Thumb Replantation Transcribed Operative Procedure Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Traumatic amputation of right thumb and index finger.

POSTOPERATIVE DIAGNOSIS:  Traumatic amputation of right thumb and index finger.

OPERATION PERFORMED:  Completion ray amputation of right index finger and microvascular replantation of the thumb with repair of bone, tendons, nerves.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room, and after induction of general endotracheal anesthesia, the right upper extremity was prepped with Betadine scrub and paint and draped out sterilely. We first started with two teams, one team worked on the patient irrigating the wounds with a Pulsavac, debriding, and then cutting back. After looking closely at the index finger, determination was made that it was not replantable. We trimmed this back, debrided the skin edges, retracted nerves, and then closed the wounds with 5-0 nylon suture.

We then went over and opened the thumb up, identified the proximal end of the flexor pollicis longus, and identified both neurovascular bundles. Nerves were easily identified and cleaned off. On the back table, the other team went ahead and debrided and cleaned off the thumb. We trimmed back just about 3.5 mm of bone just to give us a flat surface. We were so close to the joint, we did not go any further, opened him up volarly in a zig-zag type fashion and found both the radial and ulnar digital arteries and nerves on the thumb. Dorsally, we pulled the skin back and he had several nice veins we thought we could get into without too much difficulty. We went back then to the arm itself and trimmed back the bone about 5 mm and it had a nice flat surface. We ran two 0.035 K-wires retrograde up the thumb and then ran them back and affixed them to the proximal phalanx of the thumb. We then performed an end-to-end modified Kessler repair of the tendon with a core suture of 4-0 Ethibond and a 6-0 Prolene over and over around it, then repaired the extensor tendon with a 4-0 Ethibond figure-of-eight.

At this point, we brought the microscope in and carefully cleaned off the arteries on both sides. It was elected because of the large size of the ulnar artery to go ahead and repair this first and use the microscope. We let the tourniquet down and had good pulsatile flow in both neurovascular bundles. Performed an end-to-end anastomosis, and despite the fact that the caliber was quite large, probably in the order of 2.5 to 3 mm, the artery did not flow and therefore we took it down and redid it. Then, we got flow, flipped the hand over, found the dilated veins and did two venous anastomoses, but noted as we finished the second one, that the thumb was pale and not bleeding anymore. We flipped the hand back again and looked at the anastomosis. Technically, it appeared to be okay. We teased the artery a little bit and then we got flow again and it ran for about 20 minutes and stopped.

At this point, we cleaned off the radial artery proximally and distally. It was smaller, probably about half the caliber, about a millimeter and a half or so, but we hoped this would open immediately and have good pulsatile flow into the artery. Then, the thumb pinked up nicely. Went back then to the ulnar side and took it down. The patient had a lot of atherosclerosis in the vessel and we trimmed him back probably another 5 mm or so. We mobilized it, repaired it several times, and just really could never get it to flow, probably because of the atherosclerosis in the vessel and probably due to some trauma related issues. However, the radial side continued to flow quite nicely. We then brought the microscope back in again and repaired both the nerves in an end-to-end fashion with 9-0 suture. We then gently tacked the skin back together with some 5-0. The patient tolerated the procedure well, was awakened and transferred to the recovery room in stable condition.

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Total Laryngectomy Transcribed Operative Procedure Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Squamous cell carcinoma of the supraglottis. 

POSTOPERATIVE DIAGNOSIS:  Squamous cell carcinoma of the supraglottis. 

OPERATIONS PERFORMED: 
1. Total laryngectomy. 
2. Bilateral modified radical neck dissection, type 1. 
3. Indirect laryngoscopy with esophagoscopy. 

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD 

ANESTHESIA:  General via tracheostomy tube. 

ESTIMATED BLOOD LOSS:  200 mL. 

DESCRIPTION OF OPERATION:  Once the patient was appropriately identified, general anesthesia was administered via the previously placed tracheostomy tube. Once under general anesthesia, the patient's bed was rotated 90 degrees away from the anesthesia machine and the patient placed on a shoulder roll and covered with sterile fields in standard fashion. A Dedo rigid laryngoscope was used to perform a laryngeal examination and examination of the oral cavity, oropharynx and oropharyngeal cavity. The location of the tumor was confirmed on direct laryngoscopy, involving the right false vocal folds and vallecula. Direct rigid esophagoscopy was then performed to evaluate for the possibility of synchronous lesions and no lesions were found on esophagoscopy. Thus, the decision was made to proceed with total laryngectomy and bilateral modified radical neck dissection. The apron-type incision was marked out with a marking pen incorporating the tracheostomy stoma with peristomal skin excision site. Lidocaine 1% with epinephrine 1:100,000 was used to inject the premarked incision site. A total of 10 mL was used. Once this was done, the patient's neck was prepped with Betadine solution and sterile fields were done in standard fashion. 

