DATE OF PROCEDURE: XX/XX/XXXX
PREOPERATIVE DIAGNOSIS: Morton neuroma, left second and third metatarsal interspace.
POSTOPERATIVE DIAGNOSIS: Morton neuroma, left second and third metatarsal interspace.
PROCEDURE PERFORMED: Excision of Morton neuroma, left second and third metatarsal interspace.
SURGEON: First Last Name, DPM
ANESTHESIA: Laryngeal mask airway.
PREOPERATIVE ANTIBIOTICS: One gram of Ancef IV.
ESTIMATED BLOOD LOSS: Minimal.
MATERIALS: None.
PROCEDURE IN DETAIL: The patient was brought to the operating room and placed on the operating room table in normal supine position. At this time, a preoperative block was administered with total of 10 mL of 50:50 mixture of 0.5% Marcaine plain and 1% Xylocaine plain about the surgical site, left foot. At this time, a well-padded ankle pneumatic tourniquet was placed just proximal to the malleoli subsequent to Betadine prep. At this time, tourniquet was inflated to 250 mmHg and attention was directed to the left second metatarsal interspace where a 4 cm plantar longitudinal incision was made. Utilizing a 15 blade, the incision was carried deep with careful attention paid to clamp and Bovie all bleeders that were encountered. At this time, the neuroma was brought into the operative field and resected both proximally and distally. The wound was flushed with copious amounts of normal saline and reapproximated utilizing 4-0 Vicryl in simple interrupted fashion. Skin was closed utilizing 4-0 nylon in simple interrupted fashion. The identical procedure was carried out about the third metatarsal interspace plantarly about the left foot. Postoperative injection was administered for a total of 10 mL of 0.5% Marcaine pain. The wounds were dressed with Xeroform gauze, 4 x 4 inch gauze and 3 inch Kling. The patient tolerated the procedure and anesthesia well and left the operating room for the recovery room with vital signs stable and neurovascular status intact, bilateral lower extremities.
Pacemaker Implantation Medical Transcription Sample
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Intermittent Stokes-Adams events.
POSTOPERATIVE DIAGNOSIS:
Intermittent Stokes-Adams events.
PROCEDURES PERFORMED:
1. Chest fluoroscopy.
2. Implantation of Guidant Insignia Ultra DR pacemaker.
3. Implantation of a passive Guidant Fineline lead.
4. Implantation of a Guidant atrial Fineline lead.
INDICATION FOR PROCEDURE: Intermittent Stokes-Adams events.
PROCEDURE IN DETAIL: The patient was taken to the operating room and a single subclavian stick was performed. Because of his age, I elected to avoid multiple subclavian sticks and a single stick technique was employed, after the initial wire was placed via Seldinger technique. The pockets then were formed using a #10 blade to transect the skin. Curved Metzenbaum scissors and pickups were used to isolate the pectoralis muscle fascia. Pockets were formed with blunt dissection inferiorly, medially and laterally. A lot of time was spent on the cautery and keeping the pocket dry with the patient taking aspirin and Plavix. Eventually, over the two wires that had been introduced, the sheaths were introduced and then leads were introduced into optimal position. Initial testing was satisfactory and both leads were secured using the sleeves as provided. Final testing was then performed.
The R-wave was 25.4 millivolts. The impedance was 680 ohms. The threshold was 0.3 volts. The atrial leads have a P-wave of 2.0 millivolts. The impedance was 456 ohms. The threshold was 0.9 volts. There was no diaphragmatic pacing at 10 volts on either lead. The leads were attached to a pulse generator with a wrench provided. The pulse generator was secured to floor of the pocket. The pocket was flushed with vancomycin solution. The deep fascial layer was closed with 3-0 chromic. The skin was closed with 3-0 silk employing mattress sutures. Final fluoroscopy was performed. There was no evidence of pneumothorax. The RAO projection showed normal anterior location of the atrial lead and good position of the ventricular lead at the right ventricular apex. There was no significant blood loss. The patient was returned to his room in stable and satisfactory condition.
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Not dictated.
POSTOPERATIVE DIAGNOSIS: Not dictated.
OPERATION PERFORMED:
1. Extraction of a dual chamber pacemaker.
2. Intraoperative fluoroscopy.
3. Implant of a dual chamber pacemaker.
SURGEON: John Doe, MD
ASSISTANT: None.
INDICATION FOR OPERATION: The patient had a pacemaker malfunction. He understood possible risks and complications and agreed to proceed.
FINDINGS AND DESCRIPTION OF PROCEDURE: After informed consent was obtained, the following procedure was performed. The right prepectoral area was prepped and draped in the usual sterile fashion. Lidocaine was used for local anesthesia of the skin and subcutaneous tissue.
A skin incision was made over a pre-existing pacemaker. Blunt dissection was performed. Pacemaker was extracted. Leads were removed and connected to the analyzer. Right atrial lead revealed a T wave of 4.2 mV, impedance 530 ohms, threshold 1.1 volt at 0.5 milliseconds. Right ventricular lead with an R wave of 16.3 mV, impedance 600 ohms, and threshold 0.4 volt at 0.5 milliseconds. Lead was connected to the pacemaker, which secures to the underlying prepectoral fascia using nonabsorbable suture. The device was secured with one suture. Copious irrigation of the pocket with antibiotic saline solution was performed.
Testing of the lead threshold via the device revealed a T wave of 3.9 mV, R wave 12 mV, impedance in the atrium 410 ohms and the ventricle 526 ohms. Threshold in the atrium 0.75 volt at 0.5 milliseconds and in the ventricle 0.75 volts at 0.5 milliseconds. Device was programmed as DDD lower rate 60, upper rate 120 and AV delay extended to 300 milliseconds to allow normal conduction.
