Injection of Lymphazurin Blue Dye Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

 PREOPERATIVE DIAGNOSIS:  Left breast ductal carcinoma in situ with microinvasion.

 POSTOPERATIVE DIAGNOSES:  Left breast ductal carcinoma in situ with microinvasion.

 OPERATION PERFORMED:
1.  Injection of Lymphazurin blue dye for sentinel lymph node mapping, left breast.
2.  Left axillary sentinel lymphadenectomy.
3.  Left breast needle-localized lumpectomy.

 SURGEON:  John Doe, MD

 ANESTHESIA:  General laryngeal mask.

ANESTHESIOLOGIST:  Jane Doe, MD

 DESCRIPTION OF OPERATION:  After appropriate consent was obtained, the patient was brought to the operating room, placed on the table in supine position, and general laryngeal mask anesthesia was administered. The patient tolerated this well. The left breast preoperative localization films as well as sentinel lymph node mapping lymphoscintigraphy films were carefully reviewed prior to the procedure.

The patient was placed on the table in supine position, and after induction of anesthesia, the left breast and axillary regions were prepped and draped in sterile manner. Lymphazurin blue dye was injected in the subareolar region as well as around the area in the 10 o'clock region of the breast, where the tumor was located using a 25 gauge needle and approximately 3 mL of the solution.

Next, the location of the tip of the wire was identified upon physical exam and review of the localization films. Breast was marked and a line was marked for curvilinear incision to allow for excision of the lumpectomy specimen, as well as to allow for excision of the area of palpable concern at the 11 o'clock position of the breast. When the specimen was completely resected, the area of palpable concern, based on physical exam at the 11 o'clock position of the breast, was located on the superficial inferolateral aspect of the lumpectomy specimen.

Incision was made in the left axilla over the area that was noted to have increased activity indicated with a Neoprobe. Dissection was carried down with cautery through the subcutaneous and Scarpa's fascia. The retractors were placed and the sentinel lymph node was easily identified as it had a strong blue color. Hemostat was used to dissect around this area and hemoclips were used as needed for hemostasis.

Once this blue lymph node was removed, there was no significant radioactivity within the axilla. There were no palpable lymph nodes of any suspicion within the left axilla and no further blue lymph nodes. The sentinel lymph node was submitted for touch prep analysis and the pathologist called report to the room noting that there were two lymph nodes together in that specimen and they were both negative on touch prep analysis for metastatic carcinoma.

The operative field in the left axilla was noted to be hemostatic and was closed in layers using interrupted 3-0 Vicryl to close the deep dermis and running 4-0 subcuticular Vicryl suture to close the skin. Benzoin, Steri-Strips, and sterile gauze dressings were placed at the end of the case. Curvilinear incision was then made in the left breast where it had been marked with a marking pen after placing 0.5% plain Marcaine solution for local anesthetic.

Dissection was then carried down with cautery approximately 10 mm under the skin and then tissue flaps were raised medially to allow for the wire to be brought up under the skin and into the incision. Care was taken to incorporate a portion at the 11 o'clock area of palpable concern as described above. The lumpectomy specimen was centered around the area of tip of the wire to assure complete resection. Visualization and palpation of the margins of the lumpectomy as well as lumpectomy cavity revealed no evidence of any suspicious tissues. The specimen was submitted for radiographic analysis and report was called to the room confirming that the wire and tissue clips were completely resected.

The operative field was irrigated, inspected, rendered hemostatic with cautery and then closed in layers using interrupted 3-0 Vicryl to close the deep subcutaneous tissue at a level of approximately 1 cm depth. The sutures were placed so as the knots were facing upward and not down into the lumpectomy cavity. The deep dermis was then closed with interrupted 3-0 Vicryl sutures. The skin was closed with running 4-0 subcuticular Vicryl suture. Benzoin, Steri-Strips, sterile gauze dressings were placed. The patient had her anesthesia reversed. She was taken to the recovery area postoperatively.

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Hypophysectomy ENT Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Pituitary tumor.

POSTOPERATIVE DIAGNOSIS:
Pituitary tumor.

OPERATION PERFORMED:
Transseptal transsphenoidal approach for hypophysectomy.

SURGEON:  John Doe, MD

NEUROSURGEON:  Jane Doe, MD

ANESTHESIA:  General endotracheal.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old female who presented with left retro-orbital headaches.  She also had evidence of endocrinopathy.  MRI scan was consistent with microadenoma.  The patient was scheduled for hypophysectomy per Dr. Jane Doe.  Nasal history is notable for a prior nasal fracture.  The risks, benefits, alternatives, and indications of the above noted procedure and approach were reviewed in detail.  The patient agreed with the procedure planned.

 OPERATIVE FINDINGS:  The patient had a septal deviation most notably along the right dorsal aspect.  Intersphenoid sinus septum was located right at the midline.  Therefore, the left sphenoid sinus was larger than the right.  No CSF was encountered.  Doyle splints were used to assist with septal healing.

DESCRIPTION OF OPERATION:  The patient was brought in the operating room and placed on the OR table in the supine position.  After demonstration of adequate general endotracheal anesthesia, the table was turned 90 degrees.  The C-arm was positioned to allow visualization of the sella.  The nose was prepped with 6 mL of 1% lidocaine with 1:100,000 epinephrine into the nasal septum mucosal flaps.  This was also applied on the nasal floors and 1 mL total to the greater palatine foramina.  The patient was then prepped and draped sterilely including the abdomen.

A #15-blade scalpel was used to make a left hemitransfixion incision which was extended down just anterior to the floor.  Submucoperichondrial flaps were elevated with the caudal.  The septal tunnel on the left was elevated with the caudal in the anterior to posterior direction beyond the bony cartilaginous junction onto the area of the rostrum.  This was then taken down over the maxillary crest and nasal floor.  The floor was elevated in a posterior to anterior direction.  The mucosa was swept laterally to ultimately allow space for the Hardy retractor.

Next, an incision was made in the septal cartilage over 1.5 cm posterior to the tip.  A sliver of cartilage was harvested and preserved.  The opposing mucoperichondrial and mucoperiosteal flaps were then elevated with the caudal.  Through the same exposure, I was able to elevate off the maxillary crest on the right posteriorly.  I continued this elevation anteriorly and again swept the nasal floor mucosa laterally.  Anteriorly, the caudal septum was disarticulated from the crest and allowed to swing to the right.  At this time, the longer speculum was used to visualize the rostrum.  It was replaced by the self-retaining Hardy speculum.

A Penfield was used to cannulate the natural ostia of the right followed by the left sphenoid sinus.  Placement within the sinus was confirmed using the C-arm.  Next, 1 and 2 mm rongeurs were used to open up the ostia and connect them in the midline.  The intrasinus septum was visualized right of the midline and extending obliquely to the right side.  A CT scan did show that this was at the posterior attachment within the proximity of the carotid, which was well covered by bone.  It was carefully taken down along its anterior two-thirds with Takahashi forceps.

At this time, the case was turned over to the assisting doctor.  He agreed that the exposure was adequate and proceeded with his portion of the case.  There was no spinal fluid leak reported.  After repair, the case was turned back to me for closure.  The septal flaps were in good condition.  There was a small mucosal opening on the right flap with an intact opposing flap.  This was at the midway point of the septum.  Also note, earlier in the case, there was a thin stream of arterial bleeding from the septal artery on the right, which was fully controlled with the suction Bovie.  The caudal septum was then placed back on the crest using two interrupted #4-0 nylon sutures.