An incision was made along the previously marked lines and carried out through the subcutaneous layers below the platysma. Once this was performed, a skin flap was elevated in the subplatysmal plane to the level of the hyoid bone and down to the level of the clavicle. Once this was performed, the operation proceeded to modified selective neck dissection which incorporated levels 2, 3 and 4. The dissection started on the patient's right side. The sternocleidomastoid fascia was grasped and retracted medially off the sternocleidomastoid muscle towards the carotid sheath. As dissection proceeded toward the carotid sheath, the spinal accessory nerve was identified and carefully isolated from surrounding fascial attachments. Once the nerve was freed up, level 4 dissection started by identifying the omohyoid muscle. The omohyoid muscle was freed of fascial covering and retracted inferiorly exposing the carotid sheath at level 4. Fibrofatty tissue around that area was carefully dissected off the fascia overlying the anterior scalene muscles and bluntly dissected forward towards the carotid sheath and superiorly. It was then dissected off the carotid sheath and the previously identified plane with blunt and sharp dissection using electrocautery. Attention was paid to preserving the phrenic nerve, vagus nerve, brachial plexus and cervical sensory rootlets. Once the fibrofatty tissue was released along the entire carotid sheath, it was brought up superiorly where it was completely dissected off the carotid sheath and submitted to the pathology department. Prior to submission, level 2 of the neck dissection was marked with a 2-0 silk for proper orientation. Once the dissection was completed, attention was turned to the patient's left side where dissection was performed in a similar fashion incising the sternocleidomastoid fascia and releasing it off the muscle. Once this was performed, the spinal accessory nerve was identified in the medial portion of the sternocleidomastoid muscle and released from overlying fibrofatty tissue. Once that was performed, the omohyoid muscle was identified lower in the neck and was dissected off surrounding fascia and retracted inferiorly, exposing level 4 of dissection. Fibrofatty tissue was bluntly and sharply dissected off the carotid sheath and the floor of the neck and brought out the superior medial fascia. Once dissection was completed, the fibrofatty tissue was submitted to the pathology department with a marking stitch at level 2 neck dissection. 

Upon completion of the neck dissection, attention was turned to total laryngectomy. The trachea was identified along the midline and a transverse incision was made at the level below the previously created tracheostomy stoma. The incision was carried in a slightly oblique direction posteriorly to provide an adequate size stoma. Once incision was made into the trachea, a 2-0 silk suture was placed through the tracheal cartilage down to skin to prevent retrosternal retraction of the trachea. The tracheostomy and 8.0 reinforced endotracheal tube was placed in the newly created tracheal stoma and secured to the chest with 2-0 silk for ventilation. Once this was performed, the tracheal incision was completed at the posterior aspect finding the fascial plane between the trachea and esophagus. Once that was performed, attention was switched to thyroid isthmusectomy. The thyroid isthmusectomy was previously performed during tracheostomy procedure and thus the scar tissue was excised from the midline tracheal wall and the left thyroid gland was carefully dissected off the trachea where the right thyroid gland was incorporated into the specimen due to predominantly right-sided lesion. Hemostasis was achieved and the vasculature to the thyroid gland was identified and ligated to free up the thyroid gland. Once this was performed, the dissection proceeded in a superior direction along the plane between the trachea and esophagus, releasing the trachea off the esophagus to the level of the cricopharyngeus muscle. Once this was completed, attention was switched to separating the larynx superiorly. An incision was made with the Bovie along the body of the hyoid bone through the strap muscles down to the mucosa of the vallecula and epiglottis. Once the body of the hyoid was released, it was grasped with a Lahey clamp and retracted inferomedially exposing the greater horn of the hyoid. The incision was completed along the greater horn of the hyoid, releasing all fascial and ligamentous attachments in close proximity to the bone to avoid damage to the hypoglossal nerve. Once the greater horn of the hyoid was released on the right side, dissection proceeded toward the left side. In a similar fashion, the hyoid bone was rotated medially, inferiorly exposing the greater horn of the hyoid bone on the right side, and the soft tissue was released off the bone. Once that was performed, attention was turned to the thyroid cartilage. The inferior constrictors were released off the left side of thyroid cartilage and greater horn of thyroid cartilage and piriform mucosa was carefully dissected off the inner portion of the thyroid cartilage. 

The decision was made to enter the oropharyngeal cavity through the left vallecula. The mucosa of the vallecula was excised and opened and the epiglottis noted and grasped and retracted inferiorly. Exposure of the larynx was then obtained on the left side and tumor was also visualized on the left side. Mucosal cuts were made behind the larynx and along the medial walls of piriform sinuses with direct visualization of the lesion to avoid the positive margins. Once the mucosal cuts were made, the rest of the specimen was released from surrounding muscular and ligamentous attachments. Once released, the specimen was submitted to pathology for evaluation. Due to significant redundancy of piriform mucosa, about 1 cm margins were obtained circumferentially and also submitted for frozen section. Once frozen section confirmed the absence of positive margins, 3-0 Vicryl sutures were placed along the most inferior, middle and superior portions of the piriform mucosa. The mucosa was pulled up and the articular linear stapler was used to staple the mucosal edges together. There was a small area at the tongue base where the stapler could not get to. Thus, inverted 3-0 Vicryl stitches were placed along the base of tongue in interrupted fashion to provide a watertight closure. Once this was completed, the oropharyngeal cavity was irrigated with the bulb irrigator and a watertight closure was assured. Once this was completed, the mucosal closure of the neopharynx was reinforced with closure of the inferior constrictor muscles without excessive tension. Once this was performed, the total laryngectomy portion of the procedure was completed.

