Vasogram and Testicular Biopsy Transcription Sample Report

DATE OF OPERATION:
MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Azoospermia.

POSTOPERATIVE DIAGNOSIS:
Azoospermia with obstruction of ejaculatory ducts.

OPERATION PERFORMED:
Right vasogram and testicular biopsy with transurethral resection of ejaculatory ducts.

SURGEON:
John Doe, MD

ASSISTANT:
None.

ANESTHESIA:
General LMA.

OPERATION IN DETAIL:  After the patient was brought to the surgical suite, the patient was placed on the surgical table in the supine position.  He was given general LMA anesthesia and then placed on the stirrups in the dorsal lithotomy position.  He was shaved and prepped appropriately with Betadine and draped in aseptic fashion.  Testicles were injected with 0.5% Marcaine, as well as median raphe.

After this was done, the testicles were dissected out on the right side.  Testicles showed a normal consistency with a normal epididymis.  The vas was palpable.  There was no significant dilatation of the veins around the epididymis.  However, the color, size, and consistency of the epididymis and testicle were consistent with that of a normal-appearing testicle.

Then, an incision was made in the tunica albuginea and the testicular contents were removed and sent in Bouin solution for permanent evaluation.  After this was completed, the testicle was repaired and the vas was dissected out using the ring retractor.  Once dissected out, we transected the anterior wall of the vas and then dilated it with dilators.  We were able to pass a #2 Prolene stitch, greater than 12 cm, into the ejaculatory ducts indicating that this site was patent.  We placed the scope in the bladder but could not see the tip of the Prolene.

We then injected methylene blue.  There was a very narrow stream of dye coming from the very cystic verumontanum.  This was very unusual, did not show clearly defined ejaculatory ducts that were open with good output.  At this juncture, we then cannulated and placed contrast to show an outline of the convoluted vas as well as the ampulla of the vas and ejaculatory ducts.  There was the dye that did enter the bladder, but this was done under tremendous pressure and we did document that the opening from the vas to the verumontanum was inadequate.

Because of these findings, we felt that it would be best to resect the verumontanum.  The verumontanum was resected without incident.  Hemostasis was achieved.  This was done with a resectoscope.  At the end of that procedure, the area was fulgurated and a #24 French catheter was placed in the bladder and the bladder was irrigated to clear.

The scrotal area was then closed with a running #2-0 chromic stitch and the vas was repaired using a #8-0 Vicryl in an interrupted fashion and it was reinforced with a #2-0 chromic.  After the vas and the testicle contents had been placed, then the #2-0 chromic was used in order to close the skin and close the sac of the scrotum.  The patient tolerated the procedure well.  There were no surgical anesthesia complications.

Right Carotid Endarterectomy and Bovine Pericardial Patch Angioplasty

DETAILS OF OPERATION:  The patient was taken to the operation room.  In supine position, under adequate general anesthetic, the neck was prepped with povidone solution, draped using lap sheets and towels.  A transverse incision was made and the bleeding was controlled using Bovie.  The sternocleidomastoid was reflected posteriorly as was the internal jugular vein after clamping and ligating several anterior branches with 2-0 and 3-0 silk.  The common carotid was identified and the patient was given 10,000 units of heparin.  Dissection was carried superiorly, identifying and preserving the hypoglossal and vagus nerves.  The internal and external branches were delineated and vessel loops were placed around each.  A Rumel tourniquet was placed around the common carotid and the shunt was prepared in case it needed to be used.  The common carotid was cross-clamped and brain monitoring reported that there was no alteration in signal.  An incision was made extending from the common carotid up to the internal carotid.  Careful endarterectomy was then performed using a Penfield elevator.  It was noted the patient had heavily calcific plaque with superficial ulceration.  The plaque was finally removed, and after ensuring that there was no loose debris, attention was turned to closure.  A piece of bovine pericardium was brought onto the field and then fashioned as a patch.  This was sutured in place using 6-0 Prolene in continuous fashion.  Upon completing the suture line, backbleeding was allowed.  The suture line was tied down and flow was established, first of the external and then the internal.  The heparin was partially reversed with protamine, and after noting adequate hemostasis, attention was turned to closure.  Closure was performed using 3-0 Vicryl in continuous fashion to the subcutaneous tissue and 4-0 Vicryl in continuous subcuticular fashion for the skin.  After placing an adequate dressing and noting a normal neurologic examination, the patient was taken to the recovery area in good condition.

