were placed snugly. Care was taken to pass sutures approximately 50% depth in the donor stroma and 90% depth into the host tissue. The cardinal sutures were found to be torqued, as expected, once the remaining sutures had been placed. They were cut and replaced with the proper tension. Several temporal sutures were tightened as well, as the patient's keratoconus required this adjustment. Slight override of the donor tissue was noted at the 2 o'clock position; therefore, an additional 10-0 interrupted suture was placed at that point. A plastic ring was then used to check for astigmatism, and slight against-the-rule astigmatism was detected, as the ring reflex was seen to be ovalized vertically and slightly inferonasally. Two inferonasal sutures were placed, making them tighter, and the ring was again used to check for astigmatism. This time, the reflex was nearly perfectly circular. The wound was closed with additional 10-0 nylon running suture with 90% stromal depth radial bites, with a knot buried at the 9 o'clock position on the donor side. The running suture tension was evenly distributed by adjusting the tension of each bite with tying forceps. The interrupted suture knots were buried on the donor side. The anterior chamber was reformed with BSS on a 30-gauge cannula, irrigating all of the Healon from the eye. An intracameral injection of vancomycin 10 mg/mL was given. The wound was checked with a Weck-Cel sponge and fluorescein strip for leaks. There was a micro leak at the 4 o'clock position, and an additional 10-0 nylon interrupted suture was used to close this. At the end of the procedure, the wound was Seidel negative. The donor cornea was noted to be edematous throughout the case. The entire epithelial surface was absent. The endothelial cell count, however, was good when the tissue was accepted, and it is anticipated that the edema will resolve with time. The scleral ring was removed and the lid speculum was also removed. The drapes were gently removed. Multiple drops of topical anesthetic were instilled into the eye. A drop of Alphagan and a drop of Timoptic 0.5% ophthalmic solutions were used, as well as Polysporin ophthalmic ointment. Wet and dry sponges were used to clean the eye. A piece of 1 inch Transpore tape was used to close the eyelid. Next, a light eye patch was taped in place and covered with a metal eye shield. The patient was extubated without complications and taken to the PACU in good condition.

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Phacoemulsification with Intraocular Lens Implantation Operative Transcription Example

OPERATION IN DETAIL: After informed consent was obtained, the patient was brought to the operating room. The patient's head was taped in position, and the patient was prepped and draped in a sterile fashion for the procedure. A Lieberman lid speculum was inserted in the left eye. Using 0.12 forceps and blunt Westcott scissors, an incision was made through the conjunctivae and Tenon's capsule in the inferonasal fornix, through which 3 mL of 2% lidocaine was injected. A 1.0 mm side-port blade was then used to make a paracentesis wound at the 5 o'clock position on the cornea. Viscoat was injected into the eye through the paracentesis with a 30 gauge cannula to replace the aqueous. A three-plane clear corneal incision was made at the 1 o'clock position with a 2.75 mm keratome blade. A cystitome was used to create a continuous curvilinear capsulorrhexis on the anterior capsule of the lens. Capsulorrhexis forceps was used to extract the anterior capsule remnant that was created. Hydrodissection of the lens cortex from the capsular bag was performed with balanced salt solution on a 26 gauge cannula by placing the tip of the cannula under the lip of the anterior capsule at approximately the 10 o'clock position and pushing gently until a fluid wave was seen to flow under the lens. The cannula was then used to decompress by gentle posterior pressure on the lens. The nucleus was rotated with the cannula, with caution to observe any potential zonular weakness in the highly myopic eye. None was noted. Healon was injected through the clear corneal incision to elevate the Viscoat to the corneal endothelium. A phacoemulsification handpiece was introduced, and a central groove was created in the nucleus. An Osher instrument was inserted through the paracentesis wound, and the phacoemulsification tip as well as the Osher were used to crack the nucleus in half. The nucleus was then removed by phacoemulsification. Irrigation and aspiration was then used to remove the remaining cortex from the capsular bag; however, there was hardly any cortical material remaining. No capsule polishing was necessary. Healon was injected to re-inflate the capsular bag and push the posterior capsule back in order to inject an Alcon AcrySof SA60AT +9.0 diopter intraocular lens into the bag. A Lester manipulator was used to rotate the lens into a central position, and 10-0 nylon suture was preplaced in the clear corneal wound. Irrigation and aspiration was again performed to remove all viscoelastic from the bag by gentle pressure on the intraocular lens at both ends and from the anterior chamber. Balanced salt solution on a 30 gauge cannula was injected through the paracentesis wound until the eye was felt to be adequately pressurized. The anterior lip of the three-plane corneal incision was positioned properly by injecting balanced salt solution on a 30 gauge cannula into the wound. The wounds were sealed with balanced salt solution on a 30 gauge cannula by injecting into the corneal stroma on either side of the wounds. The wounds were dried with a Weck-Cel sponge and painted with a fluorescein strip to ensure they were watertight. They proved to be Seidel negative; therefore, the preplaced 10-0 nylon suture was removed as it was not needed. The eyelid speculum was removed and a drop of Betadine and a drop of Alphagan were placed in the eye. Wet and dry sponges were used to clean the periocular skin. A metal eye shield was taped on the eye and the patient was taken to the recovery room in good condition.