Prepectoral subcutaneous and subdermal layer was closed using interrupted and continuous Vicryl suture. Dermabond was applied to the skin. The patient left the operating room with no noted complications and the count was correct.
Electrophysiology Sample Reports Cardiac Cath Sample Report
PREOPERATIVE DIAGNOSIS:
Intermittent Stokes-Adams events.
POSTOPERATIVE DIAGNOSIS:
Intermittent Stokes-Adams events.
PROCEDURES PERFORMED:
1. Chest fluoroscopy.
2. Implantation of Guidant Insignia Ultra DR pacemaker.
3. Implantation of a passive Guidant Fineline lead.
4. Implantation of a Guidant atrial Fineline lead.
INDICATION FOR PROCEDURE: Intermittent Stokes-Adams events.
PROCEDURE IN DETAIL: The patient was taken to the operating room and a single subclavian stick was performed. Because of his age, I elected to avoid multiple subclavian sticks and a single stick technique was employed, after the initial wire was placed via Seldinger technique. The pockets then were formed using a #10 blade to transect the skin. Curved Metzenbaum scissors and pickups were used to isolate the pectoralis muscle fascia. Pockets were formed with blunt dissection inferiorly, medially and laterally. A lot of time was spent on the cautery and keeping the pocket dry with the patient taking aspirin and Plavix. Eventually, over the two wires that had been introduced, the sheaths were introduced and then leads were introduced into optimal position. Initial testing was satisfactory and both leads were secured using the sleeves as provided. Final testing was then performed.
The R-wave was 25.4 millivolts. The impedance was 680 ohms. The threshold was 0.3 volts. The atrial leads have a P-wave of 2.0 millivolts. The impedance was 456 ohms. The threshold was 0.9 volts. There was no diaphragmatic pacing at 10 volts on either lead. The leads were attached to a pulse generator with a wrench provided. The pulse generator was secured to floor of the pocket. The pocket was flushed with vancomycin solution. The deep fascial layer was closed with 3-0 chromic. The skin was closed with 3-0 silk employing mattress sutures. Final fluoroscopy was performed. There was no evidence of pneumothorax. The RAO projection showed normal anterior location of the atrial lead and good position of the ventricular lead at the right ventricular apex. There was no significant blood loss. The patient was returned to his room in stable and satisfactory condition.
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Not dictated.
POSTOPERATIVE DIAGNOSIS: Not dictated.
OPERATION PERFORMED:
1. Extraction of a dual chamber pacemaker.
2. Intraoperative fluoroscopy.
3. Implant of a dual chamber pacemaker.
SURGEON: John Doe, MD
ASSISTANT: None.
INDICATION FOR OPERATION: The patient had a pacemaker malfunction. He understood possible risks and complications and agreed to proceed.
FINDINGS AND DESCRIPTION OF PROCEDURE: After informed consent was obtained, the following procedure was performed. The right prepectoral area was prepped and draped in the usual sterile fashion. Lidocaine was used for local anesthesia of the skin and subcutaneous tissue.
A skin incision was made over a pre-existing pacemaker. Blunt dissection was performed. Pacemaker was extracted. Leads were removed and connected to the analyzer. Right atrial lead revealed a T wave of 4.2 mV, impedance 530 ohms, threshold 1.1 volt at 0.5 milliseconds. Right ventricular lead with an R wave of 16.3 mV, impedance 600 ohms, and threshold 0.4 volt at 0.5 milliseconds. Lead was connected to the pacemaker, which secures to the underlying prepectoral fascia using nonabsorbable suture. The device was secured with one suture. Copious irrigation of the pocket with antibiotic saline solution was performed.
Testing of the lead threshold via the device revealed a T wave of 3.9 mV, R wave 12 mV, impedance in the atrium 410 ohms and the ventricle 526 ohms. Threshold in the atrium 0.75 volt at 0.5 milliseconds and in the ventricle 0.75 volts at 0.5 milliseconds. Device was programmed as DDD lower rate 60, upper rate 120 and AV delay extended to 300 milliseconds to allow normal conduction.
Prepectoral subcutaneous and subdermal layer was closed using interrupted and continuous Vicryl suture. Dermabond was applied to the skin. The patient left the operating room with no noted complications and the count was correct.
Electrophysiology Sample Reports Cardiac Cath Sample Report
Upper Endoscopy Medical Transcription Sample Report
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Not given.
POSTOPERATIVE DIAGNOSES:
1. Sliding hiatal hernia plus possible short segment Barrett and mild esophagitis.
2. Antral gastritis.
3. Duodenitis.
PROCEDURE PERFORMED: Pan upper endoscopy and biopsies.
PHYSICIAN: John Doe, MD
INDICATION: Chronic heartburn with anemia, possibly iron deficiency.
PROCEDURE: Using the Olympus thin video gastroscope under IV sedation in the form of intravenous Diprivan, the patient underwent pan upper endoscopy and biopsies without apparent complications.
FINDINGS: In the esophagus, there was evidence of a sliding hiatal hernia with possible short segment Barrett and esophagitis. This was photographed and biopsies were taken of the distal esophagus. There were no ulcerations or evidence of neoplasms. Stomach showed some gastritis, particularly in the antrum, where they may have been some scar from previous ulcer disease. Biopsies were taken of the antrum as well as a CLOtest. Also showed a small hiatal hernia but no evidence of masses. Duodenal bulb showed duodenitis and it was photographed. No ulcers. The second duodenum appeared normal. A biopsy was taken of the antrum also to rule out the possibility of Helicobacter pylori and a biopsy of the gastritis site. He tolerated the procedure well.
