Dacryocystorhinostomy Intubation of Nasolacrimal System Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Chronic left dacryostenosis.
2.  Chronic left dacryocystitis.

POSTOPERATIVE DIAGNOSES:
1.  Chronic left dacryostenosis.
2.  Chronic left dacryocystitis.

OPERATION PERFORMED:
Left dacryocystorhinostomy and intubation of left nasolacrimal system with Crawford tube.

SURGEON:  John Doe, MD

ANESTHESIA:  Local sedation.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  Less than 25 mL.

DESCRIPTION OF OPERATION:  After adequate intravenous sedation was given, a marking pen was used to demarcate the initial skin incision.  This began 10 mm medial to the left medial canthal area and carried inferolaterally for 15 mm.  Local anesthesia of Xylocaine 2% with 1:100,000 concentration of epinephrine mixed with Marcaine 0.75% in a ratio of 2:1 was injected into the left medial canthal area and left lower eyelid.  In addition, infraorbital nerve block and an anterior ethmoidal nerve block was given with the same solution.  Same solution was injected into the left middle meatus, which was then packed with neuro patties dampened in Afrin.  The patient was prepped and draped in the usual fashion for DCR and a corneal protective lens was placed into the left eye after instillation of topical tetracaine.  Incision was made through the skin and subcutaneous tissues, along the previously demarcated line and dissection was carried down to the lacrimal crest.  An incision was made through the periorbital lacrimal crest and the lacrimal sac was reflected out of the fossa.  Osteotomy, 12 mm in diameter, was then created with the Stryker drill, removing lacrimal bone as well as part of the anterior ethmoid and a portion of the medial maxillary bone.  At this point, the upper and lower canalicular systems were dilated and Bowman probe was passed through the upper and lower systems.  The lacrimal sac was then opened and large amount of mucoid material was recovered from the sac.  A large anterior lacrimal sac flap was created and then a smaller flap was excised.  Corresponding anterior nasal flap was created and again a smaller posterior flap excised.  Crawford tubes were then woven through the upper and lower canalicular systems, through the osteotomy and out through the nose, and then ends of the tubes tied to each other and a 6-0 nylon suture tied around the ends of tube.  This was trimmed and allowed to retract into the left nostril.  Osteotomy was then packed with Gelfoam which had been dampened with dilute solution of gentamicin.  The lacrimal sac flap was then anchored to the nasal mucosa flap with mattress suture of 5-0 chromic, which was then anchored to the subcutaneous tissues.  Subcutaneous closure was performed with additional 5-0 chromic sutures.  The skin edges were reapproximated with 6-0 nylon in a running fashion.  The corneal protective lens was removed.  Surgical site was cleansed and Steri-Strips and Telfa pad applied across the incision.  Gelfilm was then coated with Gentak ointment and placed into the left middle meatus.  Gentak ointment was placed in left eye and the patient left the operating room in good condition, having tolerated the procedure without complications.


Irrigation and Debridement (I and D) Tibia Operative Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Infection, left tibia.

POSTOPERATIVE DIAGNOSIS:
Infection, left tibia.

PROCEDURE PERFORMED:
Irrigation and debridement, left tibia.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

SPECIMENS:  Multiple cultures and cell count.

ESTIMATED BLOOD LOSS:  100 mL.

COMPLICATIONS:  None.

TOURNIQUET TIME:  28 minutes.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room and placed supine on the operating room table.  He received general anesthesia by the anesthesia team.  A tourniquet was placed on the left upper thigh.  The left leg was then prepped and draped in normal sterile fashion.  The leg was then held elevated for approximately 5 minutes.  The tourniquet was inflated to 250 mmHg.  The proximal incision was then opened in elliptical fashion, excising the granulating wound proximally to healthy tissue.  Dissection was carried down.  The metal plate was directly underneath the wound and appeared intact.  There was no significant gross purulent material that was seen; however, there was some cloudy material which was expressed.  A rongeur was then used to debride any nonvitalized tissue.  Good bleeding was seen from the wound edges.  The middle incision appeared to be fully healed; however, the point of rupture was a few centimeters medial to this incision with poor skin seen.  This was the area of the previous fracture blister, which has regressed.  An elliptical excision was then performed of this tract and excised.  Dissection was carried down once again to the metal hardware.  There was communication between the middle and proximal incision, distal incision appeared to be fully healed.  It appeared that there was no tract distally.  Once again, a rongeur was used to debride any nonvitalized tissue.  Then, 9 liters of irrigation solution with vancomycin antibiotic was used to irrigate the two incisions.  The irrigation was used along the track of the hardware.  It was used in the proximal incision, both medial, lateral, proximal and distal, through the middle incision; once again medial, lateral, proximal and also distal as much as possible.  All fluid was expressed from the leg.  The ankle was arranged to allow irrigation fluid to track into the muscle and onto the bone.  The plate was irrigated with pulsatile lavage as well.  After, 9 liters of irrigation, 3-0 Monocryl was used to close the subcutaneous tissues followed by 2-0 nylon in retention suture configuration for both incisions.  There was no skin compromise or blanching after the wound closure.  The tourniquet was deflated prior to wound closure.  Hemostasis was achieved mainly with pressure.  There were good bleeding edges at the wounds, both proximal and middle.  After wound closure, sterile dressing was applied.  The left lower extremity was placed in an AO splint.  The patient tolerated the procedure well and was taken to the recovery room in stable disposition.  Multiple cultures and cell counts were sent from both proximal and middle incisions for analysis.  In the recovery room, 1 g of vancomycin was then given intravenously.


Vitrectomy Scleral Laceration Repair Air-Fluid Exchange Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
Ruptured globe, left eye; status post ocular penetrating trauma, left eye; mild cataract, left eye; vitreous hemorrhage, left eye; possible retinal detachment, left eye.

POSTOPERATIVE DIAGNOSES:
Ruptured globe, left eye; status post ocular penetrating trauma, left eye; cataract, left eye; vitreous hemorrhage, left eye; retinal detachment, left eye; perforating scleral injury, left eye; intraocular foreign body, left eye.