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Right Colon Resection Operative Transcription Example

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed on the table in the supine position. After adequate induction of general anesthesia with endotracheal intubation, a Foley catheter was placed without difficulty. The abdomen was then shaved, prepped, and draped in the usual sterile fashion. A midline incision was then made and carried sharply down to fascia, which was opened for the extent of the incision, taking care to avoid injury to underlying organs. Once exposure was obtained, exploration was undertaken. The liver was without palpable abnormality. The gallbladder was normal. The tumor was palpable at the level of the ileocecal valve. The cecum was, therefore, grasped and elevated. The avascular retrocecal plane was entered and the mesentery of the right colon was carefully dissected up off the retroperitoneal structures up to the level of the duodenum. The lateral attachments were then sharply taken down, completely mobilizing the hepatic flexure. Complete mobilization was undertaken to the level of the mid transverse colon. The ileocolic artery was divided and ligated at its base. The right colic artery was divided and ligated as was the right branch of the middle colic artery. Next, the terminal ileum was divided with a GIA stapling device. The transverse colon was likewise divided with the GIA stapling device. The specimen was handed off the field and given to the pathologist in the room, who opened it and found the ulcerated mass next to the ileocecal valve. A side-to-side functional end-to-end anastomosis was performed without difficulty. The staple line was inspected and seen to be hemostatic. This was closed with a TLH-60 stapling device and the staple line was oversewn with interrupted 3-0 Vicryl sutures. The apex of the anastomosis was reinforced with Vicryl as well. The mesenteric defect was closed with running monofilament suture. The small bowel was returned to the intraabdominal cavity in gentle S-shaped curves and covered with omentum and Seprafilm. The sponge and needle count was reported as correct. The posterior sheath was closed with chromic. The fascia of the abdominal wall was closed with two separate looped 0 Maxon sutures. The skin was stapled closed. The patient tolerated the procedure well. He was awakened, extubated, and returned to the PACU in stable condition.

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Repeat Low Transverse Cesarean Delivery Operative Transcription Example

DESCRIPTION OF OPERATION: The patient was consented and made aware of the risks and benefits of the operation. She was taken to the operating theater and administered spinal anesthesia, which was found to be adequate. The patient was then placed in a supine position with a leftward tilt. A Pfannenstiel incision was then made and carried down to the underlying fascia. The underlying fascia was nicked to the midline and muscle was visualized. The fascia was picked up with pickups and extended out lateral with Mayo scissors. The inferior portion of the fascia was grasped with Kocher clamps, tented up and the muscle was dissected off bluntly. In a similar fashion, the superior aspect of the fascia was grasped with Kocher clamps, tented up, and dissected off bluntly. The defect was carried to the midline and the peritoneum was identified and entered sharply with Metzenbaum scissors. The peritoneal defect was then extended inferiorly and superiorly with blunt stretching. The bladder blade was placed and the bladder flap was identified and grasped with pickups and the bladder flap was entered sharply with the Metzenbaum scissors. The bladder flap incision was extended out laterally and the bladder flap was created digitally. The bladder blade was reinserted below and the uterine segment was identified. The lower uterine segment was scored and defect was created in the midline. The uterine incision was extended bluntly. At the time of delivery, several attempts were made to deliver the infant's head. A vacuum was used for additional traction to remove the infant's head. It took only one application and minimal force to remove the infant. Following removal of the infant, the cord was clamped and cut and cord blood was collected. The placenta was extracted manually. Attention was then turned to the uterus. The uterus was repaired with 0 Vicryl in a running locking fashion. The gutters were cleared of all clots and debris and irrigation was used. Following that, the uterus was placed back into the abdomen and the uterine incision was visualized one more time and was found to be hemostatic. The fascia was repaired with 0 PDS in a running fashion. The subcuticular layer was reapproximated with 3-0 Vicryl. The skin was closed with staples. Sponge, lap, and needle counts were correct x2, and 2 grams of Ancef was given at the time of cord clamp. The patient tolerated the procedure quite well and was sent to the PACU.

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Catheter Ablation of AV Junction Procedure Transcription Example

DESCRIPTION OF PROCEDURE: The patient was brought to the electrophysiology laboratory in the fasting state after signing informed consent. Presenting rhythm was noted to be sinus rhythm with ICD diagnostic showing that this rhythm had been present for the last couple of days with atrial fibrillation, continuous, in the months preceding that. The patient's ICD was reprogrammed to backup VVI pacing at 40 beats per minute. The right groin was prepped and draped in the usual sterile fashion. Local anesthesia was achieved over the right femoral vessels using a combination of 1% lidocaine and 0.5% Marcaine. Using the Seldinger technique, an 8 French SRO guiding sheath was advanced over a long guidewire into the right atrium. Through the sheath, an EPT Chilli standard curve ablation catheter was advanced. Great care was taken throughout the procedure to avoid disruption of the ICD leads during catheter manipulation. The catheter was positioned across the tricuspid valve and the His bundle potential was located. The catheter was then drawn back to a more proximal site with large atrial electrogram and barely visible His potential. At this site, radiofrequency energy was delivered. The patient developed immediate rapid junctional rhythm followed by development of complete heart block, which persisted throughout the ablation delivery. Two short ablation lesions were delivered as we observed the rhythm followed by 60-second energy delivery. All of these were delivered at the same site, constituted one lesion delivery, total ablation time was 82 seconds. Following the ablation delivery, which resulted in escape pacing at 40 beats per minute, the ICD was reprogrammed to DDD pacing at 90 beats per minute. We reserved the patient's rhythm and saw no resumption of AV conduction during a 30-minute waiting period. The electrode catheter was then removed without disruption of the leads. The sheath was removed and digital pressure was applied until adequate hemostasis was achieved. The patient then left the electrophysiology laboratory in stable condition with a biventricular ICD programmed at DDD 90.