The neck was thoroughly irrigated. Hemostasis was achieved using bipolar cautery. Four #10 JP drains were placed in the patient's neck, 2 in the lateral aspect of the neck bilaterally with a drain placed underneath the sternocleidomastoid muscle and 2 along the medial portion of the neck in the area of anastomosis. They were carried out through separate stab incisions in the skin. The skin flap then was laid down and stomal stitches using 3-0 Vicryl were placed to create a widely patent stoma. Half mattress stitch technique was utilized to have the edges of the skin encroach and cover the top of the cartilage. This was done under intermittent apneic episodes with close monitoring. Once the stomal stitches were placed, the skin was closed in the platysmal layer with interrupted 3-0 Vicryl. The skin incision was closed with stainless steel staples along the entire incision. The incision was covered with antibiotic ointment. Drains were placed to suction. The patient was turned over to Anesthesia for withdrawal of the general anesthesia. When the patient was able to be maintained on ventilation, the endotracheal tube was withdrawn from the patient's newly-created laryngectomy stoma and he was transferred to the recovery room in guarded condition.

Osteotomy and Tailor's Bunionectomy Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Hallux abductovalgus, left foot.
2.  Tailor's bunion deformity, left foot.

POSTOPERATIVE DIAGNOSES:
1.  Hallux abductovalgus, left foot.
2.  Tailor's bunion deformity, left foot.

OPERATIONS PERFORMED:
1.  First metatarsal osteotomy with internal screw fixation, left foot.
2.  Tailor's bunionectomy, left fifth metatarsal.

SURGEON:  John Doe, DPM

ASSISTANT:  Jane Doe, DPM

ANESTHESIA:  General anesthetic with local block consisting of a total of 20 mL of 2% lidocaine plain.

HEMOSTASIS:  Pneumatic ankle tourniquet at 250 mmHg.

MATERIALS:  DePuy FRS 18 mm screw x 1; Vicryl suture, 3-0 and 4-0; Prolene suture, 4-0; and a 5-0 Monocryl suture.

DESCRIPTION OF OPERATION:  The patient was brought from the preoperative area and placed on the operating room table in the supine position. Following induction of a general anesthetic, the patient's left lower extremity was elevated 60 degrees and a pneumatic ankle tourniquet was placed on the patient's well-padded left ankle. At this time, a local block consisting of 20 mL and 2% lidocaine plain was administered to the first and fifth rays in a Mayo block fashion. The patient's left lower extremity was then scrubbed, prepped, and draped in the usual sterile manner. An Esmarch was then utilized to exsanguinate the patient's left foot.

At this time, attention was directed towards the patient's left foot. A wet sponge was utilized to remove all Betadine prep from the patient's left foot. At this time, approximately, a 6 cm linear incision was made just medial to the long extensor tendon. This incision was created with a #15 blade. Dissection was carried down to the level of the subcutaneous tissues with care being taken to identify and retract all vital neurovascular structures during this dissection. All venous tributaries were isolated, clamped, cut and electrocoagulated as encountered. Dissection was carried down to the level of the deep fascia. At this time, the deep fascia was incised the full length of the original incision. Blunt dissection was then carried down into the first intermetatarsal space in order to perform a soft tissue release.

At this time, the deep transverse intermetatarsal ligament was isolated with a curved hemostat. It was then transected with a #15 blade near its insertion to the lateral aspect of the first MPJ capsule. The adductor tendon was then clearly visualized. The adductor tendon was then released from its insertion of the first MPJ capsule. The great toe was grasped and pulled distally, exposing the tenting on the lateral capsule. A #15 blade was then inserted in this tenting, and the lateral collateral and fibular sesamoidal ligaments were then released both dorsally, distally, and proximally. Upon completion of this soft tissue release, the previously mentioned lateral contracture present on the great toe was reduced. Attention was directed towards the medial aspect of the joint.

At this time, capsular periosteal incision was made full length of the original incision. The capsular and periosteal structures were meticulously reflected off the head of the first metatarsal both dorsally, medially, and plantarly. Once adequate soft tissue exposure had been achieved, the articular cartilage was visually inspected. It was white and glistening in appearance with no osteochondral deficits noted. At this time, attention was directed towards the dorsomedial eminence. This was transected with a power saw from dorsal distal to proximal plantar with care being taken to preserve the sagittal groove. This portion of bone was then freed from any soft tissue attachments, extirpated in toto from the surgical site. At this time, a 0.045 K-wire was driven into the head of the first metatarsal from medial to lateral to act as an apical access guide. Care was taken to preserve the length of the first metatarsal and slightly plantarflex the osteotomy with creation of this access guide.

