Hematology Oncology Consultation Medical Transcription Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  Jane Doe, MD

CONSULTANT:  John Doe, MD

REASON FOR CONSULTATION:  Persistent macrocytosis, hyperferritinemia and significant weight loss, rule out occult malignancy.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who was recently seen in consultation for persistent macrocytosis.  She was also noted to have hyperferritinemia and significant weight loss over the last 8 months.  She underwent a workup that included lab tests and a bone marrow aspirate and biopsy.  The patient was admitted with a near syncopal episode.  She denied having chest pain, palpitations, headache, blurred vision, bowel or bladder incontinence, witnessed seizures, etc.  She also denied having bright red blood per rectum, melena, hemoptysis, hematemesis, night sweats, palpable lymphadenopathy, malaise, fatigue, etc.

REVIEW OF SYSTEMS:  She denies having chest pain, palpitations, or shortness of breath.  She denies having fever, chills, or rigors.  She denies having cough or wheezing.  She denies having abdominal pain, bright red blood per rectum, or melena.  She denies having loss of consciousness, seizures, or weakness.  She denies having headache, blurred vision, or diplopia.

PAST MEDICAL HISTORY:
1.  Left bundle branch block.
2.  Hypothyroidism.
3.  Diverticulosis.
4.  Osteoarthritis of the knees.
5.  Degenerative disk disease.

PAST SURGICAL HISTORY:
1.  Sympathectomy.
2.  Total abdominal hysterectomy.
3.  Breast biopsy.
4.  Arthroscopic surgery of the right shoulder.
5.  Bilateral cataract surgery.
6.  Partial thyroidectomy.

FAMILY HISTORY:  Positive for cancer.

HABITS:  The patient denies smoking or drinking alcohol.

MEDICATIONS AT HOME:
1.  Lasix.
2.  Darvocet.
3.  Altace.
4.  Synthroid.

PHYSICAL EXAMINATION:
GENERAL:  The patient is lying in bed in no apparent distress.
VITAL SIGNS:  Blood pressure 162/92, pulse 64 per minute, respirations 22 per minute and temperature 98.8.
HEENT:  No pallor, no icterus.  Extraocular muscles are intact.  Pupils are round and reactive to light.  Normocephalic and atraumatic.
NECK:  No JVD, no cervical lymph nodes, no bruits.
LUNGS:  Vesicular breath sounds heard in both lung fields.  No rhonchi, no crackles.
HEART:  First and second heart sound heard, regular rate and rhythm.  No S3, no S4.
ABDOMEN:  Bowel sounds heard in all four quadrants.  No hepatosplenomegaly.  Mild epigastric tenderness noted.  No rebound, no guarding.
NEUROLOGIC:  Alert and oriented x4.  Cranial nerves II through XII intact.  Motor and sensory system grossly intact.  No meningeal signs.  No cerebellar deficits.
EXTREMITIES:  No edema.  No Homans.  No cyanosis.  Pulses 2+.
LYMPHATIC:  No palpable lymphadenopathy.

LABORATORY DATA:  Stool occult blood positive.  WBC 15.6, hemoglobin 12.3, hematocrit 35.8, platelet count 439,000.  Sedimentation rate 95.  PT 15.4, INR 1.5, and PTT 32.4.  Sodium 141, potassium 4.2, chloride 102, carbon dioxide 23.7, glucose 118, BUN 31, creatinine 1.4, and calcium 9.3.

ASSESSMENT AND PLAN:
1.  Macrocytic anemia secondary to B12 deficiency.
a.  Rule out pernicious anemia.
2.  Low grade non-Hodgkin’s lymphoma.
3.  Reactive leukocytosis 
4.  Reactive hyperferritinemia.