Electrophysiology / Interventional Cardiology Sample Reports

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Implantation of Dual Chamber Permanent Pacemaker Operative Example

DESCRIPTION OF OPERATION: The patient was brought to the electrophysiology laboratory in the fasting state after signing informed consent. The left subclavian area was prepped and draped in the usual sterile fashion. Local anesthesia was achieved along the left deltopectoral groove using a combination of 1% lidocaine and 0.5% Marcaine. An incision was extended along the groove, and using a combination of blunt and Bovie dissection, the incision was extended to the level of the prepectoral fascia. A pulse generator pocket was fashioned inferomedial to the incision using blunt dissection in the prepectoral space. The left axillary vein was visualized with a Site-Rite II ultrasound device, and under direct ultrasound visualization, the vein was punctured with a Cook needle and a guidewire was placed. Using a similar ultrasound-guided technique, another guidewire was placed in the left axillary vein using a separate needle stick. Over one guidewire, a 7 French introducer sheath was advanced. Through this sheath, an active fixation pacing lead was advanced using straight and curved stylets. The lead was positioned in the right ventricular septal area at a site with favorable sensing and pacing characteristics, where the lead was actively fixed in the location and securely sutured to the underlying pectoral muscle. Final lead measurements were favorable, and there was no diaphragmatic stimulation at high output pacing. Over the second guidewire, another 7 French introducer sheath was advanced, and through this sheath, another active fixation pacing lead was advanced into the right atrium with the aid of a J-tipped stylet. The lead was positioned in the right atrial appendage at a site with favorable sensing and pacing characteristics, where the lead was actively fixed in the location and securely sutured to the underlying pectoral muscle. It should be noted that this original pacing lead did dislodge not long after closure of the wound. The patient was therefore re-prepped and the wound was opened, and the lead was again repositioned in the right ventricular appendage area at a site with favorable sensing and pacing characteristics where the lead was actively fixed in the location and securely sutured to the underlying pectoral muscle. Final lead measurements were favorable, and there was no diaphragmatic stimulation at high output pacing. The pulse generator pocket was thoroughly irrigated with antibiotic solution, and the leads were attached to a dual-chamber pacer pulse generator, which was placed into the preformed pocket. The subcutaneous fat and fascia were closed using running 2-0 Vicryl suture. The skin was closed using running 4-0 Monocryl suture. The wound was dressed with Steri-Strips and sterile gauze. The patient left the electrophysiology laboratory in stable condition with proper device function observed on the monitor.

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Repeat Low Transverse Cesarean Section with Vacuum Assistance Operative Sample