At this time, an Austin-type osteotomy was created utilizing the 0.045 K-wire with guide. The plantar arm of the osteotomy was created utilizing a sagittal saw from medial to lateral. Care was taken to exit proximal to the sesamoid apparatus and exiting the cortex. The dorsal arm was then created so that there was a 60-degree V cut. The dorsal arm of the cut was equal in length of the plantar arm of the cut. Upon completion of this, the K-wire was removed, and the capital fragment was transposed approximately 3 mm laterally. The first MPJ was put through range of motion. There was no osseous bridging or gapping noted. There was no crepitus noted. Satisfied with the correction, the capital fragment was impacted. Attention was directed towards fixation. At this time, a guidewire from the FRS system was used to temporarily fixate the osteotomy driven from dorsal proximal to distal plantar across the apex of the osteotomy site. C-arm fluoroscopy was utilized to confirm excellent reduction and placement of the guidewire. At this time, utilizing AO fixation principles and lag technique, a DePuy FRS 18 mm screw was inserted over the guidewire. The guidewire was then removed. The first MPJ was put through range of motion. There was no crepitus noted. There was no osseous bridging or gapping noted. C-arm fluoroscopy was utilized to confirm reduction of the deformity.

Satisfied with this correction, attention was now directed towards remaining medial cortical site creation created from the transposition of the osteotomy. This was then transected with a power saw. The entire osteotomy site was then rasped free of all bony irregularities of the first metatarsal head to retain a smooth anatomical contour. At this time, the wound was flushed with copious amounts of normal sterile saline as had been done periodically throughout the procedure and attention was directed towards wound closure. At this time, utilizing a #15 blade, a linear wedge of capsule was taken from the medial aspect in order to pull the sesamoid apparatus underneath the first metatarsal head. The capsular and periosteal structures were then repaired utilizing a 3-0 Vicryl suture in a running-type stitch. The subcutaneous tissues were reapproximated and maintained using a 4-0 Vicryl suture in a simple interrupted suture technique. The skin incisions were reapproximated and maintained using a 5-0 Monocryl suture in a running subcuticular stitch. Upon completion of this, attention was then directed towards the next procedure.

At this time, attention was directed towards the patient's left foot where a tailor's bunion deformity was noted to be present. At this time, an approximately 4 cm linear incision was made just lateral to the long extensor tendon. This incision was created with a #15 blade. Dissection was carried down to the level of the subcutaneous tissues with care being taken to identify and retract all vital neurovascular structures during the dissection. All venous tributaries were ligated, clamped, cut and electrocauterized as encountered. Dissection was carried down to the level of the capsular structures. At this time, a capsular periosteal incision was made the full length of the original incision to expose the head of the fifth metatarsal. At this time, there was a significant amount of exostosis noted on the dorsolateral aspect of the fifth metatarsal head. At this time, utilizing a power saw, the lateral one-third of the metatarsal head was resected. It was then extirpated in toto from the surgical site. A power rasp was utilized to remodel the fifth metatarsal head so it retained its smooth anatomic contour.

The wound was then flushed with copious amounts of normal sterile saline as was done periodically throughout the procedure. Attention was directed towards wound closure. The capsular structures were closed utilizing 3-0 Vicryl suture in a simple interrupted suture technique. The subcutaneous tissue was reapproximated using 4-0 Vicryl in a simple interrupted suture technique. The skin incision was reapproximated utilizing 4-0 Prolene suture in a simple interrupted suture technique. Upon completion of wound closure, postoperative injection consisting of 20 mL of 0.5% Marcaine plain was administered throughout the surgical incision site. Then, 1 mL of Decadron was placed in the interspace of the first metatarsal head. The wounds were then dressed with Betadine-soaked Adaptic, Mastisol, Steri-Strips, sterile 4 x 4s, 4 x 8s, sterile Kerlix, and a sterile Kling. A final C-arm was taken and it confirmed excellent reduction of the deformities. The tourniquet was then released. A prompt instantaneous hyperemic response was noted to all digits of the left foot. Coban was then applied and a postoperative shoe will be dispensed. The patient tolerated the procedure and anesthesia well. The patient left the OR with vital signs stable and vascular status intact to all digits of the left foot.


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Radiology - MRI and MRA - Medical Transcription Transcribed Sample

MRI OF THE HEAD:

The MRI of the head shows diffuse atrophy.  There is no abnormality of the craniocervical junction.  There is a small probable mucus retention cyst in the inferior right maxillary sinus.  The brainstem is grossly intact.  There is a slight increase in atrophy with regards to the left temporal lobe in comparison to the right.  This is mild asymmetry however.  No large territorial defects are noted.