The hemitransfixion incision was closed using interrupted #3-0 chromic sutures.  A running #4-0 fast absorbing on a SC-1 needle was used to close the flaps back together and help prevent hematoma formation.  The Doyle splints were coated with Bactroban ointment and placed on either side of the septum.  They were secured across the membranous septum with a #2-0 nylon suture.  The patient was turned over to the care of the anesthesia team for subsequent extubation and returned to the recovery room.  The patient tolerated the procedure well without any immediate complications.

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Hematology Oncology Transcription Consult Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REQUESTING PHYSICIAN:  Jane Doe, MD

CONSULTING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Monoclonal gammopathy.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old woman with multiple medical problems who was admitted with generalized weakness.  There is polydipsia and polyuria, in the setting of chronic pancreatitis.  Other problems include renal insufficiency, atrial fibrillation, TIA, long-term congestive heart failure and history of anxiety disorder.  During workup here in the hospital, she was found to have mild hypercalcemia and a serum immunofixation showed a kappa monoclonal gammopathy.  We are consulted regarding the possibility of multiple myeloma.  Her recent history is positive for acute renal failure.  This was associated with pancreatitis-related diarrhea.  She developed acute renal failure, which responded to IV fluids but she had some mild degree of chronic renal insufficiency since then.  She has had significant anemia and had been treated by her renal doctor with Aranesp as an outpatient.  Other medical history is positive for pacemaker placement for cardiac dysrhythmia.  She has had previous cholecystectomy, cervical fusion and previous hand surgery.

MEDICATIONS ON ADMISSION:  Coreg, Coumadin, coenzyme Q, Viokase, TriCor, Centrum Silver, magnesium and calcium.

ALLERGIES:  MULTIPLE MEDICATION ALLERGIES.

FAMILY HISTORY:  Negative for any bleeding or clotting disorders.

SOCIAL HISTORY:  Nonsmoker and nondrinker.  

REVIEW OF SYSTEMS:  Review of 16 systems at this time is positive for general fatigue.  She has got some joint aches.  She has had some abdominal pain and bloating that she relates to her chronic pancreatitis.  She is currently having no fevers or chills.  No shortness of breath.  No headache or focal weakness.  She denies long bone pain or skull pain.  She has had no difficulty swallowing.  No hematochezia.  She has had heme positive stool.

PHYSICAL EXAMINATION:  On examination today, the patient appears somewhat younger than her stated age.  Skin exam shows no petechiae, ecchymosis or jaundice.  Thorough examination of lymph node bearing regions shows no cervical, supraclavicular, axillary adenopathy.  HEENT exam shows no oropharyngeal lesions.  No thrush.  Neck is supple without masses or thyromegaly.  Her lungs are currently clear bilaterally.  Cardiovascular exam reveals a regular rate and rhythm without murmur, gallop or rub.  Abdomen is soft, mildly distended, nontender throughout.  Positive bowel sounds are present, although they appear hypoactive.  Extremities reveal no clubbing, cyanosis or edema.  She has good muscle strength throughout all four extremities.

LABORATORY DATA:  Currently shows resolved anemia with a hemoglobin of 13.1, white count 5.8, and platelets 222,000.  Her INR reflects her Coumadin use.  Her creatinine is 4.7, total calcium is now normalized but on admission was 11.1.  Total proteins were normal, globulin was normal.  Thyroid function test were normal.  Her intact PTH is in the normal range.  Immunofixation showed monoclonal free light chain of kappa type hiding in the beta globulin zone.

IMPRESSION:  Kappa monoclonal spike in this patient with renal failure and hypercalcemia.  Multiple myeloma is a consideration.  My suspicion is that she has a monoclonal gammopathy of unknown significance.  Her hypercalcemia is probably related to underlying pancreatitis and the like.  Nevertheless, multiple myeloma should be ruled out in this woman.  She had a bone scan, which was negative, but this will not predictably pick up myeloma.

RECOMMENDATION:  Bone marrow biopsy and aspirate, quantitative immunoglobulin levels and skeletal survey if bone marrow is positive.  I have discussed this in detail with the patient.  She is willing to proceed with bone marrow biopsy and aspirate.  This has been ordered.  We will await further recommendations pending those results.

Abdominal MRI Medical Transcription Sample Report

ABDOMINAL MRI WITH AND WITHOUT CONTRAST

DATE OF STUDY: MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

INDICATION FOR STUDY:  Stage III adenocarcinoma of the endometrium, rule out lymphatic spread.

TECHNIQUE AND FINDINGS: MRI of the upper abdomen with and without gadolinium and T2 fat-saturated imaging shows no evidence of fatty masses.  No metastasis or nodular presence on the periphery of the liver is present to indicate malignant spread.

The spleen is unremarkable.  The kidneys show no abnormal enhancement but do show some cortical uniform enhancement, as one would expect.

We do see that there is a small 5 mm probable cyst in the inferior pole of the left kidney.  The spleen is unremarkable.  No significant paracaval or periaortic lymphadenopathy is definitely identified on this examination.

The bony structures of the thoracolumbar spine are unremarkable and show no enhancing abnormalities.

 IMPRESSION:  No evidence of metastasis or lymphadenopathy in the upper abdomen.  Particularly, the liver shows no pathology.  The left inferior pole does suggest a 5 mm simple cyst.

MRI OF THE ABDOMEN AND PELVIS WITHOUT AND WITH CONTRAST

 DATE OF STUDY:  MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

INDICATION FOR STUDY:  Leiomyosarcoma.  Hysterectomy (XX)years ago.

 TECHNIQUE AND FINDINGS:  Multiplanar images were obtained without and with contrast of the entire abdomen and pelvis.  The patient was very claustrophobic.

The upper abdomen is unremarkable.  There is no obvious mass.  Intra-abdominal organs are grossly unremarkable.

In the pelvis, there is an ovoid mass posterior to the bladder along the left posterior aspect.  This is low signal on T1 and remains fairly low signal on T2, as it is not as bright as the bladder.  Therefore, it is not a cyst.  It does appear to enhance with contrast.  This may well represent recurrence of her primary leiomyosarcoma. The mass measures approximately AP dimension 2.3 x transverse dimension 3.0 x craniocaudal dimension 2.7 cm.

IMPRESSION:  There is a small mass posterior to the bladder, slightly to the left of midline, measuring about 3 cm that appears to be separate from the bladder.  This is low signal on T1, slightly higher signal on T2 but not nearly as high as the fluid within the bladder.  It does appear to enhance.  This is suggestive of a tumor.  It may well represent recurrence of a primary/previous leiomyosarcoma.  No other abnormality is identified in the abdomen or pelvis.  There is some motion artifact involving the abdomen images that may be due to respiratory artifact.

 MRI OF THE ABDOMEN AND PELVIS WITHOUT AND WITH CONTRAST

DATE OF STUDY:  MM/DD/YYYY

 REFERRING PHYSICIAN:  John Doe, MD

INDICATION FOR STUDY:  Left lower quadrant pain, worse with bowel movement.

TECHNIQUE AND FINDINGS: Multiplanar images were obtained without and with contrast.  The liver, spleen, kidneys, gallbladder, pancreas, and adrenals appear grossly unremarkable.  Loops of bowel appear unremarkable.  There is no obvious mass, adenopathy, or abnormal fluid collection.  The bladder has smooth walls without obvious mass.  With contrast, there is no abnormal enhancing lesion.

IMPRESSION:  Unremarkable MRI of the abdomen and pelvis without and with contrast.  Correlation with a CT may be of value, as CT has better resolution than MRI for subtle abnormality.  There is no obvious mass, adenopathy, or abnormal fluid collection.  There is no abnormal enhancing lesion.