IMPRESSION:
1. Sliding hiatal hernia, possible short segment Barrett.
2. Antral gastritis.
3. Duodenitis.
PLAN: Continue Aciphex 20 mg a day. The patient is to have an anemia workup including iron, total iron binding capacity, B12, folic acid level and hemoglobin electrophoresis because of the possibility of iron deficiency versus thalassemia minor on his labs. He is also to have an alkaline phosphatase and a GGTP.
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Early satiety.
2. Weight loss.
3. Abnormal gastric folds on CT scan.
POSTOPERATIVE DIAGNOSIS:
Grade 1 esophagitis, otherwise normal upper endoscopy.
PROCEDURE PERFORMED:
Esophagogastroduodenoscopy with biopsy.
ENDOSCOPIST: John Doe, MD
CONSENT: Risks and benefits of the procedure were discussed with the patient, including bleeding, perforation, and sedation side effects including respiratory depression. The patient verbalized understanding and wishes to proceed with the procedure.
FINDINGS: The patient was placed in the left lateral decubitus position. The Olympus video endoscope was passed under direct visualization into the esophagus. The squamocolumnar junction was located at approximately 40 cm from the incisors. The Z-line was slightly irregular. Biopsies were obtained for histology. On retroflexed viewing of the stomach, the fundus and cardia were normal. The body and antrum were normal. The duodenal bulb and second portion of the duodenum were normal. Antral biopsies were obtained for CLOtest.
SPECIMENS:
1. Antral biopsies for CLOtest.
2. Distal esophageal biopsies.
COMPLICATIONS: No immediate postprocedure complications.
IMPRESSION:
Grade 1 esophagitis, otherwise normal upper endoscopy.
DISPOSITION:
1. The patient is to call Dr. John Doe for the biopsy results.
2. We will proceed to colonoscopy.
DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURE PERFORMED: Upper endoscopy.
ANESTHESIA: Versed 2 mg and propofol 150 mg IV.
INDICATIONS: Heartburn and GERD.
ASA CLASSIFICATION: Class 2.
PROCEDURE IN DETAIL: After informed consent was obtained from the patient, the patient was placed in the left lateral decubitus position and connected to standard monitoring equipment for heart rate, blood pressure, and pulse oximetry. After the provision of intravenous medication, the adult flexible Olympus upper endoscope was passed per the mouth to the second portion of the duodenum and retroflexion was performed in the stomach. The second portion of the duodenum and stomach were endoscopically normal. There was a small hiatal hernia with a hiatus at 4 cm insertion of the Z line and 36 cm insertion at the Z line. The Z line was a sizable punched out white lesion ulcer, which was biopsied utilizing cold forceps and sent for histopathology. There were also two tongues of salmon-pink colored mucosa that was quite reddened, extending proximally for a short distance from the Z line, and these were biopsied utilizing cold forceps and sent for histopathology as well. There were no immediate complications.
PLAN: At this time, follow up on the results of biopsies, which may help direct subsequent management.
Colonoscopy and EGD Sample Reports
PREOPERATIVE DIAGNOSIS: Not given.
POSTOPERATIVE DIAGNOSES:
1. Sliding hiatal hernia plus possible short segment Barrett and mild esophagitis.
2. Antral gastritis.
3. Duodenitis.
PROCEDURE PERFORMED: Pan upper endoscopy and biopsies.
PHYSICIAN: John Doe, MD
INDICATION: Chronic heartburn with anemia, possibly iron deficiency.
PROCEDURE: Using the Olympus thin video gastroscope under IV sedation in the form of intravenous Diprivan, the patient underwent pan upper endoscopy and biopsies without apparent complications.
FINDINGS: In the esophagus, there was evidence of a sliding hiatal hernia with possible short segment Barrett and esophagitis. This was photographed and biopsies were taken of the distal esophagus. There were no ulcerations or evidence of neoplasms. Stomach showed some gastritis, particularly in the antrum, where they may have been some scar from previous ulcer disease. Biopsies were taken of the antrum as well as a CLOtest. Also showed a small hiatal hernia but no evidence of masses. Duodenal bulb showed duodenitis and it was photographed. No ulcers. The second duodenum appeared normal. A biopsy was taken of the antrum also to rule out the possibility of Helicobacter pylori and a biopsy of the gastritis site. He tolerated the procedure well.
IMPRESSION:
1. Sliding hiatal hernia, possible short segment Barrett.
2. Antral gastritis.
3. Duodenitis.
PLAN: Continue Aciphex 20 mg a day. The patient is to have an anemia workup including iron, total iron binding capacity, B12, folic acid level and hemoglobin electrophoresis because of the possibility of iron deficiency versus thalassemia minor on his labs. He is also to have an alkaline phosphatase and a GGTP.
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Early satiety.
2. Weight loss.
3. Abnormal gastric folds on CT scan.
POSTOPERATIVE DIAGNOSIS:
Grade 1 esophagitis, otherwise normal upper endoscopy.
PROCEDURE PERFORMED:
Esophagogastroduodenoscopy with biopsy.
ENDOSCOPIST: John Doe, MD
CONSENT: Risks and benefits of the procedure were discussed with the patient, including bleeding, perforation, and sedation side effects including respiratory depression. The patient verbalized understanding and wishes to proceed with the procedure.
FINDINGS: The patient was placed in the left lateral decubitus position. The Olympus video endoscope was passed under direct visualization into the esophagus. The squamocolumnar junction was located at approximately 40 cm from the incisors. The Z-line was slightly irregular. Biopsies were obtained for histology. On retroflexed viewing of the stomach, the fundus and cardia were normal. The body and antrum were normal. The duodenal bulb and second portion of the duodenum were normal. Antral biopsies were obtained for CLOtest.
SPECIMENS:
1. Antral biopsies for CLOtest.
2. Distal esophageal biopsies.
COMPLICATIONS: No immediate postprocedure complications.
IMPRESSION:
Grade 1 esophagitis, otherwise normal upper endoscopy.