There is, however, noted on both the T2 and FLAIR images an area of very vague high signal along the left mid lateral ventricle region.  This area of white matter suggests some probable demyelination.  This is brought up in particular because, when contrast was given, there was a very vague sliver of enhancement directly in that area.  This is seen on coronal imaging as well.  This could be related to some collateral vessels and they are seen with contrast.  Collateral vessels will be necessary due to the absence of good flow to the left MCA and ICA distribution on the left on the MRA, which will be described further following this report.  Therefore, that is felt the most likely etiology.  Other etiologies on this very vague and subtle enhancement would be tumor or luxury blood flow around a recent small ischemic insult.  I would recommend that this simply be followed up over time in approximately 6 to 9 months or sooner if symptoms change.

There is no other area of enhancement of concern that is noted.  We do see some asymmetry to the vascular venous drainage pattern with the gadolinium on the axial images in the posterior fossa and around the temporal lobe region on the left, which most likely again is related to the change in collateral flow to the left cerebral hemisphere.

The IAC and cerebellopontine angle regions do not show masses.  No enhancing abnormality is noted to suggest an acoustic tumor.  The inner ear and mastoid air cells are well aerated.

IMPRESSION:
1.  Diffuse atrophy.
2.  FLAIR and T2 weighted images suggests some ischemic high signal changes in the white matter adjacent to the left lateral ventricle.  In this area, with gadolinium, a small sliver of enhancement persists on both axial and coronal images.  This sliver of enhancement may be related to collateral blood flow or luxury perfusion or recent ischemic insult.  It could, though felt less likely, be related to mild enhancement of an underlying tumor.  I feel this is less likely, and in light of no change in clinical symptoms, I would recommend simply a repeat MRI with gadolinium in approximately 6 to 9 months.
3.  No other abnormal enhancement is noted.
4.  There is a mild increase in atrophy with regards to the left temporal lobe when compared to the right; however, this is diffuse and subtle.
5.  The internal auditory canal and cerebellopontine angle regions are normal in appearance.

MRA OF CIRCLE OF WILLIS:

The circle of Willis shows absence of normal flow to the left internal carotid artery.  There is no vertebral or petrous portion identified on this examination.  No supraclinoid portion is noted and no normal left middle cerebral artery is present.  We do have both a left and right anterior cerebral artery, which appears to be fed predominantly from the right side.

We see a very small amount of flow in an area, which may be a remnant or collateralized left MCA.  MRA tends to overemphasize areas of narrowing such that there may be a small residual left middle cerebral artery with reduced flow.  There is some flow that is seen distally in the left middle cerebral artery distribution, which is presumably due to some collateralization.

The right middle cerebral artery is patent without significant focal narrowing.  There is some mild atherosclerotic disease noted in the internal carotid artery as well as the mid and distal right middle cerebral artery.  The right A1 segment is pronounced and appears to predominantly feed both the anterior cerebral arteries.

There is no visible posterior communicating artery on this examination.  The basilar artery is grossly intact with some mild atherosclerotic disease.  No varying aneurysm is noted.  Bifurcation to the right and left posterior cerebral arteries is symmetrical with some mild atherosclerotic disease suggested in both of those arteries.

IMPRESSION:  
1.  Absence of a left internal carotid artery or a normal left middle cerebral artery on this examination.  There is some very minimal horizontal flow where one would expect the left middle cerebral artery such that there may be some residual small flow, which is not as easily detected on MRA.  Also, there are some distal branches in the area of the temporal artery region of the distal left middle cerebral artery distribution; this may be fed by collateral flow.
2.  There is no apparent posterior communicating artery to lend definite connection between the posterior and anterior circulations.
3.  Both the left and right anterior cerebral arteries are noted and fed predominantly by the right A1 segment.
4.  Some mild atherosclerotic disease is noted in the right internal carotid artery and some mild atherosclerotic disease is present in the distal right middle cerebral artery.

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Nephrology - Renal Consultation Medical Transcription Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  Jane Doe, MD

REASON FOR CONSULTATION:  Acute renal failure on chronic kidney disease.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old woman admitted with complaints of chest pain and shortness of breath. Per family, she also had episodes of nausea, vomiting and diarrhea. She was hypotensive. Review of data revealed that she was hypotensive in the emergency department with her blood pressure dropping to the 70s/20s. She is now on a dopamine drip with her blood pressure increasing to 90s-100s/30s-40s. Of note, on admission, her BUN and creatinine were 72 and 2.1 respectively, which decreased to 51 and 1.5 later today. She remains oliguric. Review of her other labs reveal a BUN and creatinine of 54 and 1.2 respectively 2 weeks ago. We are consulted for further evaluation and management of her renal disease. Of note, her potassium was 6.6 on admission and it has been treated medically and at present is down to 5.1.