Percutaneous Transluminal Angioplasty MT Sample Report

DATE OF OPERATION:  MM/DD/YYYY

 PROCEDURE PERFORMED:  Percutaneous transluminal angioplasty, right femoropopliteal artery bypass and aortogram.

 SURGEON:  John Doe, MD

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and sterilely prepped and draped in the supine position.  Preoperative prophylactic antibiotics were administered and appropriate monitoring lights were placed.

 A transverse incision was made in the right groin.  The skin and subcutaneous tissues were sharply incised.  The dissection was carried down to where the common femoral, superficial femoral, and profunda femoris arteries were dissected free.  These were encircled with vessel loops.  The popliteal artery was then dissected above the knee.  The Kelly-Wick tunneling apparatus was used to pass a portion of 6 mm Gore-Tex.

  The left common femoral artery was cannulated under fluoroscopy with Cournand needle and a #7 French introducer was placed.  The patient was then systemically heparinized with 8500 units of heparin.  Adequate time for circulation was allowed.  A 0.35 guidewire was then placed into the abdominal aorta under fluoroscopy.

 An aortogram with runoff into the common femoral artery was obtained.  There was noted to be, with oblique views, a 50-60% stenosis over the left external iliac artery.  An 8 x 24 mm Genesis stent was brought to profile at 8 atmospheres.  Followup angiogram showed an excellent technical result with no residual significant stenosis.

 An arteriotomy was created in the femoral artery with a #11 blade and extended with the Potts scissors, and end-to-side anastomosis was then created here with running continuous sutures of #5-0 Prolene.  An arteriotomy was created on the popliteal artery with a #11 blade and extended with the Potts scissors, and end-to-side anastomosis was then created here with running continuous sutures of #6-0 Prolene.

 The graft was opened and found to be hemostatic.  The patient was found to have palpable pulses in the foot.  The patient's heparin was partially reversed with 50 mg of protamine, given slowly IV.

 All wounds were then copiously irrigated with normal saline and Kantrex.  The leg and groin incisions were closed with #2-0 and #3-0 PDS.  The skin was reapproximated with #3-0 nylon sutures in the groin and stainless steel clips at the knee.  Needle and sponge counts were correct x2.  The patient was then transported to recovery in a stable condition.

 Electrophysiology / Interventional Cardiology Sample Reports

Carotid Bifurcation Endarterectomy Medical Transcription Sample


DATE OF PROCEDURE:  MM/DD/YYYY

 PROCEDURE PERFORMED:  Left carotid bifurcation endarterectomy with saphenous vein patch angioplasty and completion arteriogram.

 OPERATION IN DETAIL:  The patient was placed on the operating room table in a supine position.  General anesthetic was induced and maintained with an oral endotracheal tube.  EEG monitoring was utilized.  A radial arterial line was placed.  The head was turned to the right, gently, and a roll was placed beneath the left scapula.  The head was cradled on a foam headrest taking care not to hyperextend the neck.  EEG was of low amplitude bilaterally and stable in this position.  The left thigh was also laterally rotated and flexed at the hip and knee.  The patient was padded with blankets to make the area of the saphenous vein prominent.  The left thigh was shaved and then the course of the saphenous vein was marked with a marking pen.  The left side of the neck and chest as well as the left thigh were then prepped with DuraPrep and draped with sterile towels and drapes, including Ioban and Steri-Drapes, over each operative site.

The saphenous vein was harvested from the thigh simultaneously with exposure of the carotid artery in the neck.  In the thigh, the branches of the saphenous vein were divided between #4-0 silk ligatures.  The vein was ligated both proximally and distally and then placed in heparinized saline.  A longitudinal incision was then made along the anterior border of the sternocleidomastoid muscle.  The incision was deepened down through the subcutaneous tissue and platysma with electrocautery.  The external jugular veins were divided between #4-0 silk ligatures.