DESCRIPTION OF OPERATION: The patient was brought to the labor and delivery operating room and placed in a seated position. Spinal with Duramorph was performed. She was then placed in a supine position with left lateral tilt. Once an adequate level was obtained, she was placed in dorsal supine position and prepped and draped in a sterile fashion with Foley catheter inserted into the bladder. A Pfannenstiel incision was made with a knife through the skin and carried down to the fascia. The patient had a very deep pannus, approximately 6 plus cm in depth. This was carried down to the level of the fascia, nicked with the knife, and extended to both sides laterally with Mayo scissors. The fascia was then dissected off the rectus muscle, inferiorly towards the symphysis and superiorly to the level of the umbilicus. The preperitoneal fat was then grasped with pickups and incised with Metzenbaums down to the level of the peritoneum, which was grasped with pickups and incised with Metzenbaums. The peritoneum was opened clearly with no evidence of internal adhesions and incised superiorly away from the bladder and somewhat laterally and then dissected down towards the level of the bladder, avoiding the bladder for limitation-of-injury purposes. The incision was stretched. A bladder blade was inserted and the vesicouterine peritoneum was grasped, incised with Metzenbaums, and extended to both sides laterally. This was dissected off of the lower uterine segment, which was noted to be paper-thin with fluid and hair visualized below. A knife was used to create a small incision in the lower uterine segment, and bandage scissors were used to extend the incision to the right and the left, to control the direction of the incision, given the thinness of the uterine scar. Fetal head was directed into the incision and given the prospective size of the baby, the vacuum was applied to the vertex of the fetal head, hand was removed, and the vertex was delivered with fundal pressure and traction from the vacuum. Nose and mouth were suctioned. Nuchal cord was noted. This was reduced over the head easily. Shoulders were then delivered with gentle traction and fundal pressure. Body was then delivered easily. Cord was doubly clamped and cut, and the baby was passed off to the awaiting neonatologist with suction of the nasopharynx and oropharynx performed with a bulb syringe. A segment of the cord was taken for arterial blood gas and cord blood was taken for ABO/Rh. The placenta was then removed manually from the anterior surface of the uterus. The uterus contracted well and was delivered from the abdomen. The incision was closed using #1 chromic in a running locking fashion from the right to the left with adequate hemostasis appreciated. The uterus was then placed back into the abdomen. Copious irrigation was performed. Ovaries and tubes appeared normal. The uterus was well contracted. The incision was hemostatic. No evidence of bladder injury was appreciated. Peritoneum around the bladder was evaluated with no evidence of bleeding. All lap counts were correct. The fascia was then closed using #1 Vicryl in a running fashion from the right to the midline and left to the midline. Two figure-of-eight sutures were placed across the area on the right midline, where the fascia appeared to the somewhat thin. Copious irrigation was then performed again to subcutaneous tissue. This was irrigated well and cauterized for hemostasis. Due to the depth of the subcutaneous tissue, a Jackson-Pratt drain was placed with the incision made in the left lower quadrant away from the C-section incision. A Kelly clamp was pushed up to the skin. The incision was made with a knife. The Kelly clamp was then pushed through the skin incision back into the corner of the cesarean section incision. The Jackson-Pratt was placed into the incision and the tubing was then pulled out through the incision of the skin. It was fixed using 3-0 silk suture and tied in place. The skin incision for the C-section was then closed using 4-0 Vicryl in a subcuticular fashion. Pressure bandage was applied to the incision. The bandage was tied around the Jackson-Pratt drain, and it was placed to bulb suction. The vagina was evacuated of all clots, and the patient was then taken awake and in stable condition to the recovery room. The Jackson-Pratt drain will remain in place until decreased drainage is noted. Serosanguinous drainage was noted at the end of the procedure. Good urine output was noted, and the patient was comfortable and taken to the recovery room. The patient received 2 grams of Ancef intraoperatively and IV fluids with Pitocin.

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Sample Physiatric Reports - Progress Note Transcription Example

SUBJECTIVE: The patient states that she is excited about being on the rehabilitation unit so she can gain the necessary skills to head on home. She feels her pain is under fairly good control.

OBJECTIVE: Temperature 99.2 degrees, pulse 95, respirations 18, and blood pressure 134/89. The head and neck examination was unremarkable with pupils equal, round and reactive to light and extraocular movements intact. She had normal hearing acuity. She had good dentition with moist nasal and oral mucosa. Neck examination was unremarkable with no evidence of lymphadenopathy or thyromegaly. The lungs were clear to auscultation without rales, rhonchi or wheezes. The heart had a regular rate and rhythm without murmur. The abdomen was somewhat protuberant, but otherwise soft, nontender, with active bowel sounds. There was no guarding or rebound tenderness. There was no apparent hepatosplenomegaly. The patient wore a right short leg cast made out of plaster. Knee-high TED hose was worn on the left. Good capillary refill was noted at both great toes. There was at least one fingerbreadth of space between the edge of the cast and the calf on the right. Range of motion appeared to be within functional limits, although this could not be tested at the right ankle. Neurologic examination showed the patient to be alert and oriented x4 with mental status within normal limits. Mini-mental status exam had a score of 30/30. Cranial nerves II through XII were grossly intact. There was no apparent sensory deficit to pinprick or light touch. Reflexes were 3+ and symmetric throughout, except at the left ankle where it was 2+. Normal tone and 5/5 strength were noted in the upper extremities. Lower extremities showed iliopsoas strength of 3/5 on the right and 2+/5 on the left, quadriceps strength of 4-/5 bilaterally, anterior tibialis was 5/5 on the right and unable to be tested on the left, extensor hallucis longus was 4+/5 bilaterally, and gastrocnemius was 5/5 on the left and unable to be tested on the right because of the cast. The patient demonstrated fair truncal balance. Hoffmann and Babinski signs were absent.

ASSESSMENT AND PLAN:
1. Rehabilitation: The patient was admitted today from an outside hospital to begin comprehensive rehabilitation for her multiple trauma. Her trauma includes displaced fractures of the left transverse processes of the lumbar spine, superior and inferior left pubic rami fractures, widening of the left sacroiliac joint, and diastasis of the sacroiliac joint on the right. Liver contusion and contusion of the right kidney was also noted. She also has a right lower extremity pilon fracture. Comprehensive inpatient rehabilitation will work to maximize the patient’s functional abilities to the independent/modified independent level with all activities of daily living, initially at the bed level and progressing to standing using a walker, also will work to regulate the patient’s bowel/bladder function, provide adequate pain relief, maintain the cast on the right with weightbearing as tolerated on the left, provide patient/family education, address issues related to disability and sexuality, and address discharge planning. We will also make sure that there is no component of brain injury. This is unlikely because there was no loss of consciousness or history of trauma to the head. Rehabilitation Potential: Good. Estimated Length of Stay: Two to three weeks.
2. Multiple trauma: Stable. Continue to use cast on the right leg for the pilon fracture and weightbearing as tolerated for the left lower extremity. We will arrange followup with the outside hospital and orthopedic services.
3. Bowel/bladder management: We will work towards regulated programs for both. The patient had a Foley catheter removed a few days ago and will check for urinary tract infection by urinalysis, culture and sensitivity today. We will make sure that the patient has soft-formed stools and is not constipated.
4. Pain: Under good control. Continue Percocet as written.