PAST MEDICAL HISTORY/PAST SURGICAL HISTORY:
1.  Chronic kidney disease with suspected baseline creatinine of 1.3 mg/dL on labs reviewed from 2 weeks ago.
2.  Type 2 diabetes mellitus.
3.  Hypertension.
4.  Coronary artery disease, status post CABG, status post stent and angioplasty subsequent to this.
5.  Dyslipidemia.
6.  Status post hernia repair.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

CURRENT MEDICATIONS:  Isordil 10 mg 3 times daily, Synthroid 25 micrograms daily, Lipitor 40 mg daily, aspirin 325 mg daily and Coreg 25 mg daily.

SOCIAL HISTORY:  The patient denies any alcohol, tobacco or illicit drug abuse.

FAMILY HISTORY:  Noncontributory.

PHYSICAL EXAMINATION:
GENERAL:  The patient is alert, in no acute distress.
VITAL SIGNS:  Blood pressure is 98/34, temperature is 98.6, pulse is 110, respirations 20. She is saturating 99% on 8 liters of nasal cannula. Yesterday's I's and O's are 745 in and 1400 out. Today's I's and O's are 1276 in and 1000 out.
HEENT:  Reveals pink conjunctivae, moist mucous membranes, and no oral lesions.
NECK:  Her neck is supple with JVD.
CARDIAC:  Regular rate and rhythm with normal S1 and S2.
LUNGS:  Demonstrate bibasilar crackles, left greater than right, with good air exchange.
ABDOMEN:  Her abdomen is soft and nontender with normal bowel sounds.
EXTREMITIES:  There is no lower extremity edema appreciated.

LABORATORY DATA:  WBC count is 11.7, hemoglobin 10.2, platelets 232. Sodium is 137, potassium is 5, chloride 104, bicarbonate 24, BUN and creatinine are 51 and 1.5 respectively (improved from 72 and 2.1 on admit), glucose 70, calcium 8.4, BNP 1030. Urinalysis demonstrates a specific gravity of 1.010, protein is 29, pH is 5.4, 12 rbc's, full field wbc's. Random urine sodium is 120, random urine creatinine is 6.6, random urine protein is 35, fractional excretion of sodium is 21.07%.

IMPRESSION AND PLAN:
1.  The patient has acute renal failure, which I suspect is secondary to acute tubular necrosis related to her hypotension. This is supported by her markedly increased fractional excretion of sodium. I am encouraged by the fact that her hemodynamics is stable with the administration of vasopressor therapy. I will continue this to keep her systolic blood pressure greater than 80 to 90 mmHg. To further investigate this, I will check a renal ultrasound to assess for kidney size and echogenicity and to rule out any degree of obstruction. I would check her renal function at least twice daily for now.
2.  She does have some evidence of pulmonary edema, which is mild in nature. This is based on clinical exam as well as chest x-ray. We will therefore decrease her IV fluids to 30 mL/hour. We will give her one time dose of Lasix 20 mg x1. I will follow her I's and O's, daily weights and renal function very closely.
3.  Her hyperkalemia on admission is deemed secondary, predominantly, to her acute renal failure and complicated by ongoing administration of Diovan and Bactrim. I will hold Diovan and Bactrim. Her potassium is now within normal limits status post Kayexalate, insulin, D50, calcium gluconate and sodium bicarbonate. I will recheck her potassium twice daily for now and continue medical management as needed.
4.  The etiology of her hypotension is unclear, however may be related to sepsis versus acute coronary syndrome causing left ventricular dysfunction. I suspect sepsis may be a cause since her urinalysis is highly suspicious of significant urinary tract infection and she also has leukocytosis. I will pan culture her and empirically plan on starting her on Levaquin at this point. In terms of the latter, I agree with checking a 2D echocardiogram to assess her LV function.
5.  If any cardiac catheterization is deemed necessary, the patient is at risk for contrast nephropathy and therefore will need prophylaxis with Mucomyst and IV bicarbonate.

Thank you for allowing us to participate in the care of this patient. We will follow along closely with you.

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Plastic Surgery - Blepharoplasty and Facelift Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Facial aging.

POSTOPERATIVE DIAGNOSIS:  Facial aging.

OPERATIONS PERFORMED:
1.  Upper and lower blepharoplasty.
2.  Facelift.
3.  Fat injections to the upper lip.
4.  Fat injections to the marionette lines and nasolabial folds bilaterally.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  Minimal.

DESCRIPTION OF OPERATION:  After the patient was explained the risks and benefits of undergoing upper and lower lid blepharoplasty, facelifting and fat injections to her upper lip, nasolabial folds and marionette lines as well as dermabrasion to the lip, she was brought to the operating room and placed supine on the operating room table. General endotracheal anesthesia was induced, and the patient's head and neck as well as a small portion of her abdomen were prepped and draped in the usual sterile fashion. Following this, approximately 50 mL of local anesthesia was injected into her abdomen as well as several milliliters into her upper lids bilaterally after they had been marked with a classic blepharoplasty elliptical incision. Following this, approximately 15 mL of fat was liposuctioned from her abdomen using a #5 French liposuction cannula and the fat was placed in a washing tub and rinsed several times until it was purified fat. It was then placed in 10 mL syringes to be injected later into the upper lip, nasolabial folds and marionette lines.