OPERATION PERFORMED:
A 20-gauge vitrectomy, left eye; removal of intraocular foreign body, left eye; repair of scleral laceration, left eye; removal of vitreous hemorrhage, left eye; repair of retinal detachment, left eye; air-fluid exchange, left eye; silicone oil vitreous substitute air exchange, left eye; indirect laser placement, left eye.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

DESCRIPTION OF OPERATION:  The patient was identified in the holding area and dilating drops were placed in his left eye. He was brought back to the operating room and placed supine on the operating room table. General anesthesia was initiated, and a retrobulbar block using only a few mL of 2% lidocaine and 0.75% Marcaine was given to his left eye. No digital pressure was applied following the retrobulbar block in case that there was an additional scleral laceration. The left eye was then prepped and draped in the usual sterile fashion. The operating microscope was brought into position, as well as the 20-23-gauge vitrectomy system. A 360-degree conjunctival peritomy was performed. Each of the 4 quadrants were spread using the Stevens scissors. The rectus muscles were isolated with 2-0 black silk suture ties. The globe was explored and a large scleral laceration under the lateral rectus muscle was identified. The lateral rectus muscle was removed at its insertion and the scleral laceration repaired using 8-0 nylon interrupted sutures. There was vitreous presentation at the laceration site. This was removed gently using the Weck-cel technique. The intraocular foreign body was found at the distal end of the wound. The metallic foreign body was sent to pathology. The lateral rectus muscle was then resutured to the sclera. The indirect ophthalmoscope was used to inspect the retina and vitreous. View was obscured by the vitreous hemorrhage. Since it was felt that there was retinal incarceration within the wound and likely retinal detachment, the decision was made to perform the vitrectomy. The 23-gauge cannulas were placed. The infusion trocar was verified and the infusion pressure turned on to 20 mmHg. Two additional trocars were placed at the 10 and 2 o'clock positions. No light pipe or Microvit were used to enter the eye. With the assistance of intravitreal Kenalog for visualization, the central vitreous and vitreous hemorrhages were removed. There was retinal detachment found, which did involve the macula. Fortunately, the scleral laceration only extended to the temporal edge of the macula and did not involve the fovea. There was loss of overlying choroid and RPE in the area of the scleral laceration site. Using intraocular diathermy and the Microvit, the retina was removed from the sites of incarceration. Perfluoron was then used to flatten the retina and laser placed along the edges of the previously incarcerated retina using the indirect ophthalmoscope attachment. A Perfluoron air exchange was performed followed by a silicone oil vitreous substitute air exchange. I noted that the optic nerve appeared healthy. The sclerotomies were closed and the eye left watertight at a pressure of approximately 20 mmHg. Then, 0.2 mL of intravitreal Kenalog was placed to hopefully prevent formation of proliferative vitreoretinopathy postoperatively. Subconjunctival injections of vancomycin and dexamethasone were given as well. The corneal epithelium was decompensating towards the end of the case, but fortunately no corneal scraping was required. The conjunctiva was closed using 8-0 Vicryl suture. A patch and shield and TobraDex ointment were placed over the patient's left eye. The patient will be admitted for postoperative positioning and will be seen in one day for followup.

Transvitreal Fine Needle Aspiration Biopsy of Choroidal Tumor Sample

Trabeculectomy Sample Report

Rectus Recession Operative Sample Report      Entropion Repair Operative Sample Report

Ophthalmology Operative Samples # 1             Ophthalmology Operative Sample Reports #2

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ORIF Small Finger Metacarpal Shaft Fracture Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Left small finger with displaced metacarpal shaft fracture.

POSTOPERATIVE DIAGNOSIS:
Left small finger with displaced metacarpal shaft fracture.

OPERATION PERFORMED:
Open reduction and internal fixation of left small finger metacarpal shaft fracture.

SURGEON:  John Doe, MD

ANESTHESIA:  General with regional block.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and positioned supine on the operating table. A time-out was taken at which point the patient's identity, procedure, laterality and surgical plan were reviewed and confirmed. Then, 1 gram of IV cefazolin was administered and general anesthesia was induced. A regional block was placed by the anesthesiologist. A left arm tourniquet was placed and the left upper extremity was then prepped and draped in standard sterile surgical fashion. The planned longitudinal incision was marked out. After exsanguination, the tourniquet was inflated. A skin incision was made and carefully carried down to the subcutaneous tissue. The extensor tendon to the small finger was carefully retracted radially. The periosteum underling the fascial site was opened and dissected radially and ulnarly. The fascial site was cleaned and fascia reduced without significant difficulty. The appropriately-sized 2.0 mm Synthes plate was chosen and affixed to the dorsal ulnar aspect of the metacarpal. Being satisfied with the plate position, the screw holes were filled with 2.0 mm screws with good purchase. Satisfactory reduction and hardware placement were confirmed on fluoroscopy. The wound was then thoroughly irrigated. The interossei and periosteum were repaired over the plate and the dermis was then reapproximated using 4-0 Monocryl suture. The hand was then washed and dried and 10 mL of 0.5% Marcaine with epinephrine was injected into the skin about the incision. A dry sterile dressing was placed followed by a well-padded ulnar gutter splint. The tourniquet was let down with immediate reperfusion to the entire hand. Estimated blood loss was minimal. Sponge, needle and instrument counts were correct and certified x2.

ORIF of Radius and Ulnar Fracture Sample     ORIF of Thumb Intra-articular Base Fracture


Left Tube Thoracostomy Procedure Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Left persistent pneumothorax.

POSTOPERATIVE DIAGNOSIS:
Left persistent pneumothorax.

OPERATION PERFORMED:
Left tube thoracostomy.

SURGEON:  John Doe, MD

ANESTHESIA:  Morphine, fentanyl, 1% lidocaine with epinephrine.

ESTIMATED BLOOD LOSS:  Minimal.

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old female who fell and had an injury to her chest.  The patient went to the emergency room where a left-sided chest tube was placed for a pneumothorax. The patient was transferred to this facility. The patient had a persistent pneumothorax, despite the left-sided chest tube. The pneumothorax became larger as seen on chest x-ray. Therefore, the patient was recommended to have a new left chest tube placed. The patient was educated on the risks, benefits and alternatives and agreed to undergo this procedure.

DESCRIPTION OF PROCEDURE:  The patient was in the supine position on her bed. The patient's left arm was restrained above her head. The dressings from the preexisting chest tube were removed. The chest was then prepped and draped in the usual sterile manner. Lidocaine 1% was injected several centimeters above the previously placed chest tube on the mid axillary line above the level of the nipple. An incision was made with a #11 blade measuring approximately 2 to 3 cm long. The underlying tissues were dissected bluntly with a clamp and superiorly down to the chest wall. More 1% lidocaine was injected into the pleura and the underlying soft tissues. A Kelly clamp was used to puncture the pleura just above the rib and this was spread. A finger was inserted into the chest cavity and the lung was palpated. Any adhesions between the lung and the chest wall were taken down bluntly. Following this, a 36-French chest tube was placed in the chest cavity. It was then secured in place with a 2-0 silk suture and 3-0 nylon U stitch was placed. Sterile dressings were applied. The chest tube was placed to suction.  A chest x-ray was ordered for confirmation of placement.