 The incision was deepened along the anterior border of the sternocleidomastoid muscle to expose the internal jugular vein.  Branches coming from the anterior surface of the jugular vein were divided between #4-0 silk ligatures.  The common carotid artery was identified and dissected circumferentially after lowering the incision.  Vagus nerves were identified and protected throughout its course in the neck.  The hypoglossal nerve was identified superiorly and protected throughout its course in the neck.  The bifurcation was low.  Internal carotid artery was dissected above the region of the bulb.  The external carotid artery was dissected circumferentially above the superior thyroid artery.  The superior thyroid artery was ligated with a #2-0 silk ligature.  He was then given 10,000 units of heparin.  After this had circulated for about 5 minutes, atraumatic vascular clamps were placed upon the internal carotid, the common, and the external carotid artery.

An arteriotomy was made in the common carotid artery.  It was then extended proximally and then distally through the internal carotid bulb region and some more distal to the internal carotid artery.  There was marked hemorrhagic plaque within the bulb.  A previously heparinized 3 x 4 mm shunt was prepared.  It was necessary to gently dilate the internal carotid artery with a 2, 2.5, and 3 mm dilator before placing the shunt.  The shunt was then placed within the internal carotid artery securing with large Javid shunt clamp.  Backbleeding was almost negligible.  A right drain was quickly placed within the common carotid artery and secured with a large Javid shunt clamp which was then exchanged with a doubly looped maxi loop.  Continuous wave Doppler confirmed flow within the shunt.

 Endarterectomy was then done in the usual fashion.  After lowering of the arteriotomy, the intima was divided under direct vision using the Potts scissors.  The endarterectomy then proceeded distally into internal carotid artery where a nice tethering endpoint was achieved.  The external carotid was endarterectomized using an aversion-type of technique and loose adherent strands of media were removed from the endarterectomized surface with fine mosquito hemostats.  The surface of the artery was repeatedly irrigated with heparinized saline and low-molecular weight dextran.

After completing the endarterectomy, the saphenous vein patch was prepared by incising it longitudinally.  A segment without valves was selected.  The vein was then trimmed longitudinally so it was about 0.25 inch wide.  The vein patch was then sutured in place with running #6-0 Prolene.  After completing the posterior suture line, a 20 gauge Angiocath was placed retrograde through the superior carotid artery, near the common carotid artery, and secured with a #4-0 silk ligature.  This was used later for completion arteriogram.

 The anterior suture line was then closed until the shunt prevented placement of the last two sutures.  The shunt was then removed.  The artery was found with forward and backbleeding, and it was again flushed with heparinized saline.  The arteriotomy closure was then closed.  Flow was restored at the external carotid artery, and after about 15 seconds, the internal carotid artery was opened.  There were easily palpable pulses in the internal, external, and common carotid artery with no evidence of dissection.  Continuous wave Doppler signals were satisfactory in all three arteries.

The completion arteriogram was then done.  This revealed a widely patent internal and external carotid artery.  This was done by injecting approximately 4 mL of Optiray through the catheter in the superior thyroid artery.  The catheter was then removed, and the superior thyroid artery was ligated with a #4-0 silk ligature.  Heparin was then reversed with 50 mg of protamine sulfate.

 After hemostasis was achieved, the thigh wound was closed with running #3-0 Vicryl for the subcutaneous tissue and running #4-0 Vicryl subcuticular suture for the skin.  The neck wound was then closed with running #3-0 Vicryl for the platysma and running #5-0 Vicryl subcuticular suture for the skin.  Sterile bandages were applied, and he tolerated the procedure without complications.  All sponge, needle, and instrument counts were correct.  The patient left the operating room to go to the recovery room in satisfactory condition without obvious neurologic deficits.

REHABILITATION (REHAB) HISTORY AND PHYSICAL SAMPLE

CHIEF COMPLAINT:  Status post left total knee replacement.


HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male who has a history of left knee trauma.  Subsequently, arthroscopies were performed on bilateral knees.  Subsequently, the patient had a reinjury to the left knee.  He had increasing persistent pain and decreased function consistent with terminal degenerative joint disease.  Conservative management was accomplished.  The patient underwent elective procedure on MM/DD/YYYY for left total knee replacement by Dr. Doe.  Postoperatively, the patient had hypertension episode consistent with analgesic medication.  The patient was transferred to rehab on MM/DD/YYYY without problems.


PAST MEDICAL HISTORY:  History of hypertension and osteoarthritis.  He denied previous history of CVA, MI, seizure activity or head trauma.


PAST SURGICAL HISTORY:  Status post bilateral knee arthroscopies.


PSYCHOSOCIAL HISTORY:  The patient is married, lives in a single level home, has a couple of steps inside the home.  Wife is healthy.  Denies any use of tobacco products or alcohol consumption.