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MRI of the Pelvis Transcription Sample Report

MRI OF THE PELVIS:

 DATE OF STUDY:  MM/DD/YYYY

 Multiplanar images were obtained without and with contrast.  The uterus is anteverted.  There are no uterine masses.  The endometrial lining appears unremarkable.  The cervix and vagina appear grossly unremarkable.  The ovaries are difficult to localize with certainty.  There is no presacral mass.  There is a normal appearance to the bladder.  No abnormal masses are readily appreciated in the pelvis.  Marrow signal within the bony structures is unremarkable. There are no bony masses.

 IMPRESSION:  Unremarkable MRI of the pelvis.  The uterus, endometrial lining, cervix, vagina all appear grossly unremarkable.  There are no masses.  The ovaries are difficult to identify with certainty.  If clinically warranted, a pelvic ultrasound may also be of value to evaluate the ovaries.

 MRI OF THE PELVIS:

 DATE OF STUDY:  MM/DD/YYYY

 REFERRING PHYSICIAN:  John Doe, MD

 INDICATION FOR STUDY:  Stage III adenocarcinoma of the endometrium.

 TECHNIQUE AND FINDINGS:  Once again, we do not see abnormal signal within the bony structures of the pelvis to indicate metastasis.

 There is mottled and irregular uptake of the uterus and the vaginal wall, extending down including the cervix.  Of course, all of this can be tumor and edematous change.  This includes the cervix.

 We do see some high signal involving a small area of tissue to the right lateral and anterior aspect of the uterus and following the expected location of the broad ligament.  This could represent some localized tumor spread.

 There is also some mild irregularity to the left side of the uterus.  This is not substantial, presents as small stranding and some contour, mild protuberance from the uterus itself.

 What is suggested on this examination is an abnormal uterus, which is already known clinically, abnormal enhancement of the vagina, which is more mottled than is commonly seen, and more gadolinium uptake in the cervix than is sometimes seen.  This could be due to examination and trauma and contusion or due to tumor spread.

 Although there are no large areas of lymphadenopathy along the external iliac or internal iliac causeways suggested on this examination to indicate significant lymphadenopathy, there does appear to be a small amount of irregularity around the uterus itself and some areas, which do enhance in the area of what is presumed to be the more central component of the broad ligament.

 IMPRESSION:
1.  Abnormal uptake of gadolinium in the uterus, as one would expect from the clinical history and some mottling throughout the vaginal wall and uptake in the cervix directly behind the vaginal wall, in front of the bowel.  Although there is not large lymphadenopathy noted in the pelvic examination, there is some irregularity to the uterine wall and some mild high signal related to that irregular uterine wall and in one instance beginning to follow the right broad ligament's expected course.  These areas could indicate some local invasion.
2.  The pelvic bones do not show abnormal enhancement to indicate metastasis. Subcutaneous fat and muscle planes also appear intact.

 Right Elbow MRI Sample Report                         MRI Medical Transcription Sample Reports    

Right Ring Finger MRI Medical Transcription Example

DATE OF STUDY:  MM/DD/YYYY

 REFERRING PHYSICIAN:  John Doe, MD

 TECHNIQUE AND FINDINGS: Right ring finger images were taken using STIR and FatSat in the sagittal and axial planes.  Also, T1 weighted images were performed as well.

 We see extreme flexion of the fourth finger.  The bony structures of the first, second and third phalanx are grossly intact.  No lytic, blastic or erosive changes are seen.  This is including the MCP joint.

 There are metallic wires traversing the fourth metacarpal bone such that there is some artifact extending from that into the proximal first phalanx on the STIR images.  No clear identification of the fourth metacarpal bone can be identified secondary to the artifact of that K-wire.

 We do see, however, that the MCP joint, which is seen, is clean without evidence of loose joint bodies or erosive change in that area.  The prominent flexor digitorum profundus and superficialis tendon is noted flexed and intact with regards to this right fourth finger.

 There is a very minimal amount of fluid noted around the distal first phalanx or DIP joint area, but no significant joint effusion is seen.  No ligament laxity or subluxation is indicated on this examination.

 No abnormality around the extensor tendons or central band is indicated on this examination.  This is also true of the collateral ligaments around the PIP and DIP joints.  There is no evidence that would suggest that they are grossly disrupted.

IMPRESSION:  
1.  Somewhat limited examination due to the presence of a K-wire to the fourth metacarpal bone.  However, the phalanx bones of the fourth finger, which is in extreme flexion, are intact without lytic or blastic disease, no erosive changes and no significant callus formation.
2.  The metacarpophalangeal, proximal interphalangeal and distal interphalangeal joint spaces show no erosion or loose joint bodies.  No gross irregularity is seen to indicate degenerative disease of focal significance.
3.  The extensor tendons as well as the large flexor digitorum and superficialis and profundus flexor tendons are intact.

MRI of The Brain Medical Transcription Sample

Sagittal and axial images were obtained with the addition of contrast-enhanced coronal and axial images, T1 weighted.  There is no mass, mass effect or shift of midline structures.  The ventricles are symmetric.  There is no abnormal enhancing lesion.  The craniocervical junction is within normal limits.  There is no periventricular white matter disease.  There is no significant atrophy.  There is some minimal focal mucosal thickening versus mucus retention cyst or polyp in the left maxillary sinus.  There is no extra-axial fluid collection.  There is no evidence of an acute infarct.

IMPRESSION:
1.  Essentially unremarkable MRI of the brain without and with contrast.
2.  Incidental ovoid high signal on the T2 images in the left maxillary sinus.  This may be due to focal mucosal thickening, mucus retention cyst or polyp.

MRI OF THE BRAIN WITHOUT CONTRAST:

INDICATION FOR STUDY:  Headache, right arm numbness.

Sagittal and axial images were obtained.  The craniocervical junction is within normal limits.  The ventricles are symmetric.  There is no mass, mass effect, or shift of midline structures.  The IACs are symmetric.  There is no extra-axial fluid collection.  There is no abnormal area of high signal intensity on the T2 or FLAIR weighted sequences.  The visualized sinuses are clear.


IMPRESSION:  Unremarkable MRI of the brain.  MRI of the cervical spine may be of value in light of the history of right arm numbness, if clinically warranted.

MRI OF THE BRAIN WITHOUT AND WITH CONTRAST:

INDICATION FOR STUDY:  Seizures.

Multiplanar images were obtained.  The cerebellar tonsils are low-lying, extending 7 mm into the upper cervical spine based on a line drawn from the base of the clivus to the occiput.  There is no obvious syrinx in the upper cervical spine.  There is no hydrocephalus.  There is no mass, mass effect, or shift of midline structures.  There is no abnormal enhancing lesion.  There is no extra-axial fluid collection.  There is no evidence of acute infarct.  The cerebellar tonsils are not pointed inferiorly.

IMPRESSION:   
1.  The cerebellar tonsils are low-lying, 7 mm below the line drawn from the base of the clivus to the occiput.  They are not pointed however.  There is no obvious syrinx in the upper cervical spine.  There is no hydrocephalus.
2.  The remainder of the MRI of the brain without and with contrast is normal, within normal limits.

MRI OF THE BRAIN/IACs WITHOUT AND WITH CONTRAST:

INDICATION FOR STUDY:  Bilateral hearing loss, left more than right, one month.  History of respiratory infection one month ago, that is when hearing loss started.  Short-term memory loss, one month ago as well.