Ankle Tarsal Tunnel Release Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Left ankle tarsal tunnel syndrome.

POSTOPERATIVE DIAGNOSIS:
Left ankle tarsal tunnel syndrome.

OPERATION PERFORMED:
Left ankle tarsal tunnel release.

SURGEON:  John Doe, DPM

ANESTHESIA:  General anesthesia with local of 20 mL 0.5% Marcaine with epinephrine.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

INJECTABLES:  Five mL of 0.5% Marcaine with epinephrine, 1 mL of Decadron.

DESCRIPTION OF OPERATION:  Under mild sedation, the patient was brought to the operating room and placed on the operating table in the supine position. Following general anesthesia and 1 gram of Kefzol, approximately 20 mL of 0.5% Marcaine with epinephrine was injected about the left ankle. The foot was then scrubbed, prepped and draped in the usual aseptic manner. The left leg was then elevated and exsanguinated and the left high leg tourniquet was inflated to 300 mmHg.

Attention was directed to the medial aspect of the left ankle, the tarsal tunnel area, where a 4 cm incision was made along the course, just posterior inferior to the posterior tibial tendon. The incision was then deepened down to flexor retinaculum, which was incised. The compartment of the tibial nerve and tibial artery and venae comitantes were identified. The tibial nerve was identified, noted to have moderate fibrosis and fatty tissue on the tendon, but no signs of ganglion cysts or other foreign body. The scar tissue and fatty tissue was debrided from the nerve. The incisions followed inferiorly down to the porta pedis, which was opened in order to decompress the nerve. The flexor digitorum longus tendon was also identified and opened the tendon sheath. No signs of pathology or synovitis were noted.

The incision was then flushed with copious amounts of saline and Kantrex. The skin was closed with 4-0 Vicryl and 4-0 nylon. The incision was then injected with 5 mL of 0.5% Marcaine with epinephrine, 1 mL of Decadron and bandaged with Betadine-soaked Adaptic, Betadine-soaked 4 x 4's, fluffs, Kling, cast padding and short leg splint. The left high leg tourniquet was deflated at approximately 20 minutes with prompt hyperemic response to the left foot. The patient left the OR for the PACU with vital signs stable. The patient is to remain partial weightbearing with crutches.


Sample Newborn Medical History and Discharge Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY

HISTORY OF PRESENT ILLNESS:  Infant is (XX) weeks’ gestation large for gestational age female who was born via normal spontaneous vaginal delivery.  Mother is (XX) years old, gravida 1, para 0, A negative, serology negative.  Other prenatal labs were negative.  Mother had pregnancy-induced hypertension during this pregnancy and was induced at 36 weeks’ gestation secondary to PIH.  Rupture of membrane was 21 hours prior to delivery.  Mother also had temperature of 100.8 degrees Fahrenheit during labor and did receive ampicillin, multiple doses.  Baby was born with Apgars of 8 and 9, and after birth, the infant became tachypneic during transition to 70-80 breaths per minute, and the infant was admitted to NICU for further management.

PHYSICAL EXAMINATION ON ADMISSION:
VITAL SIGNS:  Tachypneic with a respiratory rate of 80 per minute.  Mild retractions.  Pink on room air.  O2 saturations were 96% on room air.
HEART:  Regular rate and rhythm.  No murmur.  Pulses were normal.
LUNGS:  Clear.
ABDOMEN:  Soft.  No hepatosplenomegaly.
GENITOURINARY:  Normal female.
NEUROLOGICAL:  Grossly good tone.

ADMISSION DIAGNOSIS:
1.  Transient tachypnea of newborn.
2.  Rule out sepsis secondary to respiratory distress and prolonged rupture of membranes and maternal fever.

PLAN ON ADMISSION:  To keep the baby NPO, on IV fluids.  Septic workup was done.  IV antibiotics were started.  Infant was observed on pulse oximetry with O2 saturations between 92-96%.  Parents were told regarding the status of the infant and management in NICU.

HOSPITAL COURSE:
1.  TTN.  The infant gradually started to breathe normal with a respiratory rate of less then 60 breaths per minute by the end of the day of admission, and the TTN problem was resolved as well.
2.  Rule out sepsis.  Workup was done secondary to respiratory distress, prolonged rupture of membranes and maternal fever.  CBC was with 8 bands, but the rest of the CBC was benign.  Blood culture remained negative until 72 hours, after which the antibiotics were stopped and the problem was resolved.
3.  Hypoglycemia.  The infant had a D-stick of 46 initially but then improved gradually with feeds and the problem was resolved.
4.  Hyperbilirubinemia.  The infant looked icteric since MM/DD/YYYY.  On MM/DD/YYYY, the bilirubin level was 10.4 and the direct was 0.4, and on MM/DD/YYYY, the bilirubin level was 12.2 with the direct of 0.4.  Baby’s blood type was A negative, direct Coombs negative.  Although looks very icteric, but the bilirubin level was only 12, and it was not adequate to start the phototherapy.  Mother is told to continue to supplement and watch for 6-8 wet diapers and make sure that the baby is well hydrated, and in case of worsening of jaundice, she will call the pediatrician right away.  On MM/DD/YYYY, the infant was in stable condition.

PHYSICAL EXAMINATION ON DISCHARGE:
VITAL SIGNS:  Stable.
HEART:  Regular rate and rhythm.  No murmur.  Pulses are normal.
LUNGS:  Clear.
ABDOMEN:  Soft.  No hepatosplenomegaly.
NEUROLOGICAL:  Grossly good tone.

DISCHARGE DIAGNOSIS:
1.  Transient tachypnea of newborn, resolved.
2.  Sepsis ruled out.
3.  Hypoglycemia, resolved.
4.  Hyperbilirubinemia, stable.

CONDITION ON DISCHARGE:  Stable.

PLAN ON DISCHARGE:  To follow up with Dr. Doe in 1 week.

Laser Iridotomy Procedure Transcription Example / Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Narrow-angle glaucoma, left eye.

POSTOPERATIVE DIAGNOSIS:  Narrow-angle glaucoma, left eye.

OPERATION PERFORMED:  Laser iridotomy, left eye.

SURGEON:  John Doe, MD

ANESTHESIA:  Topical proparacaine.

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old male with a history of narrow-angle glaucoma, at high risk for blindness or angle-closure glaucoma, diagnosed on physical examination by gonioscopy. Risks, benefits and alternatives of laser iridotomy were discussed with the patient preoperatively. The patient agreed and signed appropriate consent preoperatively.