DISPOSITION:
1. The patient is to call Dr. John Doe for the biopsy results.
2. We will proceed to colonoscopy.
PROCEDURE PERFORMED: Upper endoscopy.
ANESTHESIA: Versed 2 mg and propofol 150 mg IV.
INDICATIONS: Heartburn and GERD.
ASA CLASSIFICATION: Class 2.
PROCEDURE IN DETAIL: After informed consent was obtained from the patient, the patient was placed in the left lateral decubitus position and connected to standard monitoring equipment for heart rate, blood pressure, and pulse oximetry. After the provision of intravenous medication, the adult flexible Olympus upper endoscope was passed per the mouth to the second portion of the duodenum and retroflexion was performed in the stomach. The second portion of the duodenum and stomach were endoscopically normal. There was a small hiatal hernia with a hiatus at 4 cm insertion of the Z line and 36 cm insertion at the Z line. The Z line was a sizable punched out white lesion ulcer, which was biopsied utilizing cold forceps and sent for histopathology. There were also two tongues of salmon-pink colored mucosa that was quite reddened, extending proximally for a short distance from the Z line, and these were biopsied utilizing cold forceps and sent for histopathology as well. There were no immediate complications.
PLAN: At this time, follow up on the results of biopsies, which may help direct subsequent management.
Colonoscopy and EGD Sample Reports
Colonoscopy Medical Transcription Sample Reports
PREOPERATIVE INDICATION: History of colorectal polyps.
POSTOPERATIVE FINDINGS: Normal colonoscopy.
TYPE OF PROCEDURE: Colonoscopy to cecum.
DETAILS OF PROCEDURE: After informed consent was obtained from the patient and intravenous access was initiated, cardiopulmonary monitoring was begun and the patient was then placed in left lateral position. A visual inspection of the perianal area revealed no abnormalities. A digital rectal examination revealed no masses. An Olympus video colonoscope was inserted into the rectum and advanced without difficulty to the ileocecal area, which was identified by its landmarks, palpation and transillumination. There are no intraluminal lesions. The scope then was withdrawn from the patient, again under direct vision, and no intraluminal lesions are present. The patient agrees to followup visits with all her physicians, including me.
FINAL DIAGNOSIS: Normal colonoscopy.
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Rectal ulcer.
POSTOPERATIVE DIAGNOSIS: Rectal stricture.
PROCEDURE PERFORMED:
1. Colonoscopy via stoma.
2. Flexible sigmoidoscopy.
SURGEON: John Doe, MD
ANESTHESIA: Fentanyl 100 mcg and Versed 5 mg.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female who presented to this office after being referred about four months ago with severe rectal ulcerations, rectal perforation, and peritoneal sepsis. The patient underwent diverting colostomy. She now presents for a colostomy closure.
DESCRIPTION OF PROCEDURE: Informed consent was obtained. The patient was taken to the endoscopy suite and placed in the supine position. After adequate intravenous sedation, the stoma was digitalized.
The colonoscope was then inserted into the stoma and easily advanced to the cecum. The ileocecal valve and appendiceal orifice were identified. The entire colonic mucosa was then carefully and circumferentially inspected upon slow withdrawal of the scope. The entire mucosa up to the stoma, including the cecum, ascending and transverse, descending and sigmoid colon, was normal. The patient was then placed in the left lateral decubitus position. Digital rectal exam showed a stricture at about 6-7 cm. The flexible sigmoidoscope was placed and there clearly was still a small posterior perforation in this area with a stenotic area in the mid rectum. We were able to advance the scope through the area and the colon above was totally normal.
The patient tolerated the procedure well without any complications. Postoperatively, she was transferred to the recovery room in stable condition.
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Recurrent rectal bleeding.
POSTOPERATIVE DIAGNOSES:
1. Grade 2 to 3 internal hemorrhoids.
2. Diverticulosis.
PROCEDURE PERFORMED:
Total colonoscopy.
ATTENDING DOCTOR: John Doe, MD
ANESTHESIA: IV monitored anesthesia care by Anesthesiology.
DESCRIPTION OF PROCEDURE: Digital examination and inspection showed no rectal masses. The prostate showed questionably enlarged irregular right lobe. The Olympus colonoscope was introduced into the rectum and the scope was advanced without difficulty to the cecum. The ileocecal valve and the appendiceal orifice were identified. The preparation was excellent. The scope was gradually withdrawn. The colonic mucosa was inspected as we proceeded distally. There were rare right-sided diverticula. There was a moderate amount of sigmoid diverticulosis. The U-turn maneuver in the rectum showed grade 2 to 3 internal hemorrhoids. The colon was deflated. The scope was withdrawn. The patient tolerated the procedure well.
IMPRESSION:
1. Questionably enlarged prostate.
2. Internal hemorrhoids.
3. Diverticulosis.
PLAN:
1. High-fiber program, routine hemorrhoidal care.
2. PCP followup for prostate.
3. If the patient fails to respond to routine hemorrhoidal care, infrared coagulation of internal hemorrhoids might be considered.
Colonoscopy and EGD Sample Reports Colonoscopy and ERBE Argon Laser Cautery Sample
POSTOPERATIVE FINDINGS: Normal colonoscopy.
TYPE OF PROCEDURE: Colonoscopy to cecum.
DETAILS OF PROCEDURE: After informed consent was obtained from the patient and intravenous access was initiated, cardiopulmonary monitoring was begun and the patient was then placed in left lateral position. A visual inspection of the perianal area revealed no abnormalities. A digital rectal examination revealed no masses. An Olympus video colonoscope was inserted into the rectum and advanced without difficulty to the ileocecal area, which was identified by its landmarks, palpation and transillumination. There are no intraluminal lesions. The scope then was withdrawn from the patient, again under direct vision, and no intraluminal lesions are present. The patient agrees to followup visits with all her physicians, including me.