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Percutaneous Tracheostomy Medical Transcription Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Spinal cord injury with resultant central cord syndrome and pneumonia.

POSTOPERATIVE DIAGNOSIS:
Spinal cord injury with resultant central cord syndrome and pneumonia.

PROCEDURE PERFORMED:
Percutaneous tracheostomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General anesthesia with local infiltration.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

OPERATIVE FINDINGS:  Midline percutaneous tracheostomy was performed without complication. No evidence of air leak from the ventilator. Location was confirmed with flexible bronchoscopy.

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old male, status post motor vehicle collision, in which he sustained a cervical spine injury. He has been in the intensive care unit requiring ventilator support for approximately three weeks. He failed extubation and required reintubation. For this reason, it is felt that he will require prolonged ventilator support and therefore tracheostomy is indicated. The risks, benefits and alternatives were explained to the patient's family, and consent was obtained to proceed with the procedure.

DESCRIPTION OF PROCEDURE:  The procedure was initiated at the bed side. A time-out was performed, verifying the patient, surgical site and procedure. The patient received antibiotics prior to the procedure. His neck was positioned with a towel roll behind his shoulder blades. This allowed for mild extension of his cervical neck. The neck was then prepped with Betadine solution. The area was then draped in a sterile fashion.

Attention was directed at the midline trachea, where the cricothyroid membrane was palpated. Approximately two fingerbreadths above the sternal notch, a midline vertical incision was created with a scalpel after local infiltration with 0.5% lidocaine with epinephrine. Of note, the patient was adequately sedated and paralyzed with vecuronium, propofol and fentanyl.

Next, dissection was carried forth down to the subcutaneous tissue in a careful blunt manner with hemostats. The anterior trachea was visualized with the tracheal rings. Approximately the second tracheal ring was identified. Then, using Seldinger technique and a percutaneous tracheostomy set, the trachea was entered with a 14 gauge needle with an overlying sheath. This was all confirmed under direct visualization of a fiberoptic flexible bronchoscope. Entrance into the trachea was identified through the third tracheal ring interspace.

Following this, a guidewire was inserted. The needle was removed, leaving the sheath and the guidewire intact. Next, the sheath was removed and a small dilator was inserted. The tracheal rings were then serially dilated. A #8 Shiley was then opened. The balloon was checked. It was placed over a tracheal dilator, which was then advanced over the guidewire and through the previously dilated tract. The Shiley tracheostomy tube was noted to pass in the trachea with little resistance.

The guidewire and dilator tubes were removed from the trachea. An inner cannula was placed through the tracheostomy tube. The tracheostomy was then secured at the anterior neck with 2-0 silk x4. The oral endotracheal tube was removed and the ventilator was attached to the newly placed tracheostomy tube. Adequate tidal volumes were noted. The cuff was inflated and no evidence of air leak was noted. No evidence of bleeding was noted. At this point, the procedure was concluded and the patient tolerated the procedure well.

Pulmonary Operative Samples        Fiberoptic Bronchoscopy Sample

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Left Femoral-to-Peroneal Bypass Operative Example