DESCRIPTION OF PROCEDURE:  On the day of the procedure, the left eye was identified as the operative eye. The patient received 3 sets q. 5 minutes of the following drops; proparacaine, pilocarpine and Iopidine. Appropriate constriction and anesthesia were achieved. The patient was then brought back to the laser suite, where first the argon laser was used to pretreat the iris superiorly in an area that was covered by the lid with the following settings:  800 milliwatts, 0.06 seconds duration and 50 micron spot size, and then the YAG laser was used to complete the iridotomy with the following settings; 5 millijoules, 2 pulses and a total of 2 pulses applied. Good flow of aqueous was noted from the posterior chamber to the anterior chamber and a patent iridotomy was obtained. The patient was given the following postoperative instructions:  No bending, coughing, lifting, straining or sneezing.  Return to the clinic for further followup care, and the patient is to use prednisolone acetate 1 drop, left eye, 4 times a day for 1 week.

Extracapsular Cataract Extraction Surgery Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Senile immature cataract, right eye.

POSTOPERATIVE DIAGNOSIS:  Senile immature cataract, right eye.

OPERATION PERFORMED:  Extracapsular cataract extraction of the right eye using phacoemulsification with the insertion of a posterior chamber intraocular lens.

SURGEON:  John Doe, MD

ANESTHESIA:  Local using a solution of equal parts of 2% Xylocaine and 0.75% Marcaine. The patient was also given general anesthesia standby.

INDICATIONS FOR PROCEDURE:  To improve right eye vision.

DESCRIPTION OF OPERATION:  After the patient was given a peribulbar local anesthetic injection, he was routinely prepped and draped. Steri-Strips were used to separate the right eyelids. A Superblade was used to enter the eye from the 9 o'clock and 2 o'clock positions. Healon 5 was injected into the anterior chamber. VisionBlue dye was also injected into the anterior capsule of the lens to stain it. The 2.8 mm metal knife blade was used to enter the eye from the superior temporal quadrant. The anterior capsule was broken with a bent-tip 26 gauge needle and a capsulorrhexis was performed with the Utrata forceps. Hydrodissection was carried out with balanced salt solution. The micro tip of the Cavitron unit was then used to emulsify and remove the lens nucleus using a cracking technique. The remaining lens material was removed with an irrigation/aspiration tip. Healon 5 was injected into the capsular bag and into the anterior chamber. A foldable intraocular lens made by Alcon, SN60WF, was injected into the capsular bag using a shooter. The irrigation/aspiration tip was then placed under the intraocular lens and into the capsular bag to remove the Healon 5. The remaining Healon 5 was removed from the anterior chamber. Miostat was injected to constrict the pupil. The corneal wound appeared to be watertight, so no suture was used. The eye was irrigated with 20 mg of kanamycin and 0.5 mL of Celestone. Maxitrol ointment was instilled. The Steri-Strips and drapes were removed. The eye was covered with a dry dressing and a Fox metal shield. The patient tolerated the procedure very well and left the operating room in good condition.

Right Hemicolectomy and Ventral Abdominal Herniorrhaphy Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Lesion of the right colon.

POSTOPERATIVE DIAGNOSIS:  Lesion of the hepatic flexure.

OPERATION:  Right hemicolectomy and ventral abdominal herniorrhaphy.

SURGEON:  John Doe, MD 

ANESTHESIA:  General.

DESCRIPTION OF OPERATION:  With the patient adequately anesthetized under general anesthesia and after having already undergone mediastinoscopy, the abdomen was prepped and draped in the usual fashion. The previous periumbilical midline scar was excised sharply. Dissection was performed down to the midline fascia, which was carefully incised and the abdomen was entered. The remainder of the midline fascia was then incised using electrocautery. The fascial edges were then elevated with Kocher clamps and dense omental adhesions to the midline and laterally on both sides were taken down sharply. This revealed a string-of-pearls type hernia in the right upper abdominal fascia. These hernia sacs were emptied of the omentum, thus freeing up the omentum in order to be able to retract it aside. Once this portion of the procedure was done, the right colon was grasped and swept to the midline by incising along the left lateral gutter. This was done using electrocautery. This dissection continued around the hepatic flexure to free up the colon to the level of the mid transverse colon. The terminal ileum and right colon were then deprived of its blood supply by clamping and ligating the mesenteric vessels with a series of 2-0 or 0 silk ligatures. When the terminal ileum and colon across the level of the hepatic flexure were completely deprived of blood supply, a GIA stapler was used to transect the terminal ileum and the colon. The specimen was removed from the wound. This was sent to pathology for gross pathologic review. The colon and ileum were then sutured side by side using a series of 3-0 silk sutures. The corners of the staple lines were removed and the GIA was inserted and fired. The resultant defect was then closed with TA-60 stapling device. The anastomosis was patent and well perfused. The mesenteric defect was then closed with running 2-0 Vicryl suture. By that time, the gross inspection of the colon specimen had been performed and the pathologist called and stated that the lesion itself was very close to the distal margin. The anastomosis was therefore then excised by clamping and ligating the distal ileum across the mesenteric defect to the mid transverse colon, thus providing 4 cm to 5 cm colonic margin on lesion. The GIA was inserted in the ileum and fired and also across the transverse colon and fired. The specimen was removed from the wound. Once again, a functional end-to-end anastomosis was performed by suturing the colon and the ileum side by side. The corners of the staple lines were excised. The GIA stapler was fired and the resultant defect was closed with TA-60 stapler. When the anastomosis was proved patent, the defect was again closed with running 2-0 Vicryl suture. The abdomen was copiously irrigated with normal saline solution. By this time, the pathology on the second gross specimen revealed a good margin on the lesion. The abdominal fascia was then closed, including the two hernias to the right of the original midline wound, with running #1 looped PDS suture starting at both apices and tying in the middle. Subcutaneous tissue was closed with 3-0 Vicryl suture and the skin was closed with a running 4-0 Vicryl subcuticular stitch. Steri-Strips were applied and the wound was dressed. The patient returned to the recovery room awake, extubated, in stable condition. All counts were correct at the end of the case x2. There were no complications. Blood loss was 250 mL.

Colonoscopy and Upper Endoscopy Sample Report / Example

DATE OF PROCEDURE:  MM/DD/YYYY

PROCEDURES PERFORMED:  Colonoscopy and upper endoscopy.

INDICATIONS FOR PROCEDURE:  Previous history of polyps and chronic reflux disease.

CONSENT:  Informed consent was obtained from the patient after explaining the risks, benefits, possible complications and alternatives to the procedures. The patient is well aware of possible complications, including but not limited to bleeding, perforation, reactions to medications, missed lesions, infection and aspiration.

The patient was given premedications for both procedures by the nurse anesthesiologist. The colonoscopy was performed first.