FINAL DIAGNOSIS: Normal colonoscopy.
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Rectal ulcer.
POSTOPERATIVE DIAGNOSIS: Rectal stricture.
PROCEDURE PERFORMED:
1. Colonoscopy via stoma.
2. Flexible sigmoidoscopy.
SURGEON: John Doe, MD
ANESTHESIA: Fentanyl 100 mcg and Versed 5 mg.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female who presented to this office after being referred about four months ago with severe rectal ulcerations, rectal perforation, and peritoneal sepsis. The patient underwent diverting colostomy. She now presents for a colostomy closure.
DESCRIPTION OF PROCEDURE: Informed consent was obtained. The patient was taken to the endoscopy suite and placed in the supine position. After adequate intravenous sedation, the stoma was digitalized.
The colonoscope was then inserted into the stoma and easily advanced to the cecum. The ileocecal valve and appendiceal orifice were identified. The entire colonic mucosa was then carefully and circumferentially inspected upon slow withdrawal of the scope. The entire mucosa up to the stoma, including the cecum, ascending and transverse, descending and sigmoid colon, was normal. The patient was then placed in the left lateral decubitus position. Digital rectal exam showed a stricture at about 6-7 cm. The flexible sigmoidoscope was placed and there clearly was still a small posterior perforation in this area with a stenotic area in the mid rectum. We were able to advance the scope through the area and the colon above was totally normal.
The patient tolerated the procedure well without any complications. Postoperatively, she was transferred to the recovery room in stable condition.
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Recurrent rectal bleeding.
POSTOPERATIVE DIAGNOSES:
1. Grade 2 to 3 internal hemorrhoids.
2. Diverticulosis.
PROCEDURE PERFORMED:
Total colonoscopy.
ATTENDING DOCTOR: John Doe, MD
ANESTHESIA: IV monitored anesthesia care by Anesthesiology.
DESCRIPTION OF PROCEDURE: Digital examination and inspection showed no rectal masses. The prostate showed questionably enlarged irregular right lobe. The Olympus colonoscope was introduced into the rectum and the scope was advanced without difficulty to the cecum. The ileocecal valve and the appendiceal orifice were identified. The preparation was excellent. The scope was gradually withdrawn. The colonic mucosa was inspected as we proceeded distally. There were rare right-sided diverticula. There was a moderate amount of sigmoid diverticulosis. The U-turn maneuver in the rectum showed grade 2 to 3 internal hemorrhoids. The colon was deflated. The scope was withdrawn. The patient tolerated the procedure well.
IMPRESSION:
1. Questionably enlarged prostate.
2. Internal hemorrhoids.
3. Diverticulosis.
PLAN:
1. High-fiber program, routine hemorrhoidal care.
2. PCP followup for prostate.
3. If the patient fails to respond to routine hemorrhoidal care, infrared coagulation of internal hemorrhoids might be considered.
Electrophysiology Lab Procedure MT Sample Reports
DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURE PERFORMED: Diagnostic electrophysiology study.
SURGEON: John Doe, MD
REFERRING DOCTOR: Jane Doe, MD
INDICATIONS:
1. Recurrent, unexplained syncope.
2. Coronary artery disease.
3. Left ventricular systolic dysfunction (LVEF=15%).
SEDATION: Versed (2 mg), fentanyl (100 mcg) and propofol (250 mg).
SHEATHS: Two French 4 inch vascular sheath inserted within the right femoral vein using modified Seldinger technique.
CATHETERS: Two 5 mm interelectrode spacing, intracardiac pacer/coronary catheter advanced via the right femoral venous sheath and positioned within atrium, AV junction, right ventricular apex and right ventricular outflow tract under fluoroscopic guidance.
FINDINGS:
1. Baseline sinus rhythm with markedly prolonged HV interval in the setting of underlying interventricular conduction delay.
A. Sinus cycle length=700 milliseconds.
B. AH interval=90 milliseconds.
C. HV interval=110 milliseconds.
2. Normal sinus node function.
A. Baseline SCL=700 milliseconds.
B. Maximum CSNRT=450 milliseconds.
3. Normal AV nodal conduction.
A. Wenckebach cycle length=480 milliseconds.
B. AV nodal ERP=600/390.
4. Right atrial effective refractory=600/230.
5. Markedly abnormal His-Purkinje system conduction (baseline HV interval=110 milliseconds).
6. Right ventricular effective refractory.
A. Right ventricular apex=600/310, 400/310.
7. No inducible nonsustained or sustained ventricular tachyarrhythmias observed with right ventricular programmed electrical stimulation delivered at two RV patient sites in the setting of chronic procainamide therapy (Procan SR 500 mg q.i.d.), using:
A. One to three premature stimulations following two drive cycles (600, 400 milliseconds).
B. Rapid ventricular burst pacing (PCL=400-240 milliseconds).
8. No evidence for carotid sinus hypersensitivity with either right or left-sided carotid sinus massage.
Upon completion of the procedure, all catheters and sheaths removed and adequate hemostasis was achieved using manual compression. The patient was subsequently transferred to the stretcher and returned to the cardiac catheterization laboratory area in stable condition.
COMPLICATIONS: None.
IMPRESSION:
1. Normal sinus rhythm function.
2. Normal AV nodal conduction.
3. No evidence for carotid sinus hypersensitivity.
4. Markedly abnormal His-Purkinje system conduction (in the setting of longstanding procainamide therapy and underlying interventricular conduction delay manifested on surface ECG).
5. No inducible ventricular tachyarrhythmias with right ventricular programmed electrical stimulation (in the setting of chronic procainamide therapy).