TECHNIQUE AND FINDINGS:  Multiplanar images were obtained without and with contrast.  The craniocervical junction is within normal limits.  In the region of the IACs, there is no abnormal enhancing lesion.  Bilaterally, there is marked high signal in the mastoid air cells.  This is suggestive of an infectious/inflammatory process.

In the inferior right maxillary sinus, there is a less than 1 cm round area of high signal on T2 and FLAIR sequences suggestive of a mucus-retention cyst, polyp, or focal mucosal thickening.

On the FLAIR sequences, there is slight high signal in the fourth ventricle.  This is probably artifactual that is sometimes seen in midline.  This area appears low signal on contrast-enhanced T1 images.

There is no mass, mass effect, or shift of midline structures.  There is no extra-axial fluid collection.  There is no infarct.

IMPRESSION:
1.  There is marked abnormal increased signal in the mastoid air cells bilaterally suggestive of an infectious/inflammatory-type process seen on the FLAIR and T2 weighted sequences.  This is abnormal.
2.  There is very minimal right maxillary sinus disease inferiorly.
3.  There is no abnormal enhancing lesion in the region of the internal auditory canals.

MRI OF THE BRAIN WITHOUT CONTRAST INCLUDING AN MRV:

Multiplanar images were obtained.  Additionally, an MRV was obtained of the venous system.

The craniocervical junction is within normal limits.  There is some atrophy of the sulci, and ventricles are prominent.  The lateral ventricles are prominent as well as slight prominence of the third ventricle.  The temporal horns of the lateral ventricle are not prominent.  There is suggestion of a prior infarct involving the posterior left high parietal region, as there is a large area of encephalomalacic change.  The sulci are quite prominent suggestive of some atrophy.  There is no extra-axial fluid collection.  There is no mass, mass effect, or shift of midline structures.  There is some high signal on the FLAIR sequences in the third ventricle as well as just posterior to third ventricle.

On the sagittal FLAIR sequences, this is less well identifiable.  The pineal gland region appears unremarkable.  This may be some artifact on the axial FLAIR images.  There is also some high signal in the right transverse process on the FLAIR axial sequences.

An MRV was performed and raw data and composite images are available using 3D technique.  The right transverse sinus does have flow within it; however, it does appear to be slightly less than that of the left.  Low flow may have accounted for the findings on the FLAIR sequences.  There is no obvious evidence of an acute infarct.

IMPRESSION:
1.  Atrophy and prominent ventricular system.
2.  The high signal of the right transverse process appears to be due to some slow flow compared with that of the left.  The right transverse process is smaller and more difficult to appreciate than the left but does appear to have flow within it on the MRV.
3.  Some incidental high signal on the FLAIR axial images in the third ventricle and posterior third ventricle that is difficult to confirm on the sagittal FLAIR images, probably represents some type of artifact as it is quite midline.  There is no evidence of a pineal cyst.
4.  No obvious acute infarct.

Right Elbow MRI Sample Report                         MRI Medical Transcription Sample Reports 

MRI of Upper Arm Medical Transcription Example

DATE OF STUDY:  MM/DD/YYYY

 REFERRING PHYSICIAN:  John Doe, MD

 INDICATIONS FOR STUDY:  Abnormal soft tissue mass over right deltoid muscle.  Pain, paresthesia down arm.  Abnormal bone scan with no known primary.

 TECHNIQUE AND FINDINGS:  Multiplanar images were obtained without and with contrast.  A vitamin E tablet was placed over the palpable abnormality.  The marker is along the lateral posterior humerus.  The patient shook throughout the exam.  The patient could not control the shaking.

Overall, the images are of diagnostic quality.  There is a fatty mass that follows fat on all sequences and does not enhance corresponding with the palpable abnormality.  This is compatible with a lipoma.  There is no soft tissue mass component.

Again, it appears to be homogeneous fat on all sequences suggestive of benign etiology.  This measures approximately 6.5 cm craniocaudal dimension x 3.3 cm AP dimension x approximately 2.5 cm transverse dimension.

The marrow signal within the humerus is homogeneous.  There is no abnormal low signal to suggest metastatic disease.  There is no frankly destructive lesion.

Muscle planes appear preserved.  There is no large fluid collection.

 IMPRESSION:  The palpable abnormality corresponds with a fatty mass that does not enhance.  This is most suggestive of a lipoma.  Underlying bony structures appear intact without evidence of occult malignancy, as there is no abnormal low signal on T1 weighted sequences.

MRI of The Left Hip Medical Transcription Sample Report

MRI OF THE LEFT HIP

DATE OF STUDY: MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

 INDICATIONS FOR STUDY:  Left hip pain.  Evaluated for AVN.  Woke up with left hip pain.  Hip pain getting worse despite physical therapy.

 TECHNIQUE AND FINDINGS: Multiplanar images were obtained without contrast. The left hip is markedly abnormal compared with that of the right. There is abnormal low signal involving the left femoral head, neck, and intertrochanteric region on T1 that is high signal on the STIR sequences. This is suggestive of edema in the proximal left femur.

 There is also some mild edema in the superolateral left acetabulum. There is a prominent left medial joint effusion involving the left hip. There is marked flattening of the superolateral left femoral head.

 The left hip appears slightly subluxed laterally, as there is a large medial joint effusion. The acetabulum still appears to cover the femoral head. This may be due to stage IV AVN, which appears as advanced articular collapse and osteoarthritis.

 There is a subtle lucent line through the femoral head, on the left, that could be a component of AVN. It possibly could represent a fracture; however, it is more difficult to see on the T1 weighted images and better seen on the STIR sequences. It is suggested on the axial images as well. If clinically warranted, a CT may be of value to ensure there is not an incomplete fracture. On the sagittal images, this linear component is less so appreciated as well. The right hip is fairly normal in appearance. The femoral head on the right is well preserved. There is no flattening of the right femoral head. The right acetabulum is unremarkable. There is no obvious fracture or dislocation on the right. There is no significant joint effusion on the right.

 IMPRESSION: Left hip is markedly abnormal compared with that of the right with edema, flattening, and collapse of the superolateral left femoral head. There is a line traversing the subchondral surface of the femoral head that may be a component of avascular necrosis.

 Alternatively, this may be related to the closed physis or perhaps an incomplete fracture. Most likely, this probably represents the closed physis. CT may be of value to ensure that there is not an incomplete fracture in this area. The left femoral neck is deformed and misshapened and widened compared with that of the right. This may be due to a longstanding process from a congenital anomaly.

 Sequela from perhaps hip dysplasia/dislocation is a possibility as well given the marked asymmetry in the two hips. There is a prominent medial left joint effusion. The right hip is unremarkable.

MRA Circle of Willis and Head MRI Sample       Left Shoulder MRI Sample Report

MRA of Carotid Arteries Transcription Sample Report

MRA OF CAROTID ARTERIES

 DATE OF STUDY:  MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

 INDICATION FOR STUDY:  A 50-69% stenosis of the right carotid, per carotid Doppler done, MM/DD/YYYY.

TECHNIQUE AND STUDY FINDINGS: A 3D time-of-flight study was performed. Contrast was not given, as venous access could not be obtained, despite attempts three times.

Raw data was obtained as well as selected images of the right and left carotid artery separately as well as together. Vertebral arteries are also included on the composite images. The vertebral bodies appear fairly symmetric without significant obvious narrowing. The left internal carotid artery appears normal. There is no obvious stenosis involving the left system.