COLONOSCOPY:  With the patient comfortable in the left lateral position, a well-lubricated colonoscope was introduced into the rectum. She was noted to have severe diverticulosis of the sigmoid colon with narrowing and distortion of the colon, perhaps somewhat fixed. It was somewhat difficult to negotiate past this area, and the patient needed to be repositioned onto supine and right lateral positions. In these positions, we were able to advance into mid sigmoid and then positioned back onto her supine position briefly to get past the sigmoid. The patient remained otherwise on the right lateral side throughout the colonoscopy. The colonoscope was advanced all the way down to the cecum, eventually, without difficulty. She was noted to have severe diverticulosis throughout the colon, most impressive in the sigmoid colon. There were also several stool balls noted throughout the colon, probably from the diverticula. Careful inspection, otherwise, with washing revealed no obvious polyps. A long segment in the sigmoid colon was somewhat hard to examine due to narrowing and redness and being fixed. This area was hard to insufflate. Retroflexion in the rectum revealed moderate internal hemorrhoids.

IMPRESSION:
1.  Severe diverticulosis throughout the colon, most impressive in the sigmoid colon.
2.  Internal hemorrhoids.
3.  No polyps seen on this exam. The patient will need a colonoscopy in 5 years for followup.

UPPER ENDOSCOPY:  After the colonoscopy, the patient was repositioned for an upper endoscopy. Her dentures were removed. A mouthpiece was placed. When she was comfortable, a well-lubricated upper scope was introduced into the posterior pharynx and under direct visualization advanced all the way down to the duodenum, up to the third portion, without difficulty. Second and third portions of the duodenum appeared normal. At the apex of the bulb, a small superficial ulcer was noted with slightly erythematous mucosa surrounding. Antrum revealed a similar area, which was a very superficial pale area, appearing to be an ulcer with erythema surrounding. Two other areas were noted which appeared to be old scar tissue. The rest of the stomach and the body and fundus appeared atrophic and pale. Biopsies were obtained separately from antrum and body. Retroflexion revealed a normal cardia. She was noted to have a hiatal hernia extending from 40 to 36 cm from the incisors. The patient also was noted to have a nonobstructing Schatzki ring at the GE junction. The rest of the esophagus was normal.

IMPRESSION:
1.  Small duodenal ulcer with erythema.
2.  Antral small ulcer with erythema and scar tissue.
3.  Atrophic body and fundus.
4.  Hiatal hernia.
5.  Nonobstructing Schatzki ring.

The patient tolerated both procedures well.

Hand Assisted Laparoscopic Nephrectomy Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Right renal mass.

POSTOPERATIVE DIAGNOSIS:  Right renal mass.

OPERATION PERFORMED:  Right hand-assisted laparoscopic nephrectomy with takedown of abdominal adhesions.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  Less than 100 mL.

SPECIMEN:  Right kidney.

COMPLICATIONS:  None.

INDICATION FOR OPERATION:  The patient is a (XX)-year-old female with right renal mass. Staging workup showed no definitive evidence of disease. After discussion of the potential risks, benefits, complications and alternatives, including but not limited to, bleeding, infection, possible injury to internal structures, possible need for a conversion to open procedure as well as possible need for additional procedures, the patient agreed to proceed.

DESCRIPTION OF OPERATION:  The patient was correctly identified and informed consent was obtained. She was brought to the operating room, and once sufficient anesthesia had been rendered, she was prepped and draped in modified flank position. A 7 cm vertical incision was made in the right paramedian space. The incision was taken down with electrocautery and the peritoneum was then sharply entered. At that point, the GelPort device was placed in standard fashion. A trocar was then placed through the GelPort and insufflation was administered through the trocar. A 30 degree laparoscope was passed through the trocar and immediately visualized were some abdominal wall adhesions, presumably secondary to her previous open appendectomy. These were bypassed and two other 12 mm trocars were placed, one in the subcostal area and one in between the GelPort and the subcostal trocar. The laparoscope was moved to one of the secondary 12 mm ports and the hand was then placed through the GelPort. Using Harmonic scalpel, adhesiolysis of the abdominal adhesions was carefully performed to allow the hand unrestricted access to the surgical bed. Once the adhesions were taken down, the colon was then reflected off the surface of the kidney using blunt dissection and Harmonic scalpel. In similar fashion, the duodenum was kocherized medially using Harmonic scalpel. At that point, a laparoscopic Kittner was used to gently probe the area of the expected renal hilum. This did result eventually in visualization of what appeared to be renal artery and vein. These were stapled using a laparoscopic Endo-GIA stapler. Two loads were used. At this point, the Harmonic scalpel was used to dissect around the lower pole of the kidney. The ureter was encountered which was double clipped and sharply divided in between the clips. Harmonic scalpel dissection was carried up past the hilum and around the upper pole. Lateral attachments were taken down bluntly and with the Harmonic scalpel. In this fashion, the entire kidney was freed. It was then removed through the GelPort opening. The insufflation pressure was brought down to 5 mmHg. There did not seem to be any active bleeding in the surgical bed. Some Surgicel was placed in the area of the hilum. At that point, the trocars were removed under visualization with no evidence of bleeding. The GelPort was removed. The GelPort hand incision was closed using figure-of-eight 0 Vicryl sutures. The wound was then irrigated and the skin was closed with surgical staples. The two 12 mm trocar sites were also closed with surgical staples. Anesthesia was reversed. The patient tolerated the procedure well.


Finger Nail Bed Repair Surgical Procedure Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Right third finger crush injury.
2.  Right third finger nail bed injury.

POSTOPERATIVE DIAGNOSES:
1.  Right third finger crush injury.
2.  Right third finger nail bed injury.

PROCEDURE PERFORMED:  Repair of right third finger nail bed.

SURGEON:  John Doe, MD

ANESTHESIA:  Digital block with IV sedation.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old right-hand dominant male who crushed his right third fingertip in a metal door.  He sustained significant trauma to the fingertip.  There was underlying injury clinically.  The patient was brought to the operating room for exploration of the wound and repair as needed under anesthetic.  The procedure, postoperative protocol and all the risks and benefits were explained to the patient.  These include, but are not limited to, nail deformity, neurovascular damage, tendon damage, soft tissue loss and even loss of life or limb.  The patient understood all of this and agreed to proceed.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and laid supine on the operating table.  General anesthetic was administered under the direction of the anesthesiologist.  The patient was positioned comfortably with all bony prominences well padded.  The right upper extremity was prepped with DuraPrep and then draped out in the usual sterile fashion.  Approximately 4 mL of 0.25% plain Marcaine was injected at the base of the third finger to provide a digital block.  The nail was removed and there was some avulsion to the soft tissue over the distal nail bed and fingertip.  There was evidence of injury to the nail bed distally and 2 simple stitches of 4-0 chromic were placed to secure the soft tissue down to the distal nail bed.  The eponychial fold was lifted and then the nail was fashioned and secured down with a 4-0 chromic stitch under the eponychial folds so as to protect the nail bed and allow for future growth.  The wound was then irrigated with antibiotic solution and antibiotic ointment was placed over it with Adaptic.  A soft dressing of rolled-up 4 x 4 and then 2 inch gauze was placed around the finger and the hand.  Hand and wrist splints were applied and secured with an Ace wrap to protect the limb until seen in the office.  The patient tolerated the procedure well.  He was awoken from anesthesia and brought to the recovery room in stable condition.