The patient is a (XX)-year-old female who was seen in consultation for progressive leukocytosis, eosinophilia, and hyperferritinemia.  Following an outpatient consultation, she was subjected to lab tests and a bone marrow aspirate and biopsy.  At the time of her consultation, she had also complained of a 30-pound weight loss over the last one year.  Her lab tests that included leukocyte alkaline phosphatase and methylmalonic acid level noted an elevated methylmalonic acid consistent with B12 deficiency.  Her leukocyte alkaline phosphatase was also elevated suggesting a reactive leukocytosis rather than a chronic myeloproliferative disorder.  She then underwent a bone marrow aspirate and biopsy and was noted to have a normal cellular marrow showing normal maturation of myeloid precursors.  Rare hypersegmented neutrophils and rare dyserythropoietic cells were also identified.  Megakaryocytes appeared increased in numbers, and the blast count was less than 2%.  There was no evidence of reticulin fibrosis, and the bone marrow biopsy findings were not suggestive of a chronic myeloproliferative disorder.  Incidentally, a flow cytometry that was done on the bone marrow aspirate noted a small monoclonal B-cell population with chronic lymphocytic leukemic phenotype versus a small lymphocytic lymphoma phenotype with lambda light chain restriction.  B cells accounted for less than 3% of the total cells analyzed.  Based on this evaluation, she has been diagnosed with B12 deficiency and a low-grade lymphoma.  Her leukocytosis is secondary to a reactive process rather than a chronic myeloproliferative disorder.  Her hyperferritinemia was further investigated with a hemochromatosis gene analysis.  This gene analysis was negative for a hereditary hemochromatosis.

PLAN:
1.  Vitamin B 12 one mg intramuscular every month.
2.  Folic acid 1 mg by mouth every day.
3.  Antiparietal cell antibodies.
4.  Anti-intrinsic factor antibodies.
5.  CAT scan of the chest, abdomen and pelvis to further evaluate her lymphoma.
6.  No intervention required for her leukocytosis.
7.  Consider upper endoscopy in light of severe dyspepsia.
8.  Awaiting Philadelphia chromosome analysis.
9.  Consider screening upper endoscopy if the patient has pernicious anemia.

Thank you, Dr. Doe, for this interesting consult.  We will follow the patient with you.


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Left Shoulder MRI Medical Transcription Transcribed Sample Report / Example

INDICATION: Pain and weakness, rule out rotator cuff tear.

TECHNIQUE: Routine images of the left shoulder are performed. There is significant hypertrophy and inflammation at the AC joint. Both superior and inferior spurring are present. There is loss of the normal subacromial space with elevation of the humeral head. There is a large extracapsular fluid collection and an intracapsular effusion. There is a full-thickness tear of the infraspinatus tendon with retraction of the muscle and tendon. There is modeling of the supraspinatus tendon but not a complete or full-thickness tear is seen. There is some depression of the spurring from the AC joint on that tendon. The modeling of the distal supraspinatus tendon can indicate that there is a longstanding or chronic injury that is not readily apparent. In a very longstanding chronic change, the changes might not be present with edema to be easily recognized on the examination. Therefore, there could be changes to the distal supraspinatus tendon that are not readily apparent on this examination but would be suggested by the loss of the subacromial space. The modeling does indicate at least some partial tearing has occurred in the past. There is, however, retraction of the infraspinatus tendon that is suggested. There is also fluid around the biceps tendon, which may indicate some element of chronic tendinitis. It is grossly intact however. There is also a mild concavity of the medial and anterior humeral head, which may indicate that there had been some trauma in this region against the anterior glenoid structures. Mild high signal within the humeral head is seen indicating a possible contusion. No frank fractures are seen.

IMPRESSION:
1. There is a full-thickness tear suggested of the infraspinatus tendon with muscle and tendon retraction noted. There is also modeling of the distal supraspinatus tendon indicating what may be a chronic or old injury and partial tearing, which is simply not as apparent now because much of the inflammation or edema is now not present. There is some height loss of the subacromial space indicating injury to the underlying structures as well.
2. There is acromioclavicular joint spurring in both the cephalad and caudal motion with inflammation. Part of this does impress upon the underlying supraspinatus structures. No significant edema is noted, however, in that area at this time.
3. Fluid is seen around the biceps tendon, which could indicate some inflammation in that area.
4. Some cortical concavity of the anteromedial humeral head is noted. It is closely related to the anterior glenoid bony structure, and there is some contusion or edema of the humerus in that area indicating what may be the result of some trauma.

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Medical Transcription Pediatric Discharge Summary Transcribed Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY

HISTORY OF PRESENT ILLNESS:  The infant is (XX) weeks' gestation appropriate for gestational age baby boy. Birth weight was 5 pounds 8 ounces.  Dr. John Doe is the OB.  Pediatrician is Dr. Jane Doe.  Mother is (XX) years old, gravida 4, para 3-0-0-3, O positive, serology negative.  Other prenatal labs negative.  Mother is group B strep unknown.  There was a history of previous C-section, but this time, it was a VBAC and delivered vaginally.  Apgars were 8 and 9.  Rupture of membrane was 5 hours prior to delivery.  No antibiotics were given during labor.  Infant was born with Apgar scores of 8 and 9 and then infant developed decreased perfusion, pale color, grunting, retractions, tachypnea.  The infant was brought to NICU and was placed on pulse oximeter.  Although the O2 saturations were okay on room air, the infant had increased work of breathing, grunting, retractions, respiratory rate was 70-80 breaths per minute, which increased to 90 breaths per minute.  The infant was admitted to NICU for further management.