On the right, the internal carotid artery is narrowed compared with that of the left; this is not severe and this is moderate in significance. There is no obvious ulceration. The narrowing is in the region of the right carotid bulb and does appear to be moderate, approximately 50-70%, as appreciated by a carotid Doppler ultrasound.

IMPRESSION:
1.  The vertebral arteries appear symmetric and unremarkable.
2.  The left system appears unremarkable. There is no obvious stenosis or ulceration involving the left internal or external carotid arteries.
3.  On the right, there is some narrowing of the right internal carotid artery at the level of the bulb that appears moderate in degree. This is notably different than the left side. This stenosis is approximately 50-70% correlating with the findings by ultrasound. There is no obvious ulcerative plaque.

MRA OF THE CAROTID ARTERIES WITH CONTRAST

DATE OF STUDY:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

INDICATION FOR STUDY:  Status post CVA.

TECHNIQUE AND STUDY FINDINGS:  Raw data and composite images were available.  A 2D time-of-flight study was performed.

The left vertebral artery is much larger than that of the right and clearly dominant.  There is some narrowing of the right vertebral artery compared to the left.

The left internal carotid artery is slightly narrowed compared with that of the right suggestive of some mild to moderate stenosis.  There is no severe stenosis.  There is no alteration.

The left ICA/ECA complex is slightly splayed compared with that of the right.  There is no obvious mass seen on the raw data.  This may be congenital anomaly or some tortuosity.

IMPRESSION:
1.  The left vertebral artery is dominant compared with that of the right, as the right is more narrowed.
2.  The internal carotid arteries are minimally narrowed more in the left than the right.  This is suggestive of some mild to moderate stenosis.  There is no severe narrowing.  There is no alteration.
3.  The left internal carotid artery/external carotid artery complex is slightly splayed compared with that on the right.  We do not see a discrete mass on the raw data.  This may be some atherosclerosis, some tortuosity, or congenital asymmetry.
4.  If clinically warranted, carotid Doppler ultrasound could be obtained to confirm the mild to moderate stenosis in the carotid artery system, more in the left than the right.

Right Elbow MRI Sample Report          MRI Medical Transcription Sample Reports 

MRI of The Knee Medical Transcription Sample Report

MRI OF THE LEFT KNEE

Left knee MRI is performed in the usual fashion. The patient had significant trauma. There is a nondisplaced fracture, which is vertical in orientation, primarily between the condyles of the distal femur. Much edema is noted around it. The axial planes show a well-demarcated line extending directly between the medial and lateral femoral condyles and extending anterior to a location directly behind the patella. However, there is not a definite cortical break to the most anterior component to indicate that this is a complete fracture. No fragmentation is noted. Edema on either side of the fracture line is apparent. There is no meniscus in portions of the medial meniscus. This is either iatrogenic or is due to a complete tear and possible buckling. There is loss of the normal condyle surface involving the medial tibial plateau and medial femoral condyle. The lateral meniscus anteriorly is intact. Posterior component suggests some mucoid degeneration and possible partial and peripheral horizontal tear. The PCL is thickened and on fat saturated images shows some edema within it, which may indicate a strain. It is grossly intact. The ACL is not completely visualized on this examination and suggests that it is completely torn. Age of that tear is uncertain. There is some chondral injury to the posterior patella and the anterior femoral condyle. No Baker's cyst is present on this examination. Minimal joint effusion is present.

IMPRESSION:
1.  Nondisplaced fracture placed directly central between the lateral and medial femoral condyles, extending both in anteroposterior and vertical component. Edema and contusion is noted around it. It is questionable  as to whether it is complete. No dislocation or fragmentation is associated with it.
2.  Either iatrogenic removal of part of the lateral meniscus or a complete tear with possible flap has occurred over time. There is chondral erosion noted at the lateral femoral condyle and lateral tibial plateau as well.
3.  Posterior cruciate ligament appears grossly intact but does have edema and some thickening indicating a possible strain.
4.  Anterior cruciate ligament is not visualized indicating that it is not intact. Age is uncertain, however, as there is not much edema in that area to indicate an acute injury directly at that time.

MRI OF THE RIGHT KNEE

Multiplanar images were obtained.  The PCL is intact.  The ACL appears to be grossly intact but slightly increased signal.  Some partial injury to the ACL is not excluded.  Overall, the menisci appear to be grossly intact.  There is some slight globular increased signal in the posterior horn of the lateral meniscus for which a degenerative-type change is not excluded.  The menisci are otherwise within normal limits.  The collateral ligaments are grossly intact.  There is soft tissue edema laterally, lateral to the lateral collateral ligament.  There is no significant suprapatellar joint fluid.  There is no significant popliteal cyst.

IMPRESSION:
1.  There is edema in the lateral soft tissues.  Collateral ligaments are intact.
2.  Anterior cruciate ligament is grossly intact but increased signal for which a partial injury is not excluded.
3.  Menisci are intact.  There is some globular increased signal in the posterior horn of the lateral meniscus for which degenerative change is not excluded.
4.  The underlying bony structures appear intact.

MRI OF THE LEFT KNEE

Multiplanar images of the left knee were obtained without contrast.  The ACL and PCL are both intact.  The collateral ligaments are intact.  There is some mild anterior lateral fluid.  There is some very minimal posterior medial fluid.  The menisci are intact.  The marrow signal within the bony structures is within normal limits.  On the coronal images only, there is a mild defect involving the medial aspect of the lateral femoral condyle suggestive of a nondisplaced fracture.

IMPRESSION:
1.  Menisci, collateral ligaments, and cruciate ligaments are all intact.
2.  There is some very minimal fluid posteromedially suggestive of a minimal popliteal cyst.
3.  There is no significant suprapatellar joint fluid.
4.  There is some lateral fluid collection that is more posteriorly located.
5.  There is a nondisplaced osteochondral defect involving the mid aspect of the lateral femoral condyle medially.  The cartilage appears intact.  This is suggestive of a nondisplaced fracture such as an osteochondritis dissecans.

LEFT KNEE MRI

Routine MRI of the left knee is performed.  There is a horizontal peripheral tear suggested of the most peripheral and posterior aspect of the medial meniscus.  No vertical tear component is definitely seen. There is an unusual presentation of the anterolateral meniscus.  It is separated from the superior tibia.  This would suggest the possibility of a partial detachment.  Much fluid is noted in that area.  No injury to the underlying tibial surface is noted however.  Please correlate to any sign of discomfort in that region.  The lateral meniscus itself is grossly intact without vertical or degenerative tear suggested. No osteochondral defects are noted. The ACL and PCL are intact. There is some chondral irregularity of the posterior patellar surface indicating some contusion or chronic inflammation/irritation to that region.  A small-to-moderate joint effusion is present. The medial and lateral retinaculum and collateral ligaments are intact. No significant Baker's cyst is present.

IMPRESSION:
1.  Small horizontal and peripheral posterior tear of the medial meniscus is suggested.  No vertical tear component is definitely seen.
2.  Possible, at least partial detachment of the inferior aspect of the anterolateral meniscus relating to the underlying tibial surface.  The tibial surface, however, is without contusion or trauma indicated.  Please correlate to clinical exam.

LEFT KNEE MRI

INDICATION FOR STUDY:  The patient has a possible posterior medial meniscal tear.  The patient has a known osteochondral defect.  History of skeletal dysplasia and prior meniscal repair on the right knee.