Insertion of Vas-Cath in the Left Internal Jugular Vein Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  End-stage renal disease.

POSTOPERATIVE DIAGNOSIS:  End-stage renal disease.

OPERATION PERFORMED:  Insertion of Vas-Cath in the left internal jugular vein.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  Local.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old female with end-stage renal disease who had a left AV fistula placed. Attempts were made to use this; however, the nurses had difficulty. The patient now requires access for initiation of acute dialysis.

DESCRIPTION OF PROCEDURE:  The patient was placed in a supine head-down position and the left neck and chest prepared and draped in a sterile fashion. Approximately 5 mL of 1% lidocaine was used for local anesthesia. A 21 gauge needle was used to find the left internal jugular vein. In a similar fashion, an 18 gauge needle was passed down the left internal jugular vein. Guidewire was then passed through the needle into a central location. After dilatation of the tract, a dual lumen 11.5 French 19 cm Mahurkar catheter was threaded over the guidewire and was sutured in place with 2-0 silk. Good venous return was obtained in each port, after which each was flushed with saline followed by 2500 units of heparin. A sterile dressing was then placed over this. The patient tolerated the procedure well, and the chest x-ray following this showed no pneumothorax and the line tip to be in the SVC-RA junction.

Total Thyroidectomy with Central Neck Dissection Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Metastatic papillary thyroid cancer.

POSTOPERATIVE DIAGNOSIS:  Metastatic papillary thyroid cancer.

OPERATION PERFORMED:  Total thyroidectomy with central neck dissection and intraoperative recurrent laryngeal nerve monitoring.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old female who previously presented as a trauma patient and ultimately was further evaluated and found to have multiple lung nodules. This was biopsied and noted to be positive for papillary thyroid cancer. She underwent followup including ultrasound which demonstrated a 2.8 cm right thyroid mass. Cervical ultrasound did not reveal any obvious suspicious lymphadenopathy. However, CT scan demonstrated some nonspecific lymphadenopathy in the right central neck. Biopsies of these nodes were attempted; however, it was noted to be nondiagnostic as the nodes were calcified. She underwent further imaging studies including FDG-PET scan that demonstrated multiple lesions in the brain as well as lung. The patient underwent brain biopsy for these lesions and it was noted to be non-neoplastic. After extensive discussion, it was agreed that the patient would benefit from total thyroidectomy. Risks and benefits of the surgery were explained to the patient, who elected to proceed. She understood the risks included but were not limited to bleeding, infection, nerve injury, hypoparathyroidism with hypocalcemia, as well as the risk of death. The patient agreed to proceed.

DESCRIPTION OF OPERATION:  After informed consent was obtained, the patient was taken to operating room and placed supine on the operating table. Time-out was taken to verify the patient's name and procedure. She was subsequently placed under general endotracheal anesthesia, prepped and draped in standard surgical fashion and placed in semi-Fowler with neck being hyperextended. Attention was then turned to the anterior neck, where a transverse collar incision was made approximately 1.5 cm above the sternal notch along the Langer lines with a #15 blade scalpel. Bovie electrocautery was used to dissect through the underlying dermis and subcutaneous tissue. Flaps were raised superiorly up to the thyroid notch and inferiorly down to the sternal notch. A Mahorner retractor was assembled to allow excellent exposure to entire anterior neck. The midline raphe was identified and divided in the longitudinal fashion with Bovie electrocautery. The strap muscles were lateralized and the thyroid gland was medialized. We noted a large, dominant, firm calcified right thyroid mass. It appeared to not be infiltrating the surrounding tissue. At this point, NIM monitor was used to assess the recurrent laryngeal nerve. This was identified both audibly as well as visually. We traced it emanating to the tracheoesophageal groove. The superior as well as the inferior parathyroid glands were identified and preserved appropriately. With further medialization of the thyroid, we were then able to use 2-0 silk sutures as well as the Harmonic Focus to ligate and divide the superior as well as inferior pole vessels. Cautery as well as the knife was used to dissect the right lobe of the thyroid off of the trachea without event. In similar fashion, the left lobe of thyroid was medialized and the straps were lateralized. The superior and inferior parathyroid glands were identified and preserved. The recurrent laryngeal nerve was identified in similar fashion and not injured. The superior and inferior pole vessels were similarly taken with 2-0 silk sutures as well as the Harmonic Focus with a combination of Bovie electrocautery as well as the knife. The right thyroid isthmus and the left thyroid was subsequently removed and passed off the field as a specimen. It was sent to pathology for frozen section, which identified negative margins. At this point, we proceeded to perform central neck dissection. From an area of the hyoid superiorly down to the sternal notch inferiorly, as well as medially to the right carotid artery, we dissected off the central neck nodes. There were 3 enlarged nodes that were firm and approximately 1 cm in size. They were carefully dissected and lymphatics ligated with 3-0 silk sutures. It was passed off the field as a specimen. We went to the contralateral central neck; however, we did not note any evidence of significant adenopathy. At this point, hemostasis was appropriately achieved. The NIM monitor was used to confirm audibly again the function of the bilateral recurrent laryngeal nerves. We also were careful to not injure the superior laryngeal nerve. At this point, the raphe of the midline strap muscles was closed with 3-0 running locking Vicryl suture. The platysma was closed in a transverse interrupted fashion with 3-0 Vicryl pop-offs. The skin was closed with a running 4-0 subcuticular Monocryl stitch. Steri-Strips and benzoin were placed over the incision and a dry dressing was placed over the wound. The patient was subsequently extubated and taken to the recovery room in stable condition. Sponge, needle and instrument counts were correct x2.



Right and Left Heart Catheterization Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Dilated cardiomyopathy.
2.  Single-vessel coronary artery disease.

POSTOPERATIVE DIAGNOSES:
1.  Dilated cardiomyopathy.
2.  Single-vessel coronary artery disease.

OPERATION PERFORMED:  Right and left heart catheterization.

SURGEON:  John Doe, MD

ANESTHESIA:  Local Xylocaine anesthesia.