FAMILY HISTORY:  Noncontributory.


ALLERGIES:  PENICILLIN.


MEDICATIONS:  Zestril 20 mg daily, Pepcid 20 mg daily, and Restoril 15 mg at bedtime p.r.n.


REVIEW OF SYSTEMS:  Denies fever, chills, nausea, vomiting, shortness of breath or chest pain.


PHYSICAL EXAMINATION:
General:  Examination reveals a pleasant male.  He is comfortable.
Vital Signs:  Blood pressure 128/77, pulse 79, respirations 18, and temperature 97.6 degrees.
Skin: Warm and dry.  The incision area on the left knee is without drainage.  The right knee incision is well healed.  There is no pressure or decubitus ulcer identified.
HEENT:  Normocephalic.  Extraocular movements are intact.  Oropharynx is clear.  Trachea is midline.  Laryngeal elevation is good.
Chest:  Symmetrical bony structures.
Lungs:  Clear to auscultation.
Heart:  Regular rhythm and rate.  No murmurs or gallops.  Peripheral pulses are 2+ and symmetrical.
Abdomen:  Benign.  Active bowel sounds.  No tenderness on deep palpation noted.
Extremities:  All extremities are normal in alignment.  Good plantar surfaces for weightbearing purposes.  The left knee has 1+ effusion as well as left lower leg 1+ edema.  Range of motion is –5 to 30 degrees with some tenderness noted.  No displacement.  The knees appear to be stable.  No clubbing or cyanosis noted.
Neurological:  Alert and orientated x3.  Motor and sensory are intact, except for examination of the left knee limited postoperatively.  Sensory is intact, light touch and proprioception.  Cerebellum is intact with midline alternating movement.  Tone is symmetrical.  No spasticity or clonus.  Reflexes are symmetrical except for left knee, not tested.  Mentation is appropriate.  No overt depression or major anxiety.


REHABILITATION POTENTIAL:  Good to achieve home discharge at modified independent/independent level.


REHABILITATION ELOS:  Anticipated 5 to 7 days to accomplish ambulation more than 200 feet with assistive devices, transfers and self-care skills at modified independent/independent level with knee flexion at 90 degrees.


REHABILITATION ASSESSMENT:
1.  Status post left total knee replacement complicated with a previous history of right knee arthroscopy and anterior cruciate ligament repair.
2.  History of hypertension.
3.  Osteoarthritis.


PLAN AND SUMMARY:  This is a (XX)-year-old male who is a good rehabilitation candidate to achieve home discharge in 5 to 7 days at a modified independent/independent level.  It is anticipated that the patient would benefit from following physical therapy, occupational therapy, increased strength, overall function, and develop home exercise program.  Nursing will continue with wound care and monitor vital signs.  Care management will assist with discharge planning.  Rehabilitation physicians will maintain optimal medical status as well as coordinate discharge planning and followup care as needed.


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Bilateral Vasectomy Varicocelectomy Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

 PREOPERATIVE DIAGNOSIS:
Left varicocele, left spermatocele, and elective sterility.

 POSTOPERATIVE DIAGNOSIS:
Not dictated.

 OPERATION PERFORMED:
Bilateral vasectomy, left varicocelectomy, and left spermatocelectomy.

 SURGEON:
John Doe, MD

 ASSISTANT:
None.

 ANESTHESIA:
General LMA.
ANESTHESIOLOGIST:
Jane Doe, MD

 DESCRIPTION OF OPERATION:  After informed consent had been obtained, the patient was given general laryngeal mask airway anesthesia.  The patient was prepped appropriately giving access to the left inguinal area and scrotum.  After this, the local was placed in the left inguinal, after being draped in aseptic fashion, 0.5% Marcaine with epinephrine was infused into the left inguinal area.  Marcaine 0.5% plain was injected into the median raphe and to the left cord.

 Then, the puncture scissors were used in order to open up the median raphe, and using the ring forceps, the vas was brought into the surgical field; it was dissected out.  Once it was dissected out, it was transected and ligated appropriately, and the segment was handed off for pathological identification.  The cords were tied proximally and distally x2 with #3-0 silk, and the tips were fulgurated.  Then, this site was closed with #4-0 chromic.