RECOMMENDATION: Consider future pacemaker implantation +/- additional cardiac resynchronization therapy, given history of recurrent syncope in the setting of severe conduction system disease and required antiarrhythmic drug therapy, +/- additional cardiac resynchronization therapy given refractory NYHA class III CHF symptoms (despite optimized medical therapy) versus biventricular cardiac defibrillator implantation despite lack of inducible ventricular tachyarrhythmias, given possible false and negative results related to ongoing antiarrhythmic drug therapy in accordance with recent COMPANION and SCD-HeFT trial results supporting prophylactic biventricular cardiac defibrillator implantation among subjects with severe cardiomyopathy, moderate-severe cardiomyopathy (LVEF <35%), moderate-severe congestive heart failure (refractory medical therapy), and widened surface QRS (QRS duration >130 milliseconds.)
Electrophysiology Sample Reports Cardiac Cath Sample Report
PROCEDURE PERFORMED: Diagnostic electrophysiology study.
SURGEON: John Doe, MD
REFERRING DOCTOR: Jane Doe, MD
INDICATIONS:
1. Recurrent, unexplained syncope.
2. Coronary artery disease.
3. Left ventricular systolic dysfunction (LVEF=15%).
SEDATION: Versed (2 mg), fentanyl (100 mcg) and propofol (250 mg).
SHEATHS: Two French 4 inch vascular sheath inserted within the right femoral vein using modified Seldinger technique.
CATHETERS: Two 5 mm interelectrode spacing, intracardiac pacer/coronary catheter advanced via the right femoral venous sheath and positioned within atrium, AV junction, right ventricular apex and right ventricular outflow tract under fluoroscopic guidance.
FINDINGS:
1. Baseline sinus rhythm with markedly prolonged HV interval in the setting of underlying interventricular conduction delay.
A. Sinus cycle length=700 milliseconds.
B. AH interval=90 milliseconds.
C. HV interval=110 milliseconds.
2. Normal sinus node function.
A. Baseline SCL=700 milliseconds.
B. Maximum CSNRT=450 milliseconds.
3. Normal AV nodal conduction.
A. Wenckebach cycle length=480 milliseconds.
B. AV nodal ERP=600/390.
4. Right atrial effective refractory=600/230.
5. Markedly abnormal His-Purkinje system conduction (baseline HV interval=110 milliseconds).
6. Right ventricular effective refractory.
A. Right ventricular apex=600/310, 400/310.
7. No inducible nonsustained or sustained ventricular tachyarrhythmias observed with right ventricular programmed electrical stimulation delivered at two RV patient sites in the setting of chronic procainamide therapy (Procan SR 500 mg q.i.d.), using:
A. One to three premature stimulations following two drive cycles (600, 400 milliseconds).
B. Rapid ventricular burst pacing (PCL=400-240 milliseconds).
8. No evidence for carotid sinus hypersensitivity with either right or left-sided carotid sinus massage.
Upon completion of the procedure, all catheters and sheaths removed and adequate hemostasis was achieved using manual compression. The patient was subsequently transferred to the stretcher and returned to the cardiac catheterization laboratory area in stable condition.
COMPLICATIONS: None.
IMPRESSION:
1. Normal sinus rhythm function.
2. Normal AV nodal conduction.
3. No evidence for carotid sinus hypersensitivity.
4. Markedly abnormal His-Purkinje system conduction (in the setting of longstanding procainamide therapy and underlying interventricular conduction delay manifested on surface ECG).
5. No inducible ventricular tachyarrhythmias with right ventricular programmed electrical stimulation (in the setting of chronic procainamide therapy).
RECOMMENDATION: Consider future pacemaker implantation +/- additional cardiac resynchronization therapy, given history of recurrent syncope in the setting of severe conduction system disease and required antiarrhythmic drug therapy, +/- additional cardiac resynchronization therapy given refractory NYHA class III CHF symptoms (despite optimized medical therapy) versus biventricular cardiac defibrillator implantation despite lack of inducible ventricular tachyarrhythmias, given possible false and negative results related to ongoing antiarrhythmic drug therapy in accordance with recent COMPANION and SCD-HeFT trial results supporting prophylactic biventricular cardiac defibrillator implantation among subjects with severe cardiomyopathy, moderate-severe cardiomyopathy (LVEF <35%), moderate-severe congestive heart failure (refractory medical therapy), and widened surface QRS (QRS duration >130 milliseconds.)
Electrophysiology Sample Reports Cardiac Cath Sample Report
How To Search Using Google - Some Tips
We, as medical transcriptionists, use Google all the time. We use it to search for words dictated by doctors. These words can be medical words, drug names, doctor names, hospital names, lab terms, etc. As medical transcriptionists, it is vital that you find the word you are looking for quickly. The quicker you find the word you are looking for, the quicker you can complete your file and move on to the next. You can therefore increase your productivity if you are able to research words faster. If you use Google, like I do, there are a number of handy operators you can use to get to what you are looking for faster. You may know some of them, but not all. Let me briefly explain!!
A. If you just enter the words surgical fixation in the Google search box and search - Google would show all webpages containing both words, i.e. surgical and fixation but it might not show both terms together or in any particular order.
B. Now, let's see how the usage of quotes changes things. The words are the same, i.e. surgical fixation --- however you would input the words in this fashion "surgical fixation" Note, the usage of quotes. For this query, Google would show all pages that contain both words, BUT in this instance, the two words would display together and in the same order as the query.
C. Following from the above example, you can also use the * operator to search for unknown words. Take this example. "open * surgery" In this case, the words open and surgery are clear, but you know that there is a word in between that you cannot listen to clearly.
If you input the query "open * surgery" in Google using quotes as shown, Google would show you all webpages containing words open and heart and any words in between both. For instance, "open heart surgery" "open rhinoplasty surgery," etc.