DESCRIPTION OF PROCEDURE AND FINDINGS:  After sterile prep and drape and local Xylocaine anesthesia, diagnostic right and left heart catheterization was performed. The left heart catheterization was performed from the right femoral artery. Right heart catheterization was performed from the left femoral vein. Attempts at doing left heart catheterization from the left femoral artery were unsuccessful due to inability to pass the guidewire past the left femoral artery. Cardiac output was performed using the thermodilution technique. O2 saturations were taken on room air. Following completion of procedure, both the right and left femoral artery puncture sites were sealed with the AngioSeal device. The patient's resting right and left heart pressures are unremarkable with no evidence of valvular heart disease. There is no systolic gradient on pullback across the aortic or pulmonic valves. The left ventricular angiogram showed mild global hypokinesis, EF of 50% without mitral regurgitation. The aortic root angiogram is normal without aortic insufficiency. Selective coronary angiography shows a single-vessel coronary artery disease with diffuse atherosclerosis and a right dominant system. Injection into the left coronary artery shows the left main stem is free of significant lesion. It bifurcates into left anterior descending and left circumflex. The left anterior descending has minimal luminal irregularities but no flow-limiting lesion. The left circumflex artery shows the first obtuse marginal branch to be 100% occluded. This is where the previously deployed stent was placed. The remainder of the left circumflex artery has minimal luminal irregularities but no significant flow-limiting lesion. Injection into the right coronary found it to be the dominant vessel. It had minimal luminal irregularities, worst being a 30% proximal PDA stenosis.

IMPRESSION:  Single-vessel coronary artery disease characterized by occluded first obtuse marginal branch of circumflex in a patient with mild global hypokinesis, ejection fraction 50% with no evidence of valvular heart disease.
1.  Left main stem artery has minimal luminal irregularities.
2.  Left anterior descending artery and diagonals have minimal luminal irregularities.
3.  Left circumflex has minimal luminal irregularities. It has a 100% proximal occlusion of the first obtuse marginal branch where the previously deployed stent was placed.
4.  Right dominant coronary artery has minimal luminal irregularities, worst being a 30% proximal posterior descending artery stenosis.
5.  Mild left ventricular global hypokinesis, ejection fraction of 50% without mitral regurgitation.
6.  Normal aortic root angiogram without aortic insufficiency.
7.  Unremarkable resting right and left heart pressures with no evidence of valvular heart disease.
8.  Right ilial and left iliofemoral angiogram shows diffuse irregularities with no flow-limiting lesions.
9.  Attempts at negotiating the guidewire past the left femoral artery were unsuccessful requiring left heart catheterization to be performed from the right femoral artery.

Lab Data Transcription Examples / Template Format

LABORATORY EXAMINATION:  Includes the following; hemoglobin 11.6, hematocrit 34.5, white blood cell count 5100 and platelet count 293,000.  INR 1.5.  Urinalysis shows positive esterase, negative nitrites and negative protein.  Sodium 142, potassium 4.4, chloride 106 and CO2 of 26.  BUN 36 and creatinine 1.5.  Glucose 96.  Protein 5.5 and albumin 3.4.  Calcium 8.9.  Bilirubin 0.7.  AST 21, ALT 39 and alkaline phosphatase 86.  CK 35.  Magnesium 2.2.  Troponin of 0.72.  Triglyceride 106, cholesterol 136, HDL 23 and LDL 91.  B12 of 810 and folic acid 24.  T4 of 1.2 and TSH 1.29.  CEA of 2.1.  ANA negative.  Hepatitis A negative.  Hepatitis B surface antigen negative.  Hepatitis B core IgM negative.  Hepatitis C negative.  The pH is 7.4, pCO2 of 24, pO2 of 79 and bicarbonate of 82.  Urine culture showed no growth.  Chest x-ray showed cardiomegaly, right effusion.  CT of the chest shows moderate right effusion with no mass.  EKG shows atrial fibrillation, poor R-wave progression.

LABORATORY DATA:  Biopsy of the duodenum showed focal mild chronic inflammation.  There was intact villous architecture.  On MM/DD/YYYY, WBC 5300, hemoglobin 12.8, hematocrit 38.6 and platelets 239,000.  Sodium was 136, potassium 3.8, chloride 104, CO2 of 26, glucose 282, BUN 6, creatinine 1.1, total protein 5.6, albumin 3.2 and calcium 8.6.  Total bilirubin 0.7, alkaline phosphatase 132, AST was 298, ALT was 318 and this was on MM/DD/YYYY.  On MM/DD/YYYY, AST was 172 and ALT was 238.  Hepatitis B surface antibody was negative, hepatitis B surface antigen was positive and hepatitis C antibody was negative.  Urinalysis showed 2+ glucose, otherwise normal.  CT scan of the abdomen without contrast showed pneumobilia, air within the gallbladder, and cholelithiasis and contrast in both renal collecting systems, most likely from prior contrast study.  X-ray of the abdomen and KUB were normal.

LABORATORY DATA:  BUN 52, creatinine 2.4, sodium 132, potassium 5.2, chloride 102, CO2 of 24, AST 44, alkaline phosphatase 362.  Albumin was low at 2.  Total protein 5.6, calcium 7.8, ALT 56, amylase 18 and lipase was normal at 156.  CBC, white count 11.6, hemoglobin 11.8, platelets 306.  BNP was 154.  Significantly, the patient did have positive hepatitis C antibody.  Hepatitis B surface antigen nonreactive.  Urinalysis today reveals 1+ protein, 3+ blood, 1+ leukocyte esterase, 10 to 15 hyaline casts, 20 to 40 wbc's, 20 to 40 rbc's and 2+ bacteria.

LABORATORY DATA:  Hemoglobin 13.6, hematocrit 40.2, white blood cell count 6400 and platelet count 466,000.  UA did show positive blood.  Sodium 138, potassium 4.2, chloride 104, CO2 of 28, BUN 8, creatinine 0.8, glucose 104, protein 6.6, albumin 3.2 and calcium 9.2.  Bilirubin 0.44, AST 66, ALT 92 and alkaline phosphatase 132.  Amylase 52 and lipase 218.  Hepatitis B surface antigen negative.  Hepatitis B core antibody negative.  KUB showed no free air.  Chest x-ray showed improvement of pleural effusions.  EKG showed normal sinus rhythm with no acute ischemia.

LABORATORY DATA:  The patient’s initial blood work showed blood type to be A positive, VDRL nonreactive, rubella titer indicated immunity, hepatitis B surface antigen was negative, HIV screen was negative, GC and Chlamydia cultures were negative.  Pap smear was normal.  Her 1-hour glucose tolerance test was within normal parameters.  The patient’s blood count remained well within normal parameters as well.  Her quad screen for maternal serum alpha-fetoprotein was normal.  Strep culture was likewise negative at 34-35 weeks.