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed on the operating table in the supine position. After adequate induction of anesthesia, the left groin and leg were prepped and draped in a sterile fashion. The procedure was begun by making an oblique incision in the left groin crease through the previous incision. Subcutaneous tissue was divided using electrocautery and scalpel down to the palpable fluid of the thrombosed femoroperoneal bypass. Using sharp dissection, the hood of the previous femoroperoneal bypass was exposed and dissected. It was controlled for a distance of approximately 2 cm out onto the graft. The graft had a stump that remained patent from the proximal anastomosis for approximately 1 cm distally, and the vessel was controlled at this point. The common femoral artery proximally was controlled to allow for clamping if necessary. The intent was to clamp across the old hood of the graft and use the remaining stump as a site for proximal anastomosis. The wound was then packed with saline-soaked gauze and attention was directed to the calf. A longitudinal incision was made in the midcalf just medial and posterior to the tibial border. Subcutaneous tissue was divided down to the fascia of the calf, which was opened. The soleus muscle was then taken down from its origin of the tibia, exposing the posterior tibial vein and artery as well as tibial nerve. Deep to this, the flexor digitorum muscle was mobilized. Beneath this, muscle was identified, the peroneal vein and artery. The peroneal vein was then carefully dissected away from the peroneal artery, which was found to be soft and minimally diseased. It was superficially dissected for a distance of 2 cm and appeared to measure approximately 2 mm in size. The wound was then packed with saline-soaked gauze. A Kelly-Wick tunneler was then used to create a subcutaneous tract and tunneled between the calf incision in the groin. The tunneler was left in place. The patient was given 3000 units of heparin. While the inflow and outflow had been exposed, the CryoLife greater saphenous vein had been prepared according to normal technique. The vein was then brought onto the field after adequate circulation of 3000 units of heparin. The hood of the old graft was clamped and the graft was divided. The vein was patent at this point. The old vein graft was patent at this point and was spatulated slightly. The CryoLife vein was then reversed and the proximal end was spatulated. A standard end-to-end spatulated anastomosis was created using two separate running 6-0 Prolene. After completion of this anastomosis, there was noted to be excellent flow out the cadaveric vein graft. The vein graft was marked with double length and was sutured to the tunneler. It was then tunneled through the subcutaneous plane into the calf incision. The patient was given additional 1000 units of heparin, and the tourniquet was applied to the proximal thigh. The patient's leg was then exsanguinated using elevation and Esmarch, and the tourniquet was inflated to 350 mmHg. The peroneal artery was exposed deep in the calf wound, and a longitudinal arteriotomy was made measuring 1 cm in length. The vein graft was then cut to an appropriate length and shape, and a standard end-to-side spatulated anastomosis was created using a running 7-0 Prolene. Prior to completion of the anastomosis, the artery and graft were forward and backbled and flushed with heparinized saline. The anastomosis was then completed and flow was restored. There was noted to be an excellent pulse in the graft. Doppler evaluation demonstrated good flow characteristics throughout the graft in the outflow vessels. Hemostasis was obtained in both groin and the calf incision. The calf incision was then closed with 3-0 Vicryl for the fascia and the subcutaneous tissue with 3-0 Vicryl as well. The skin was closed with 4-0 subcuticular Monocryl. The groin was closed with three separate layers of 3-0 Vicryl and skin with 4-0 Monocryl. Clean sterile dry dressings were applied, and the patient was transferred to the recovery room in stable condition, having tolerated the procedure well.

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NEUROPSYCHOLOGICAL EVALUATION MEDICAL TRANSCRIPTION EXAMPLE

REASON FOR REFERRAL: The patient is a (XX)-year-old male who returns at this time for yearly neuropsychological evaluation. He has been diagnosed with mild cognitive impairment and evaluation at this time was recommended to determine the presence of any improvement following implementation of CPAP for sleep apnea.

TESTS PERFORMED: Selected Wechsler Adult Intelligence Scale-III subtests and the Wechsler Memory Scale-III, California Verbal Learning Test, Clock Drawing, Trail Making Test, Semantic and Phonemic Verbal Fluency Tests, Boston Naming Test, Rey-Osterreith complex Figure with recall and recognition trials, Grooved Pegboard, Geriatric Depression Scale, and interview.

INTERIM HISTORY: The patient stated that his wife thinks that his memory has gotten worse over the last year. He gave the example of thinking about something with his eyes closed and forgetting what it was when he opens his eyes. He also finds that he forgets what he is thinking about when interrupted by any kind of activity or distraction. When asked about any changes in his temperament, as noted in past evaluations, he agreed that he does sometimes get impatient with his wife. He said that his wife has told him that his speech is not as loud as it used to be and that he mumbles. He continues to be independent with all of his activities of daily living, including driving and bill paying. He remembers to take his medications, and if on occasion he forgets, his wife will remind him. He was in the habit of golfing four days a week until he fell about a week ago and bruised his elbow. He said that he does not sleep that well. He only gets about 3 hours of sleep at night and will often take a nap in the afternoon. A few months back, he underwent left carotid endarterectomy with no apparent complications. He stopped using his CPAP machine at that time and has not resumed its use. He questions whether his apnea is that significant. He is not sure if the CPAP actually helped him.

BEHAVIORAL OBSERVATIONS: The patient was alert and fully cooperative. He presented as a neatly dressed and groomed man, appearing slightly younger than his age. He answered questions with an appropriate degree of elaboration. His affect was normal in range and intensity and his overall mood was good. In fact, he seemed to be in better mood at this evaluation than last year. He joked and laughed several times throughout the interview and formal testing. He was able to comprehend all the instructions, but occasionally they had to be repeated because of difficulty hearing. He does have a hearing aid in his left ear. His level of effort was felt to be good. He was able to establish rapport with the examiner. He understood the nature and the purpose of the examination.

RESULTS OF EXAMINATION: The patient demonstrated a mild decline on measures of attention and concentration, but improvement on measures of visual motor processing speed. Measures of verbal learning and memory are essentially unchanged for both paragraph length material and unrelated words. These scores fall into the average to below average range for his age. Immediate memory for a complex figure declined somewhat from the average to the below average range and delayed recall fell into the mildly impaired range. In contrast, his immediate and delayed recall of pictures of a family were essentially unchanged and in the normal range. Language functions declined somewhat from the previous visit, though not universally. His semantic verbal fluency declined from average to below average, whereas his phonemic verbal fluency actually improved slightly from impaired to below average. Confrontational naming still from superior to average. His visual-spatial functions were essentially unchanged. Fine motor speed and dexterity remained unchanged from last year, but declined slightly on the nondominant side. His clock drawing was unchanged, showing intact spatial planning and conceptualization. With respect to his mood, he endorsed about the same number of symptoms of depression as he did last year, with a score of 9 on the Geriatric Depression Scale as oppose to 8. This is in some contrast to his presentation, which was clearly more cheerful than last year.