 Then, incision was made in the left inguinal area, just at the external ring.  The cord was dissected out.  The testicle was brought to the surgical field and the tunica vaginalis was opened.  The complex cyst on the gland, on the globus major, was then dissected off, the area was dissected out, and the clamp was placed at the point of the epididymis and the specimen was removed.  The epididymis was repaired with #3-0 Vicryl stitch, and the tunica was closed appropriately.

 Then, attention was given to the varicocele.  The spermatic cord was dissected out.  The cremasteric was opened.  The veins were identified and ligated with #3-0 silk suture.  After this was completed, attention was given to the vas.  The segment of the vas near the area of the varicocele ligation was dissected out using the sharp tip hemostat.  Once this was done, we then transected the vas to make sure there were no vessels included and then we took out a segment.

 Hemostats were used and the proximal and distal segments were then tied appropriately with #3-0 silk x2 and the tips were fulgurated.  The patient's wound was closed with #3-0 chromic, and the skin was approximated with a running #4-0 Vicryl stitch.  The patient tolerated the procedure well.

Discharge Summary Transcribed Sample Report

DATE OF ADMISSION:  MM/DD/YYYY


DATE OF DISCHARGE:  MM/DD/YYYY


DISCHARGE DIAGNOSES:
1.  Hypovolemia.
2.  Protein-calorie malnutrition.
3.  Pneumonia.
4.  Urinary tract infection.
5.  Clostridium difficile infection.
6.  Respiratory failure.
7.  Head and neck cancer.


PROCEDURES DONE DURING THIS ADMISSION:  Temporary tracheostomy.


HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male with a history of right retromolar squamous cell carcinoma of the head and neck, status post local resection and two courses of radiation therapy followed by hyperbaric treatment for nonhealing ulcer that has subsequently recurred.  He has been felt to be a nonsurgical candidate.  He has increasing difficulty in opening or closing his mouth, maintained on liquid diet at home with pain medication and oral nutrition.  He is in danger though of airway obstruction and compromise, and he has been admitted for placement of a feeding tube and to evaluate his nutrition and treat his pain, as well as his dehydration.


HOSPITAL COURSE:  Upon admission, the patient was admitted and placed on IV fluids.  Labs were obtained.  Continued home medications, methadone elixir and oxycodone elixir.  Consult was made to the surgeon, Dr. John Doe, with regard to the patient's need for a port as well as G-tube placement and a consult was made to the ear, nose, and throat specialist, Dr. Jane Doe, with patient need for a tracheostomy.  On MM/DD/YYYY, the patient was seen by the surgeon, Dr. John Doe, and after his assessment; impression, history of head and neck cancer with metastatic disease status post radiation therapy, inability to open mouth, and chronic pain.  The patient and his wife were present.  I told them that this is a very difficult situation due to the fact that he is unable to open his mouth and it would be impossible to obtain an airway orally.  He would have to consider tracheostomy, which could have been done under sedation, then followed obviously by gastrostomy placement, which would require an incision of his abdominal wall, and there are certain risks associated with that including bleeding, infection, scarring, leakage, and abscess.  All of this has been discussed.  Particularly, because of his nutritional status, we also discussed port placement, which could be done.  Risks though would include bleeding, infection, scarring, and pneumothorax and obviously high risk of infection if he has a tracheostomy placed.  The other possibility for feeding purposes would be to consider radiologic placement nasally of a Dobbhoff feeding tube, which could be done by radiology department if they evaluate him and feel that it could be done.  On MM/DD/YYYY, the patient underwent tracheostomy by Dr. Doe.  Postoperatively, he was monitored in the ICU and given morphine sulfate for narcotic analgesia.  The patient did opt for the placement of nasogastric tube under fluoroscopy with percutaneous placement of gastrostomy tube under fluoroscopy under physician monitored conscious sedation.  Post-placement, he was then started on Jevity tube feedings.  A consult was made to the IV team for placement of PICC line and this was placed for IV access.  Because of his overall poor condition, the patient and his wife considered hospice with comfort care measures only.  He was made a DNR with full active treatment.  A consult was then made to hospice for post-discharge care, and arrangements were made for the patient to be discharged home under the care of hospice.  He continued to be supported with medications for pain, transfusion of blood and platelets, and tube feeding for nutritional support.  Once arrangements were made for discharge home with hospice, the PICC line was discontinued, and the patient was discharged home under the care of hospice.
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