Today's examination is compared to the report of the left knee MRI of MM/DD/YYYY.  Those films are not present for a direct comparison. We once again see, as was indicated on the prior report, a large osteochondral defect seen in the posterior medial femoral condyle.  This is a large broad-based defect.  It is filled with a substance having a similar intensity to the fluid in the joint space, and therefore, it is believed simply to be a fluid space occupying.  This defect does involve both a small portion of the osteoid and the chondral area involved.  The largest diameter in its horizontal plane is approximately 1.5 cm in width.

The underlying posterior medial meniscus is not normally seen on this examination.  There is much edema within that area of the joint space, which could obscure some smaller fragments but most of the posterior medial meniscus is not present or not identified due to a possible very thin nature.  This includes both the sagittal and coronal imaging using several different planes.  This would suggest at least a degenerative tear if not a component, which may involve a bucket handle type tear. The lateral meniscus appears intact.  The lateral femoral condyle is intact. There is again extreme thinning of the ACL and the orientation of the lower half of the ACL, which lies horizontal to the tibial plateau, indicates a tear.  Please correlate to clinical examination. The chondral surface of the lateral femoral condyle and the posterior patella is within normal limits.  There is a moderately significant joint effusion present.  There is a very minor, approximately 5 mm x 1 cm Baker's cyst suggested.

IMPRESSION:
1.  There is no normally visualized posterior medial meniscus present.  It does appear in one image to have a degenerative-type tear with a very minimal amount of meniscus still remaining, which indeed on one of the images suggests even a large bucket-handle type tear.  This area is obscured with a large amount of fluid due to the overlying large osteochondral defect.  This osteochondral defect does present as a broad-based cavity, which is filled with probable effusion.
2.  There is questionable tear of the anterior cruciate ligament.

MRI of Shoulder Medical Transcription Sample Report

MRI OF THE LEFT SHOULDER

Left shoulder MRI was performed in the usual fashion. There is no evidence of a full-thickness rotator cuff tear. No high signal within the distal supraspinatus tendon of marked significance to indicate a significant tendinitis. There is only a very small amount of high signal directly at the insertion site of the distal supraspinatus tendon, which may indicate a very small amount of tendinosis directly at that insertion site area.  There is some moderate hypertrophy of the AC joint. There is inflammatory increase of fluid in the joint space itself. There is spurring both caudally and superiorly. The caudal spurring impresses upon the underlying supraspinatus structures somewhat. This may be producing some type of mild entrapment symptoms. One may want to correlate clinically to that entity.  Also, the most distal component of the acromion suggests what may be a small loose joint body or spur, which minimally depresses the underlying structures as well.

In neither of these two areas do I see significant edema or irritation of the underlying supraspinatus structures, radiographically.  The remaining rotator cuff tendons are intact. The glenoid and humeral bony structures do not show lytic or blastic disease or microfractures.  There is a focal area of high signal involving the inferior and anterior glenoid labral area. One may want to perform a CT arthrogram to rule out labral injury.

IMPRESSION:
1.  No full-thickness rotator cuff tendon tear or muscle or tendon retraction. Minimal high signal at the distal supraspinatus tendon insertion site to indicate possible mild tendinosis.
2.  Acromioclavicular degenerative joint disease with cephalad and caudal spurring. The caudal spurring does impress upon the underlying supraspinatus structures minimally. Also, there is possible loose joint body near the inferior and lateral acromion, which may be depressing the underlying structures somewhat.
3.  Questionable injury to the inferior, anterior glenoid labrum. Focal area of high signal is noted in that area. One may need to do an arthroscopic examination or perhaps a CT arthrogram to rule out labral injury.

MRI OF THE RIGHT SHOULDER:

Rule out short biceps tendon tear.

The tendons of both the long head of the biceps and the short head of the biceps appear intact.  We see no focal edema within those structures or around them to indicate partial strain or definite focal injury.  Both show an intact course.  It is also noted that the coracobrachialis muscle is intact, adjacent to the short head of the biceps tendon.  We see no injury to the coracoid process as well.

No full-thickness rotator cuff tear with muscle or tendon retraction is seen.  No significant injury is noted of the subscapularis muscle or tendon.

There is very minimal AC joint hypertrophy.  No significant spurring is seen.

No significant joint effusion is noted.  The humerus and glenoid bony structures are grossly intact.

IMPRESSION:
1.  No definite evidence of rupture of the short head tendon biceps or of the long tendon of the biceps.  Also, there is no injury to the coracobrachialis muscle nearby or the coracoid process.
2.  No rotator cuff tears are noted as well.

MRI OF THE RIGHT SHOULDER

Multiplanar images were obtained.  There are some degenerative changes involving the AC joint that do cause some inferior impingement on the supraspinatus muscle/tendon junction.  There is some fluid along the superior aspect of the subscapularis suggestive of at least a partial tear.  There is fluid along the posterior aspect of the deltoid.  There is some edema in the posterior superolateral humeral head suggestive of contusion in this area.  This is low signal on T1.

Biceps tendon is well located within the groove.  There is some fluid around the biceps tendon that may represent tendinosis or partial tear.  There is no significant fluid in the subacromial/subdeltoid bursa.  There is some fluid along the posterior aspect of the humeral head.  The supraspinatus muscle/tendon appears fairly intact with some minimal high signal in it, inferior to the AC joint that may represent some edema in this area.

IMPRESSION:
1.  Fluid along the superior aspect of the subscapularis suggestive of at least a partial tear.  Some of this fluid is seen along the posterior aspect of the deltoid.
2.  Some degenerative joint disease involving the acromioclavicular joint that does cause some inferior impingement on the supraspinatus muscle/tendon.  There is some edema in this area.
3.  There is some contusion/edema in the posterior superolateral aspect of the humeral head.

RIGHT SHOULDER MRI

Routine right MRI of the shoulder reveals no full-thickness tear of the rotator cuff tendons.  No retraction of muscle or tendons.  There is a very small amount of signal change at the most distal component of the supraspinatus tendon, which may indicate a very minimal tendinosis.

What is noted is a focal area of signal change in the biceps tendon as it courses up to the humeral head.  There is a pocket of fluid noted approximately 3 cm from the superior aspect of the humeral head.  Question whether there may be a strain or even small tear.  Biceps tendon is grossly intact however.

There is no contusion of the bony structures noted.  No fractures seen.  The glenoid structures appear grossly intact.  There is moderate hypertrophy of the AC joint with some inflammation in that area.  This minimally depresses the underlying supraspinatus structures but there is not any edema of the underlying structures.

IMPRESSION:
1.  No full-thickness rotator cuff tear with or without muscle and/or tendon retraction.
2.  Very small high signal is seen at the distal supraspinatus tendon insertion site, which could indicate a very small amount of tendinosis.
3.  Possible small injury to the biceps tendon, approximately 3 cm distal to the humeral head.  There is a focal area of high signal in this area, which may indicate some partial strain or even a very small tear.  It is grossly intact however.  There is focal fluid collection directly in that area as well.  Please correlate to exam.
4.  Minimal to moderate hypertrophy with high signal within the joint space of the acromioclavicular joint.  Minimal but not significant compression of the underlying structures is seen.

More MRI Sample Reports

Tracheostomy Medical Transcription Sample Report

DATE OF OPERATION:
MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Respiratory failure.

POSTOPERATIVE DIAGNOSIS:
Respiratory failure.

OPERATION PERFORMED:
Tracheostomy.

SURGEON:
John Doe, MD

ASSISTANT:
None.

ANESTHESIOLOGIST:
Jane Doe, MD

INDICATIONS FOR PROCEDURE:
The patient is a (XX)-year-old female in the ICU with sepsis related to pseudomembranous colitis.  She underwent total abdominal colectomy approximately seven days ago.  She has failed to wean from the ventilator.  She has had problems with pulmonary toilet due to an indwelling endotracheal tube, and it was thought that tracheostomy would be in her best interest.