CONCLUSIONS: Neuropsychological reevaluation shows some inconsistent results. There is an increase in processing speed, but a slight decrease on measures of attention and concentration and some aspects of language function. Also, his performance on a visual memory test decreased slightly. Overall, there is not enough evidence in the results to indicate a significant decline. I continue to feel that he has mild cognitive impairment that could be due to sleep apnea. Given the relatively stable performance over the last several years, the likelihood of early dementia of the Alzheimer's type is slim.

DIAGNOSTIC IMPRESSION: Mild cognitive impairment.

RECOMMENDATIONS:
1. Encouraged the patient to continue using the CPAP.
2. Will discuss the results of the evaluation with him in a feedback session next week.
3. Unless he begins to experience significantly increased cognitive problems or his wife observes significant changes in his cognitive or behavioral functioning, there is no need for further neuropsychological followup. Should either of these occur, I would be happy to see him for further evaluation and consultation.

ERCP with Sphincterotomy Extension, Stone Removal, Bile Duct Brushings, Bile Duct Dilation and Stent Placement Procedure Example

DESCRIPTION OF PROCEDURE: The patient was placed in the supine position and was subsequently intubated by the anesthesiologist. Once this was completed, a side-viewing duodenoscope was advanced to the area of the papilla. The patient was noted to have a previous sphincterotomy. The papilla appeared normal. A short-nose traction sphincterotome was utilized for selective bile duct cannulation. Initially, superficial injection of the pancreatic duct appeared normal. No visualization of the pancreatic tail was made, as vigorous injection of contrast was not performed. Selective bile duct cannulation was then performed. This was performed using the sphincterotome. Initial contrast injection was made with the duodenoscope in the long position. This allowed good visualization of the area of the proximal common bile duct, where a mild stricture was identified on MRCP. Contrast injection revealed what appeared to be a stricture present around the area of previous surgery as noted by multiple clips. Additional contrast injection revealed partial filling of the right main hepatic duct. The patient was purposely kept in the supine position to allow better filling of the right main hepatic duct. Once this was identified, a small sphincterotomy extension was then performed after placement of a Jagwire. The Jagwire was purposely inserted across the right main hepatic duct for later access to that specific duct. No significant filling defects that were compatible with stones were identified. However, with sphincterotomy, some additional sludge was visualized. It was suspected that there may have been some retained contents somewhat more proximally. Therefore, a small basket was utilized and a number of sweeps were made across the common bile duct as well as across the right main hepatic duct. Some additional sludge was removed, though again no stones were identified or withdrawn. Following this, additional clearance of the patient's bile duct as well as the right main hepatic duct was performed using a 9 to 12 mm extraction balloon. The basket was exchanged over a guidewire and the balloon was passed over the guidewire into the bile duct. The balloon was able to traverse the proximal bile duct stricture at 9 mm. There was very mild resistance, although the balloon was able to traverse the affected region. Repeat balloon occlusion cholangiograms appeared to demonstrate effective opening of this area with just the balloon itself. Again, no filling defects were identified. There appeared to be a very short-segment within the right main hepatic duct that appeared mildly strictured. Decision was made to dilate this particular region rather than stenting across it due to the concern that the stent itself may occlude the left main hepatic duct. The extraction balloon was then removed and a cytology brush was passed over the guidewire. Common bile duct brushings were obtained for cytology. Following this, the brush was exchanged in favor of a dilating balloon. An 8 mm dilating balloon was utilized to dilate both the base of the right main hepatic duct, as well as the proximal common bile duct. Following dilation, confirmation of adequate opening was performed utilizing the extraction balloon and a balloon occlusion cholangiogram was again performed. There appeared to be adequate patency in the area of the right main hepatic duct as well as the proximal common bile duct. Following this, a biliary stent was placed up to the level of the bifurcation. Measurement on fluoroscopy estimated the length to traverse the affected area of the proximal common bile duct to about 8 cm. Stents that were manufactured and available for use included 7 cm stents, which were thought to be too short for this use as well as a 10 cm stent. Secondary to this, decision was made to stent the patient using a 10 French 10 cm stent. The stent was successfully placed and deployed. The end of the stent, however, appeared to travel a bit too proximally into the right main hepatic duct and therefore a small snare was utilized to pull the stent a bit more distally back into the area of the hepatic bifurcation. There was very good drainage that was observed. Air and fluid were then aspirated. The scope was withdrawn and the procedure terminated.