Following this, attention was turned to the bilateral upper eyelids and a 15 blade was used to incise down through skin and subcutaneous tissue through the orbicularis oculi muscles and a skin-only resection of upper eyelid skin was performed. Following this, tenotomy scissors were used to dissect the orbicularis muscle free from its underlying structures and a small strip of orbicularis muscle was also excised. Of note, the vertical dimensions of the upper eyelid skin resection were approximately 13 mm in vertical diameter at the midpupillary line. Following this, careful hemostasis was obtained and a small incision was made in the medial aspect of the eyelid to access the medial fat pad of the upper eyelid. A small amount of medial upper eyelid fat was resected in order to deal with the pseudoherniation of the patient's upper medial fat pad. Following this, once again, careful hemostasis was obtained and the patient's eyelids were then closed in two layers. The first layer was several interrupted 6-0 nylon sutures and the final layer was a running nylon in classic fashion.

Following this, the bilateral lower eyelids were injected with approximately 8 mL of our local anesthetic mix. After allowing 10 minutes to elapse during which time 4 mL of fat were injected into the upper lip, the patient's lower blepharoplasty subciliary incision was made with a 15 blade. Following this, a skin-only flap was dissected on the preorbital orbicularis oculi, and following this, skin and muscle flap was elevated down to the upper orbital rim. The patient's lower eyelid, skin and muscle were elevated, thus revealing the septum and beneath that the infraorbital fat pad. The medial and middle fat pads were accessed and approximately 1 mL of fat was resected from the fat pads on each side. Care was taken to resect a symmetrical amount of fat from both sides, and following this, Bovie electrocautery was used to obtain very careful hemostasis. Following resection of the fat pads, a 2 mm rim of lower eyelid skin was removed. A 4-0 interrupted Vicryl suture was used to pass through the lateral orbicularis oculi muscle to the lateral orbital rim and then the lower eyelids were closed in a single layer of running 6-0 nylon sutures.

Following this, attention was turned to injecting approximately 2.5 mL of fat in the bilateral nasolabial folds and bilateral marionette lines, and following this, a standard facelift incision was incised using a 15 blade down through the skin and dermis. Following this, the subcutaneous plane was dissected free in classic facelift fashion using facelift scissors. Careful hemostasis was then obtained on all the subcutaneous spots as well as the deep tissues taking care to avoid injury to any underlying neurovascular structures. Once this had been performed, bilateral SMAS flaps were elevated and were sutured into position in a vertical vector using an interrupted 4-0 Monocryl suture. Excess skin of the facelift incisions was then resected and the facelift was closed in two layers. The dermis was closed with interrupted 5-0 Vicryl sutures and the skin was closed with running 5-0 nylon in a preauricular position and running the 4-0 chromic in the postauricular and hairline region. The patient was then awoken from general anesthesia and taken to the recovery room in good condition.

Plastic Surgery Operative Sample Reports      Plastic Surgery Operative Sample Reports #2

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Allergy and Immunology Medical Transcription SOAP Note Sample

SUBJECTIVE:  The patient is a (XX)-year-old female who has been previously evaluated and treated by Dr. Doe. His initial note stated that she was skin tested with multiple positive tests. Subsequently, she became pregnant and was lost to followup. The patient has year-round allergic rhinitis and to some extent conjunctivitis, which is exacerbated in the spring and to a lesser extent in the late summer. At times in the spring and late summer, she will wheeze. She may also wheeze when she has an upper respiratory infection. With the wheezing, her chest may be tight. She claims to have a history of 3 to 4 upper respiratory infections a year. She also has a history of recurrent ear infections, primarily on the left, not in the past 3 years. Her sense of smell appears to be intact. She denies history of sinusitis, pneumonia or cigarette smoking. She claims to have had bronchitis on 3 different occasions; the last episode was several years ago. In the spring of (XXXX), she had 2 episodes of hives on her anterior neck and chest.

The patient also has multiple food allergies, primarily to apples, plums, strawberries, peaches, pears, cherries, melons, pineapples, kiwi, and bananas, primarily with itchy throat, etc. Nuts such as walnuts and almonds provoke an itchy throat as well. Her sister has allergic rhinitis. Her mother has allergic conjunctivitis. For the past 4 years, she has lived in a 5-year-old house, central air conditioning, regular pillow and mattress, wall-to-wall carpeting. The patient has a 15-month-old daughter who is taken care of by the patient's mother during the day. There is no animal exposure. For the past 6 years, she has worked in an office with central air conditioning.

MEDICATIONS:  Present medications include Claritin, which does not seem to help. She has hydrocortisone cream for eczema. She uses Cetaphil cleansing lotion. She is not aware of any allergies to medications.