LABORATORY EXAMINATION:  Includes the following; hemoglobin 11.4, hematocrit 34.2, white blood cell count 5100 and platelet count 294,000.  INR of 1.5.  UA shows positive esterase, negative nitrites and negative protein.  Sodium 142, potassium 4.6, chloride 104 and CO2 of 26.  BUN 34 and creatinine 1.5.  Glucose of 94.  Protein 5.6 and albumin 3.4.  Calcium 8.9.  Bilirubin 0.7.  AST 22, ALT 39 and alkaline phosphatase 88.  CK 35.  Magnesium 2.2.  Troponin of 0.72.  Triglyceride 106, cholesterol 136, HDL 24 and LDL 92.  B12 of 812 and folic acid 24.  T4 of 1.4 and TSH 1.29.  CEA of 2.3.  ANA negative.  Hepatitis A negative.  Hepatitis B surface antigen negative.  Hepatitis B core IgM negative.  Hepatitis C negative.  The pH is 7.4, pCO2 of 25, pO2 of 79 and bicarbonate of 82.  Urine culture showed no growth.  Chest x-ray showed cardiomegaly, right effusion.  CT of the chest shows moderate right effusion with no mass.  EKG shows atrial fibrillation, poor R-wave progression.

LABORATORY TESTS:  WBC 17.8, hemoglobin 11.4, hematocrit 35.8, platelets 156, neutrophils 67, bands 17, lymphocytes 7, monos 8.  Creatinine 7.46, on hemodialysis.  Alkaline phosphatase 98, ALT 24, AST 36.  Vancomycin random 22.6.  Blood cultures shows gram-positive cocci, 4/4.  X-ray of the foot; bony destructive changes suggestive of osteomyelitis, but there is no evidence of soft tissue swelling along the plantar aspect of the foot.

LABORATORY DATA:  Inpatient white blood cell count was 11,200, hemoglobin 12.8 and hematocrit 38.2.  INR was 1.  Sodium was normal at 142, potassium was reduced at 3.2.  Amylase, lipase and transaminases were all normal.  Urinalysis was normal.  The patient was typed and crossed.  Occult bloods were done which came back positive.  Hemoglobin has fluctuated and is currently at 10.8 with hematocrit of 32.4.  Renal function has remained normal.

LABORATORY DATA:  Laboratory evaluation revealed a white cell count of 5700, hemoglobin 11.6 and platelets of 226,000; polymorphs 69, lymphocytes 21, monocytes 5 and eosinophils 2.6.  Glucose 86, BUN 9, creatinine 1, sodium 142 and potassium 4.2.  His albumin was 4.2, alkaline phosphatase 83, total bilirubin 0.6, SGOT 18 and SGPT 28.  His T4 was 1.27 and TSH was 1.6.  His urinalysis revealed no protein, no glucose, but nitrite was positive and wbc’s were 6 to 15 and a culture showed MRSA greater than 100,000 colonies, which was sensitive to tetracycline, rifampin, vancomycin and linezolid.

LABORATORY DATA:  CBC on admission revealed a white blood cell count of 5200, hemoglobin 9.2, hematocrit 27.6 and platelet count 282,000.  Lowest hemoglobin was 8.9.  Final H&H 11.8 and 34.8.  The patient received 2 units of packed red blood cells.  The INR on admission was 2.55.  The INR at the time of discharge was 3.72.  Electrolytes on admission showed sodium of 139, potassium 4.4, chloride 106, CO2 of 24, glucose 106, BUN 34, creatinine 2.2.  The final electrolytes showed sodium of 141, potassium 3.7, chloride 108, CO2 of 24, glucose 151, BUN 16, creatinine 1.  B-type natriuretic peptide was 224.  Iron 45, iron-binding capacity 238, 28% saturation.  Serial cardiac enzymes showed no evidence of myocardial injury.  The liver function tests were normal.  Urinalysis normal.  Stool for CDT was positive.  Chest x-ray showed postsurgical findings, no acute changes.  CT of brain showed old-appearing lacunar infarct, left periventricular white matter, encephalomalacia, right occipital cortex, consistent with previous injury or infarction.  No acute intracranial hemorrhage.  Renal ultrasound showed no focal abnormalities of the kidneys.  

DIAGNOSTIC DATA:  Radiographs show good joint space maintained in both hips. Concerned about the left one being slightly lateralized. Her left lateral center edge angle is about 21 and the right is about 24. Tonnis angle is less than 10 with the right being about 4 and the left being closer to 3. The patient has lines intact bilaterally. There is good offset on both hips on the frog lateral and cross-table laterals. False profile shows about 20 degrees of anterior coverage with good congruency of both hips. The patient had an MRI, which was read as unremarkable. No signs of labral tears as read by the radiologist.

LABORATORY DATA:  The patient had a recent metabolic profile that showed sodium of 142, potassium 5.2, chloride 108, bicarbonate 24, BUN 26, creatinine 1.3 with her baseline being around 1.2 to 1.3. Glucose 102. Urine culture showed mixed urogenital flora. Urinalysis was positive for occult blood, as well as leukocyte esterase. There were no red blood cells or white blood cells. CT of the abdomen and pelvis performed, hematuria protocol, which showed a 1.3 x 0.6 cm nonobstructing calculus in the left kidney. Also had evidence of known polycystic kidney disease bilaterally. Of note, the CT contrast did not extend into the distal parts of bilateral ureters. There was no evidence of any masses in the upper urinary tract or bladder on CT.

LABORATORY DATA:  Labs show antimitochondrial antibody negative, anti-smooth muscle antibody negative, anti-endometrial antibody less than 20, alpha-1 antitrypsin 162, iron level 156, percent saturation is 32, ferritin is 34, albumin 4.2, AST 64, ALT 72, alkaline phosphatase 66, total bilirubin 1.4, direct bilirubin 0.2. White count 4.6, hematocrit 45.6, platelets 214. Liver biopsy results are as above. The patient's hepatic iron index is 0.1.

DIAGNOSTIC DATA:  Chest x-ray revealed new retrocardiac infiltrate.  X-ray of the hip and pelvis revealed progression of osteoporosis, stable erosive changes of the left sacroiliac joint.  X-ray of the knee revealed osteopenia with mild degenerative changes.  MRI of the right hip revealed changes consistent with septic arthritis with associated osteomyelitis involving the right sacroiliac joint and adjacent musculature.  MRI of the left hip revealed no evidence of osteomyelitis.  MRI of the pelvis revealed chronic osteomyelitis of the coccyx with marked improvement of the left sacroiliac joint.



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