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Modified Brostrom Lateral Ligament Repair and Calcaneal Dwyer Osteotomy Operative Example

DESCRIPTION OF OPERATION: Under mild sedation, the patient was brought in and placed on the operating table in the lateral position. Following general anesthesia, approximately 20 mL of 0.5% Marcaine with epinephrine was injected about the left lateral foot and ankle. The leg was then scrubbed, prepped, and draped in aseptic manner. The left leg was then elevated and exsanguinated. The left thigh tourniquet was inflated to 300 mmHg. Attention was then directed to the lateral aspect of the left heel where a 7 cm curvilinear Ollier incision was made from the anterolateral ankle to the lateral posterior heel. The incision was then deepened down through subcutaneous tissue. The sural nerve and lesser saphenous vein were identified and retracted. The pronator tendons were identified and retracted. The calcaneofibular ligament was identified and noted to be attenuated and partially ruptured. The lateral ankle ligaments and joint capsule were also noted to be attenuated; this was incised. There was a moderate amount of synovial fluid expressed in the ankle joint. There were no signs of loose body or damage to the lateral aspect of the talus and talar dome. The incision was then flushed with copious amounts of normal saline and Kantrex. Attention was then directed to the lateral aspect of the calcaneus, where a Dwyer calcaneal osteotomy was performed along the lateral aspect of the heel. An approximately 6 mm wedge bone was taken from the lateral heel, leaving the medial cortex intact. The osteotomy was reduced and then fixated with two percutaneous screws in the posterior aspect of the heel, Acutrak Plus screws. Good compression of the osteotomy was noted clinically and radiographically. The incision had been flushed once again with copious amounts of normal saline and Kantrex. The percutaneous incisions were closed with 4-0 nylon and then the anterior and lateral and calcaneofibular ligaments were repaired with #2 FiberWire. The foot was dorsiflexed and everted and then was reinforced along the joint capsule with 0 Vicryl and the skin and subcutaneous tissues were closed with 3-0 Vicryl and 4-0 nylon. Good alignment of the foot and ankle was noted with the foot slightly everted. The foot was injected with an additional 10 mL and 0.5% Marcaine with epinephrine and then bandaged with bandages, Adaptic, 4 x 4's, fluffs, KIing, cast padding, and a short leg 3-way splint. The left thigh tourniquet was deflated approximately 80 minutes, and prompt hyperemic response was noted to all digits of the left foot. The patient left the operating room for the PACU with vital signs stable.

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Knee Arthroscopy with ACL Reconstruction and Arthroscopic Debridement of Medial Meniscus Tear

DESCRIPTION OF OPERATION: The patient was prepped and draped in the routine sterile manner. The patient was given 1 gram of Ancef prior to the start of the procedure. A graft was taken with a 4 cm incision overlying the insertion of the pes anserinus. The pes was dissected out and the insertion on the tibia was incised. The sartorius was reflected and the semitendinosus tendon and the gracilis tendons were identified and tagged with #2 FiberWire using the Krackow suture method. The fascial bands were dissected free of both, including the bands connecting to the gastroc. The close-ended harvesting device was then used to strip the muscles from the tendon. They were taken to the back table, cut to 19 mm and then the #2 FiberWire was whipped into both ends of the tendons. They were folded so we would have a quadruple graft and then placed on the tensioning board, placed under 15 pounds of tension. The graft was then baseball stitched to gather the tendons together. The tendons were marked at 25 mm at the folded ends to assure there would be good placement into the femur. At this point, diagnostic arthroscopy was started. The diagnostic arthroscopy showed no chondral lesions. The ACL was completely torn. The PCL was intact. The medial meniscus had a posterior horn medial meniscus tear that was complex type with a horizontal as well as a vertical zone. After debridement using a straight basket biter and a shaver, approximately 15-20% of the posterior horn was debrided leaving the majority of the meniscus. At this point, the lateral meniscus was evaluated and noted to have no tears. The ACL stump was debrided using shaver and cautery. A notchplasty was performed so the over-the-top position could be found. Once the over-the-top position was defined, a position approximately 5 to 6 mm from the over-the-top position was defined at a position of 10 o'clock. An awl was used to create a point spot there and the Beath pin was then placed at this position through the medial portal. The knee was hyperflexed and the pin was driven through the lateral cortex of the femur and then 8 mm reamer was used to ream a 30 mm tunnel. This was predetermined based on the graft thickness. Once this was drilled, a suture was passed through this tunnel. The tibial tunnel was then drilled using the Arthrex guide resting on the PCL and the pin was placed so it would be in the central portion of the ACL stump, slightly on the medial side. The reamer was then placed over this with a 9 mm reamer and this was reamed overlying. The shaver was then used to debride all of the bony elements within the joint. The suture was then passed through both tunnels. A notcher was then used to notch the tunnels to allow the BioScrews to be placed. The graft was passed. The knee was hyperflexed again and the femoral side was fixed using 8 x 23 mm BioScrew. The graft was cycled and noted to be isometric. The graft was then tensioned placing the knee to full extension and a guide pin was placed and a Delta BioScrew was then placed 9 x 35. This gave excellent fixation of the graft. The knee had full symmetric range of motion, had a negative Lachman and a negative pivot shift following fixation of the graft. The suture ends were then cut. The fascia was closed using 2-0 Vicryl, 3-0 Monocryl, and 4-0 Monocryl were used for the skin. The portals were closed using 4-0 Monocryl. Marcaine was infiltrated into the incisions and into the knee joint. A total of 25 mL was used. Sterile dressing was placed. The patient was taken to the recovery room in stable condition.

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