Consent was obtained from the family, understanding the risks and benefits and the following procedure was performed today.

BLOOD LOSS:
Zero.

COMPLICATIONS:
None.

FINDINGS:
Thick secretions within the trachea.  Excellent oxygenation and CO2 return following tracheostomy insertion.

DESCRIPTION OF PROCEDURE:
The patient was brought directly from the ICU to the operating room.  The patient was given light intravenous sedation and the area over the neck was prepped and draped in usual sterile fashion.  Lidocaine 1% with epinephrine was used to infiltrate the skin and subcutaneous tissue.

A transverse incision was made one fingerbreadth above the suprasternal notch and dissection taken down through the platysma to the strap muscles, which were divided in the midline.  Hemostasis was excellent.  Dissection continued through the thyroid gland, which was thin and atrophic and the pretracheal fascia was cauterized.  A box-type incision was made in the second tracheal ring and the trachea was opened.  The endotracheal tube was slid back and dense secretions were aspirated.  A #6 low-pressure cuff Shiley tracheostomy tube was successfully inserted into the trachea and the balloon inflated.

The patient was then ventilated successfully with excellent oxygen saturations and CO2 return.  Saline was instilled into the trachea and pulmonary toilet ensued.  The tracheostomy tube was secured to the skin using 3-0 Prolene suture.  A tracheostomy tape was used to secure the flange around the neck leaving two fingerbreadths space beneath the tape.  Stay sutures used to secure the trachea were taped to the skin in the event of accidental extubation.  Sterile dressing was applied.  Hemostasis was excellent throughout the case.  Needle and sponge counts were correct at the end.  The patient was moved back to the intensive care unit directly in critical but stable condition.

Laparoscopic Roux-en-Y Gastric Bypass MT Sample Report

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Obesity.
2.  Hypertension.
3.  Arthritis.
4.  Hypercholesterolemia.
5.  Reflux disease.

POSTOPERATIVE DIAGNOSES:
1.  Obesity.
2.  Hypertension.
3.  Arthritis.
4.  Hypercholesterolemia.
5.  Reflux disease.

PROCEDURES PERFORMED:
1.  Laparoscopic Roux-en-Y gastric bypass with Silastic ring.
2.  Gastrostomy tube placement.

SURGEON: John Doe, MD

ANESTHESIA:  General endotracheal.

COMPLICATIONS:  None.

DRAINS:  A 19 round Blake drain.

ESTIMATED BLOOD LOSS:  100 mL.

SPECIMENS:  None.

DESCRIPTION OF OPERATION:  The patient was identified in holding and brought to the operating suite, where the patient was placed in supine position and general endotracheal anesthesia was induced without complications.  The patient's abdomen was then prepped and draped in the usual sterile manner.  Abdominal cavity was entered with an Optiview trocar under direct visualization and CO2 insufflation of the abdomen was achieved.

Under direct visualization, two trocars were placed in the left side of the abdomen followed by three trocars in the right side of the abdomen.  A liver retractor was inserted in the right lateral-most trocar site.  The fat pad at the angle of His was identified and excised and the peritoneal reflection at the angle of His opened using blunt dissection.  Next, a window was created into the lesser sac along the lesser curvature.  A divided transverse staple line was then created perpendicular to the lesser curvature, 6 cm distal to the GE junction.

Next, a divided vertical staple line was created from the transverse staple line up to the angle of His using two green loads and a blue load of Ethicon linear staples with SeamGuard as a buttressing device.  It completely divided the proximal gastric pouch.  An anvil corresponding to a 21 circular stapler was then positioned in the distal aspect of the gastric pouch using an orogastric tube and a transoral transesophageal technique.  A Silastic ring measuring 16.25 cm in circumference was then fashioned around the distal aspect of the gastric pouch just proximal to the anvil.

Next, a Penrose drain was placed into the lesser sac.  The ligament of Treitz was identified.  A window was created in the transverse mesocolon just above and to the patient's left of the ligament of Treitz and one end of the Penrose drain retrieved.  Small bowel was measured for a distance of 45 cm from the ligament of Treitz and divided.  It was measured an additional 75 cm and the proximal small bowel stump was then anastomosed to the 75 cm mark in a side-to-side functional end-to-end fashion with a linear stapler.  The resulting enterotomy was closed with Vicryl in a running two-layer fashion.  The mesenteric defect was closed with silk in a running fashion.  The distal divided small bowel stump which represented the alimentary limb was then brought retrocolic, retrogastric with the use of a Penrose drain.

A 21 circular stapler was then used to create a side alimentary limb to end gastric pouch anastomosis.  The redundant afferent stump of the alimentary limb was amputated with a linear stapler.  The gastrojejunal anastomosis was then reinforced with Vicryl in a running fashion.  The retrocolic window was closed to the alimentary limb with silk in running fashion to include Petersen space in the closure to prevent internal hernias.  The upper abdomen was then carefully irrigated.  A gastrostomy tube was then placed percutaneously through the anterior abdominal wall to a Silastic ring to serve as a radiological marker and into the excluded stomach.  The excluded stomach was tacked up to the anterior abdominal wall with silk in an interrupted fashion around the gastrostomy tube.

A 19 round Blake drain was positioned in the lesser sac.  All trocars including the liver retractor were removed.  On the left side, trocar site which was dilated to accommodate a 21 circular stapler was closed by reapproximating the fascia with 0 Prolene.  All trocar sites were closed by reapproximating the skin with 4-0 Vicryl.  This was reinforced with Dermabond.  The patient was then extubated and then brought to postanesthesia care unit in stable condition.

ORIF Orbital Floor Fracture Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Right orbital floor fracture.

POSTOPERATIVE DIAGNOSIS:
Right orbital floor fracture.

OPERATION PERFORMED:
Open reduction internal fixation of right orbital floor fracture.

SURGEON:  John Doe, DDS

EBL:  Minimal.

IV FLUIDS:  950 mL.

URINE OUTPUT:  Not recorded.

 INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old female who was playing hockey approximately eight days ago when she was head-butted in the right face. She immediately noted difficulty with vision and in fact experienced double vision. She also experienced significant rapid onset of periorbital swelling. She presented to the emergency department for evaluation. A CT scan was obtained, which revealed a right orbital floor fracture.

Oral and Maxillofacial Surgery was consulted. Given the patient's significant swelling, surgical intervention was deferred at that time. She was followed up in clinic and continued to display significant diplopia and upward gaze. For correction of her orbital floor fracture, she was then taken to the operating room for the aforementioned procedure under general anesthesia.

SIGNIFICANT FINDINGS:  Right orbital floor fracture.

DESCRIPTION OF OPERATION:  Once the oral endotracheal tube was placed, the patient was turned for surgery.  The patient was prepped and draped in the usual sterile fashion.  The surgeon gowned and gloved after scrubbing.  Three mL of 1% lidocaine with 1:100,000 of epinephrine was locally administered in the right lateral canthal region as well as in the right lower eyelid.  Approximately 1 mL was deposited in the middle, medial, and lateral infraorbital fat pads.  A forced duction test was performed and the eye was noted to be mobile.  A corneal shield was placed after applying ophthalmic ointment.