D. Now, let's come to the + operator. Let's say Google is ignoring a particular term when you search for a phrase (for example). This can sometimes happen. You want results with that word included, but Google just wouldn't show you those results. With the use of the + operator, you can force Google to include that particular term in the search results. You do so by putting a '+' sign along with the word.
For example, +heparin (note that there is no space between the '+' sign and the word.
E. The - operator works in a similar fashion. It does the exact opposite of the + operator mentioned above. If you find that Google results are showing up a term that you don't want it to show, just precede the word with the '-' operator. For example, -heparin (again, note that there is no space between the '-' search operator and the word).
F. Next is the 'OR' operator. Say, for example, you search using the search query surgery OR hernia, you would find pages that contain the words "surgery" or "hernia" or both words, but not webpages that contain neither “surgery” nor “hernia.”
There are some other operators as well, but the ones mentioned above are the more important ones every MT should know!
For additional search operators and their functions, you can follow this link. The "define" operator mentioned there is yet another useful search operator.
http://hubpages.com/hub/Google-Search-Tips-For-More-Efficient-Searches
A. If you just enter the words surgical fixation in the Google search box and search - Google would show all webpages containing both words, i.e. surgical and fixation but it might not show both terms together or in any particular order.
B. Now, let's see how the usage of quotes changes things. The words are the same, i.e. surgical fixation --- however you would input the words in this fashion "surgical fixation" Note, the usage of quotes. For this query, Google would show all pages that contain both words, BUT in this instance, the two words would display together and in the same order as the query.
C. Following from the above example, you can also use the * operator to search for unknown words. Take this example. "open * surgery" In this case, the words open and surgery are clear, but you know that there is a word in between that you cannot listen to clearly.
If you input the query "open * surgery" in Google using quotes as shown, Google would show you all webpages containing words open and heart and any words in between both. For instance, "open heart surgery" "open rhinoplasty surgery," etc.
D. Now, let's come to the + operator. Let's say Google is ignoring a particular term when you search for a phrase (for example). This can sometimes happen. You want results with that word included, but Google just wouldn't show you those results. With the use of the + operator, you can force Google to include that particular term in the search results. You do so by putting a '+' sign along with the word.
For example, +heparin (note that there is no space between the '+' sign and the word.
E. The - operator works in a similar fashion. It does the exact opposite of the + operator mentioned above. If you find that Google results are showing up a term that you don't want it to show, just precede the word with the '-' operator. For example, -heparin (again, note that there is no space between the '-' search operator and the word).
F. Next is the 'OR' operator. Say, for example, you search using the search query surgery OR hernia, you would find pages that contain the words "surgery" or "hernia" or both words, but not webpages that contain neither “surgery” nor “hernia.”
There are some other operators as well, but the ones mentioned above are the more important ones every MT should know!
For additional search operators and their functions, you can follow this link. The "define" operator mentioned there is yet another useful search operator.
http://hubpages.com/hub/Google-Search-Tips-For-More-Efficient-Searches
Urology Medical Transcription Procedure Sample Reports
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES: Right hydronephrosis, right renal colic, hematuria, recurrent interstitial cystitis, and irritative/obstructive urinary bladder symptoms.
POSTOPERATIVE DIAGNOSES: Right hydronephrosis, right renal colic, hematuria, recurrent interstitial cystitis, irritative/obstructive urinary bladder symptoms, hemorrhagic cystitis, right distal ureteritis, no evidence of gross right ureteropelvic junction obstruction, right pyelocaliectasis, female urethral syndrome with subacute interstitial cystitis, mild leukoplakia, and severe trigonitis.
PROCEDURES PERFORMED: Urethral calibration, dilatation, right diagnostic ureteroscopy with transureteroscopic fulguration of all right distal ureteric bleeding points, retrograde pyelogram, hydrodistention, hydrodilation of urinary bladder, transurethral fulguration of all bleeders, especially trigone region.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female referred because of right hydronephrosis, right renal colic with hematuria plus irritative/obstructive bladder symptoms. Evaluation showed the above findings. Options were offered to the patient, of which she agrees to undergo the above-mentioned procedure. General information, alternatives and risks were explained to the patient. The patient understands and agrees to undergo the above-mentioned procedure.
PROCEDURE IN DETAIL: The patient was brought to the cystoscopy suite. General anesthesia was then given. The patient was then placed in the dorsal lithotomy position. The patient was then scrubbed, prepped and draped in the usual sterile manner. General evaluation showed grade 1 cystocele with urethral meatal stenosis, calibrated at French #10 and #12. Urethral meatal opening was progressively dilated to French #20, #22 and #24 using the female urethral sounds. Then passed a #22 French cystourethroscope instrument into the female urethra, into the bladder, showing acute female urethritis, mild leukoplakia, severe trigonitis. Classic picture of interstitial cystitis changes were observed, including ulceration, glomerulation, submucosal hemorrhages and petechia. The right ureteric orifice was found to be gaping and hemorrhagic.
At this point in time, ureteroscopic evaluation was carried out showing evidence of subacute right distal ureteritis with bleeding hemorrhagic lesions. There was no gross obstructive uropathy, no gross evidence of ureteric stricture or evidence of gross obstructive stricture formation involving the right ureteropelvic junction. There was mild pyelocaliectasis as confirmed by a right retrograde ureteropyelogram study that was performed. There were no complications during the ureteroscopic evaluation such as ureteric rupture, ureteric bleeding or evidence of urinary extravasation. From the retrograde study, we diverted our attention to the interstitial cystitis. Hydrodistention, hydrodilation of the urinary bladder was then carried out to a maximum bladder capacity of approximately 425 mL x2 cycles. During this maximum bladder filling, all bleeding points, especially in the trigone region, were electrocoagulated and fulgurated. Satisfactory hemostasis was then initiated and completed.