OBJECTIVE:
GENERAL:  The patient is a well-developed, well-nourished female, in no acute distress.
VITAL SIGNS:  Blood pressure 132/84. Pulse 78 and regular.  Height 68 inches. Weight 142 pounds.  Pain score 0.
HEENT:  Conjunctivae within normal limits.  The left tympanic membrane was distorted and scarred with some centralized erythema.  The right tympanic membrane and both auditory canals were within normal limits.  The nasal mucosa was boggy. Nasal septum was within normal limits.  The oropharynx was clear.
NECK:  Examination revealed soft movable anterior nodes. There were no palpable thyroid masses.
LUNGS:  Clear.
HEART:  Examination at the base was within normal limits.
SKIN:  Generally dry. There were scattered fine maculopapular lesions on her arms with some excoriations.

ASSESSMENT AND PLAN:
1.  The patient has perennial and seasonal allergic rhinitis with conjunctivitis. She also has mixed asthma, primarily extrinsic. She has food allergies to the aforementioned foods. The patient will avoid fruits and all nuts. The patient will carry Benadryl. I also gave her an EpiPen to use if she has an allergic reaction that was associated with difficulty breathing or lightheadedness.
2.  She also has atopic dermatitis. I gave her some Lidex E to be applied b.i.d. p.r.n. to erythematous dermatitis.  She has mite covers on her bedding.  I prescribed Allegra D 24 hours 1 p.o. daily p.r.n. and Patanol drops 1 each eye b.i.d. p.r.n. I also gave her a prescription for albuterol 2 inhalations q.i.d. p.r.n. wheezing and tightness in her chest. I told her that if she started to use this regularly, more than once or twice a day, she is to call me.

I plan to see her in June for followup evaluation of her regular allergies. I plan to bring her in earlier for local anesthetic testing. In the meanwhile, I have ordered a RAST to latex, bananas, kiwi, cherries, melons, avocado, and chestnut. The patient’s spirometry ordered and reviewed by me today was within normal limits.

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Dental / Maxillofacial Surgery Transcribed Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Obstructive sleep apnea.
2.  Dental caries, tooth #4, nonrestorable.

POSTOPERATIVE DIAGNOSES:
1.  Obstructive sleep apnea.
2.  Dental caries, tooth #4, nonrestorable.

OPERATION PERFORMED:
Advancement genioplasty and surgical extraction of tooth #4.

SURGEON:  John Doe, DDS 

ANESTHESIA:  General via oral endotracheal tube.

ESTIMATED BLOOD LOSS:  Minimal.

SPECIMENS:  Tooth #4, sent to surgical pathology for gross identification.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and placed in the supine position. After induction of general anesthesia via an oral endotracheal tube, the patient was prepped and draped in the usual sterile fashion. The patient received preoperative antibiotics and steroids intravenously. Also, approximately 6 mL of lidocaine with 1:100,000 epinephrine was injected around tooth #4 and also infiltrated into the anterior mandibular labial vestibule.

We began with the extraction of tooth #4. A periosteal elevator was used to elevate the mucoperiosteal flaps and a straight elevator and bayonet forceps were used to deliver the tooth. No sutures were placed over the extraction site. The tooth was sent to pathology for gross identification only.

Next, we performed the advancement genioplasty. Monopolar Bovie electrocautery set at 25 cut, 25 coag, was used to make a 5 cm curvilinear incision on the mucosal surface of the lower lip. This was carried down to and through the mentalis muscle and to and through periosteum. Superior and inferior mucoperiosteal flaps were elevated. We took great care to dissect bluntly and identify the mental nerves, first on the left side and then the patient's right side. Great care was taken throughout the procedure to preserve these nerves intact.

Next, a hole was drilled with a small tapered fissure bur in the midline, exactly 25 mm inferior to the incisal edges of the mandibular central incisor teeth. This hole was to mark our midline and the superior and inferior position of our osteotomy cut. Two holes were drilled approximately 5 mm superior and inferior to this hole to also assist with marking the midline. A reciprocating saw was then called for and the osteotomy cut was performed. This cut was in an oblique fashion through the osseous chin, and it was 5 mm inferior to the mental foramen on both sides and through our midline hole that was marked. The chin was then freed up and our usual set of three pairs of drilled holes were placed to advance the chin. Finally, a total of three 24 gauge surgical stainless steel wires were placed through these paired holes and tightened to advance the chin 10 mm. Good bone-to-bone contact was noted on the lingual edge of the distal segment. There was good fixation of the osteotomized segment.

A meticulous layered plastic closure was then performed. Copious amount of irrigation was used to cleanse the wound and 3-0 Vicryl interrupted sutures were used to reapproximate the mentalis muscle and 4-0 chromic gut sutures were used to reapproximate the mucosa. There were no complications during this procedure. The patient appeared to tolerate the procedure well. The sponge and needle count was correct at the end of the procedure.


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