A subciliary incision was performed with a #15 blade and this was carried lateroinferiorly at the lateral canthus.  Tenotomy scissors were used to dissect approximately 4 to 5 mm inferiorly under the skin.  They were then used to perform a blunt dissection laterally over the lateral orbital rim.  At this point, dissection was carried inferiorly just anterior to the infraorbital rim, medially along the orbital rim.  The incision in the tunneled dissection plane was then opened with the tenotomy scissors in a preseptal fashion.  The periosteum was then incised approximately 3 to 5 mm inferior to the infraorbital rim.

Periosteal elevators were used to then dissect superiorly and then the periorbita was dissected free from the orbital floor.  This was gently teased from the fractured floor segments and held in a retracted manner with malleable retractors.  Once a medial and lateral stable bony segment had been identified, the Synthes medium-sized orbital floor plate was then adapted.  The arms of this plate were then folded inferiorly over the infraorbital rim.  The middle arm had to be removed as this was impinging on the infraorbital nerve.  The medial and lateral arms were each secured with a single 4 mm x 1.3 mm Synthes screw.

The wound was explored again and the periorbita was noted to be free from all edges of the plate.  A forced duction test was performed again and the eye was noted to be freely mobile.  The wound site was irrigated with copious normal saline.  The periosteum was closed with multiple interrupted 4-0 Vicryl sutures and the skin incision was closed with a running 5-0 nylon suture.  The eyes were washed with balanced salt solution and the patient was returned to the care of the anesthesia service prior to awakening.  Pressure was held in the infraorbital area to prevent hematoma formation.  The patient was extubated in the operating room and tolerated extubation well.  The patient was taken to the postanesthesia care unit to continue recovery.

More Maxillofacial Surgical Samples             More Dental Surgery Sample Reports 

Supracondylar Humerus Percutaneous Pinning Sample

DATE OF OPERATION:  MM/DD/YYYY

 PREOPERATIVE DIAGNOSIS:
Left elbow supracondylar humerus fracture, closed, type 2.

 POSTOPERATIVE DIAGNOSIS:
Left elbow supracondylar humerus fracture, closed, type 2.

 OPERATION PERFORMED:
Left elbow supracondylar humerus closed fracture and percutaneous pinning.

 SURGEON:  John Doe, MD

 ASSISTANT:  None.

 ANESTHESIA:  General.

 COMPLICATIONS:  None.

 TOURNIQUET TIME:  None was used.

 HARDWARE UTILIZED:  K-wires x2, 0.062 size.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old Hispanic male who fell, injuring his left elbow. The patient was diagnosed with a closed type 2 supracondylar humerus fracture. Recommendation for closed reduction and casting versus percutaneous pinning of the supracondylar humerus fracture was offered to the patient and his parents to provide adequate alignment for optimal healing and function. Risks, benefits, and alternatives of the surgery were discussed in detail. Risks including, but not limited to scar, infection, bleeding, nerve or vessel injury, need for further surgeries, malunion, loss of motion of the elbow, and pain were discussed in detail with the patient and his parents. Questions regarding surgery were answered and verbal and written consent was obtained from his parents prior to the surgery.

 DESCRIPTION OF OPERATION:  After informed consent was obtained from the patient's parents, he was taken to the operating field, transferred from gurney to the operating table, placed in supine position.  General anesthesia was administered by the anesthesia staff.  He was intubated without complication or difficulty.  The patient received Ancef 500 mg IV preoperatively for infection prophylaxis.

While the patient was under general anesthesia, the left elbow was manually manipulated with traction and hyperflexion with attempted reduction of supracondylar humerus fracture.  There was a 30-degree extension deformity of the distal aspect of the humerus.  This was corrected with manual manipulation.  There was some hinging that went on with attempted range of motion of the elbow and concern for instability with closer management of the fracture would be persistently present.  It was then decided that percutaneous pinning of the fracture site would be in the best interest of the patient to provide a stable construct for healing.  The left upper extremity was then sterilely prepped and draped in the usual fashion.

Using the C-arm as a working table, the left elbow was evaluated and the supracondylar humerus fracture was held in a reduced position.  Next, 0.062 K-wire was then placed percutaneously on the lateral epicondyle, and under C-arm guidance, it was passed across the fracture sites on the lateral epicondyle to the medial cortex of the metaphysis.  C-arm images confirmed placement in AP and lateral planes of the percutaneously placed pin.  With this completed, a second pin was placed in a converging fashion and providing stable fixation of the supracondylar humerus fracture.

The elbow was taken through range of motion and the fracture appeared to be stable.  The anterior humeral line, on the lateral projection, did bisect the capitellum as per normal alignment of the elbow.  The K-wires were then cut short, bent, and pin caps were applied.  Xeroform was placed around the pin sites.  Well-padded dressing was placed over the pin sites and a long, more padded fiberglass cast was then placed on the left upper extremity with the elbow in 90 degrees of flexion in neutral forearm rotation.  Care was taken not to wrap the cast tightly to allow for any mild swelling that may occur following the procedure.

The patient did not have severe swelling at the elbow at the time of surgery but only mild swelling about the elbow.  The patient had 2+ radial pulses prior to casting and adequate capillary refill to his hand, less than 2 seconds.  General anesthesia was reversed at the completion of the case.  He was extubated and returned to the recovery room in stable condition, appearing comfortable.


Primary Low Transverse Cesarean Section Operative Sample

DESCRIPTION OF OPERATION:  After informed consent was obtained, the patient was taken to the operating suite and an adequate anesthetic level was confirmed.  A Foley catheter had been previously placed or was placed in the operating suite.  The patient was placed in the supine position, left lateral tilt, and prepped and draped in the usual sterile fashion for cesarean section.  A Pfannenstiel skin incision was made with a knife and carried down sharply through the subcutaneous tissues. The fascia was incised in the midline and the fascial incision was extended laterally and elliptically using curved Mayo scissors.  Sharp and blunt dissection was then used to separate the fascia from the underlying rectus muscles.  The rectus muscles were divided in the midline and the peritoneum was entered using sharp dissection.  The peritoneal incision was extended superiorly and inferiorly down to the level of the dome of the bladder.  Next, the operative hand was used to determine the position of the uterus, which was noted to be midline.  The vesicouterine peritoneum was then incised and sharp and blunt dissection was then used to separate the bladder from the lower uterine segment.  The bladder blade was then placed.  Next, a transverse incision was made in the lower uterine segment and carried down sharply until the amniotic membranes were ruptured and this confirmed clear fluid.  The incision was then extended using the bandage scissors in a transverse manner.  The fetal head was grasped, flexed and delivered through the incision.  The infant's nose and mouth were suctioned.  The rest of the infant was delivered.  The cord was doubly clamped and cut awaiting nursery team.  At this time, a specimen of cord blood was obtained and Pitocin was added to the IV fluid.  The placenta was then manually extracted from its implantation site.  The uterus was exteriorized and draped in a moist lap.  The endometrial cavity was curetted with a dry lap to free it of any remaining products of conception.  The incision was inspected and noted to be free of extensions.  The incision was closed in a single layer of running locking #1 chromic suture.  The incision was confirmed to be hemostatic.  The uterus was returned to the intra-abdominal site.  The paracolic gutters were cleansed with a moist lap.  The peritoneum was then reapproximated using running 3-0 Vicryl suture. The subfascial space was confirmed to be hemostatic.  The fascia was reapproximated using 2-0 PDS suture, beginning at the lateral margins of the incision and meeting in the midline.  The subcutaneous tissues were made hemostatic with electrocautery and the skin was then reapproximated with skin staples.  The patient tolerated the procedure well.  All counts were correct x3, and the patient was transferred to the recovery room in good condition.

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