The procedure was terminated, bladder decompressed and the scope was then withdrawn. The patient was then transferred to the recovery room in satisfactory condition. Postoperative orders were given.
DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURE PERFORMED: Right extracorporeal shock-wave lithotripsy.
SURGEON: John Doe, MD
ANESTHESIA: General.
CHIEF COMPLAINT: Right renal stones.
INDICATION FOR PROCEDURE: This patient is a (XX)-year-old woman who presented with a 1 cm obstructing right ureteral stone with urosepsis. The stone was pushed back into the kidney and the kidney drained with a stent. She went on to obtain successful antibiotic therapy and now returns for definitive stone treatment.
OPERATIVE FINDINGS: Two stones, each one approximately 1 cm in the right kidney, both of which were fragmented adequately with shock-wave lithotripsy.
PROCEDURE FINDINGS AND DETAILS OF PROCEDURE: After the patient obtained adequate general anesthesia, she was placed in supine position on the lithotripsy table. Using fluoroscopic guidance, the stone in the renal pelvis, which had been the obstructing stone, was placed at the focal point of the shock waves. A total of 1500 shocks were delivered with excellent fragmentation.
The patient subsequently manipulated so that the lower pole of stone, also approximately 1 cm, was identified and placed at the focal point of the shock waves. Another 1500 shocks were delivered to this, once again with excellent fragmentation. The patient tolerated the procedure well and was transferred to the recovery room in satisfactory condition.
PREOPERATIVE DIAGNOSES: Right hydronephrosis, right renal colic, hematuria, recurrent interstitial cystitis, and irritative/obstructive urinary bladder symptoms.
POSTOPERATIVE DIAGNOSES: Right hydronephrosis, right renal colic, hematuria, recurrent interstitial cystitis, irritative/obstructive urinary bladder symptoms, hemorrhagic cystitis, right distal ureteritis, no evidence of gross right ureteropelvic junction obstruction, right pyelocaliectasis, female urethral syndrome with subacute interstitial cystitis, mild leukoplakia, and severe trigonitis.
PROCEDURES PERFORMED: Urethral calibration, dilatation, right diagnostic ureteroscopy with transureteroscopic fulguration of all right distal ureteric bleeding points, retrograde pyelogram, hydrodistention, hydrodilation of urinary bladder, transurethral fulguration of all bleeders, especially trigone region.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female referred because of right hydronephrosis, right renal colic with hematuria plus irritative/obstructive bladder symptoms. Evaluation showed the above findings. Options were offered to the patient, of which she agrees to undergo the above-mentioned procedure. General information, alternatives and risks were explained to the patient. The patient understands and agrees to undergo the above-mentioned procedure.
PROCEDURE IN DETAIL: The patient was brought to the cystoscopy suite. General anesthesia was then given. The patient was then placed in the dorsal lithotomy position. The patient was then scrubbed, prepped and draped in the usual sterile manner. General evaluation showed grade 1 cystocele with urethral meatal stenosis, calibrated at French #10 and #12. Urethral meatal opening was progressively dilated to French #20, #22 and #24 using the female urethral sounds. Then passed a #22 French cystourethroscope instrument into the female urethra, into the bladder, showing acute female urethritis, mild leukoplakia, severe trigonitis. Classic picture of interstitial cystitis changes were observed, including ulceration, glomerulation, submucosal hemorrhages and petechia. The right ureteric orifice was found to be gaping and hemorrhagic.
At this point in time, ureteroscopic evaluation was carried out showing evidence of subacute right distal ureteritis with bleeding hemorrhagic lesions. There was no gross obstructive uropathy, no gross evidence of ureteric stricture or evidence of gross obstructive stricture formation involving the right ureteropelvic junction. There was mild pyelocaliectasis as confirmed by a right retrograde ureteropyelogram study that was performed. There were no complications during the ureteroscopic evaluation such as ureteric rupture, ureteric bleeding or evidence of urinary extravasation. From the retrograde study, we diverted our attention to the interstitial cystitis. Hydrodistention, hydrodilation of the urinary bladder was then carried out to a maximum bladder capacity of approximately 425 mL x2 cycles. During this maximum bladder filling, all bleeding points, especially in the trigone region, were electrocoagulated and fulgurated. Satisfactory hemostasis was then initiated and completed.
The procedure was terminated, bladder decompressed and the scope was then withdrawn. The patient was then transferred to the recovery room in satisfactory condition. Postoperative orders were given.
DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURE PERFORMED: Right extracorporeal shock-wave lithotripsy.
SURGEON: John Doe, MD
ANESTHESIA: General.
CHIEF COMPLAINT: Right renal stones.
INDICATION FOR PROCEDURE: This patient is a (XX)-year-old woman who presented with a 1 cm obstructing right ureteral stone with urosepsis. The stone was pushed back into the kidney and the kidney drained with a stent. She went on to obtain successful antibiotic therapy and now returns for definitive stone treatment.
OPERATIVE FINDINGS: Two stones, each one approximately 1 cm in the right kidney, both of which were fragmented adequately with shock-wave lithotripsy.
PROCEDURE FINDINGS AND DETAILS OF PROCEDURE: After the patient obtained adequate general anesthesia, she was placed in supine position on the lithotripsy table. Using fluoroscopic guidance, the stone in the renal pelvis, which had been the obstructing stone, was placed at the focal point of the shock waves. A total of 1500 shocks were delivered with excellent fragmentation.
The patient subsequently manipulated so that the lower pole of stone, also approximately 1 cm, was identified and placed at the focal point of the shock waves. Another 1500 shocks were delivered to this, once again with excellent fragmentation. The patient tolerated the procedure well and was transferred to the recovery room in satisfactory condition.
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