PHYSICAL EXAMINATION:  On admission, respiratory rate of 70-80 per minute, grunting and retracting, increased work of breathing.  Lungs had occasional rales bilaterally, good air exchange.  Heart with regular rate and rhythm.  No murmur.  Pulses were normal.  Abdomen was soft.  No hepatosplenomegaly.  Mean arterial pressure was low in 20s.  Neurological exam was grossly normal.  Genitourinary exam was normal.  Preterm male, testes descended bilaterally.

LABORATORY DATA ON ADMISSION:  Chest x-ray had bilateral streaky infiltrates along with granularity consistent with moderate RDS.

DIAGNOSIS ON ADMISSION:
1.  A 35 weeks' gestation appropriate for gestational age male.
2.  Respiratory distress syndrome.
3.  Rule out sepsis.
4.  Rule out hypoglycemia.
5.  Hypovolemia secondary to low mean arterial pressure and metabolic acidosis.

The initial blood gas which was done, because of O2 saturations staying stable on room air, had base deficit of –6.  The parents were told regarding the sick status of the infant and management in NICU.

HOSPITAL COURSE:
1.  RDS.  The infant had significant respiratory distress.  Although initially O2 saturations remained stable on room air, saturations started to drift down and the infant had significant metabolic acidosis, which did not correct with a bolus of normal saline x2, so the infant had to be started on about 30% FiO2, which was weaned gradually.  The infant was given sodium bicarbonate bolus to fix the metabolic acidosis.  The infant continued on chest PT and suctioning, the respiratory distress gradually improved.  The infant was weaned to room air, and the pulse oximetry was discontinued and the problem was resolved after the respiratory rate had decreased to normal, O2 saturations were stable, and metabolic acidosis was resolved.
2.  Metabolic acidosis.  As above.  Base deficit started at –6, remained at –5 and –6 until after two boluses of normal saline and sodium bicarbonate was given and until the infant was started on FiO2, after which it resolved gradually.
3.  Rule out sepsis.  Workup was done secondary to respiratory distress.  Workup remained negative.  The infant was on ampicillin and gentamicin until 72-hour negative cultures, after which the antibiotics were stopped and the problem was resolved.
4.  Fluid, electrolytes, and nutrition.  Initially, the infant was NPO, on IV fluids.  TPN was started.  The infant was started on feeds slowly and was advanced to full feeds.  Currently, the infant is nippling all his feeds and nippling it well, voiding and stooling.
5.  Hyperbilirubinemia.  Bilirubin increased to 6.5 on day #1.  The infant was started on phototherapy.  Bilirubin further increased later on and then remained stable subsequently.  The phototherapy was discontinued.  Bilirubin stayed stable, so the infant was observed clinically.

The infant was in stable condition.  Vital signs were stable.  Heart, regular rate and rhythm.  No murmur.  Pulses were normal.  Abdomen was soft.  No hepatosplenomegaly.  Neurological exam, grossly good tone.  Genitourinary exam was normal male.  No circumcision was done.  Testes were descended bilaterally.

DIAGNOSIS ON DISCHARGE:
1.  A 35-week gestation appropriate for gestational age male.
2.  Respiratory distress syndrome, resolved.
3.  Sepsis, ruled out.
4.  Hypovolemia, resolved.
5.  Metabolic acidosis, resolved.
6.  Hypoglycemia was ruled out.
7.  Hyperbilirubinemia, resolved.

CONDITION ON DISCHARGE:  Stable.

PLAN ON DISCHARGE:  Follow up with Dr. Jane Doe in 1 week.

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Medical Transcription Psychiatric (Psych) Consultation Transcribed Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

ATTENDING PHYSICIAN:  John Doe, MD

CONSULTING PHYSICIAN:  Jane Doe, MD

REASON FOR CONSULTATION/HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old female with a history of end-stage COPD, previous CVA, seizure disorder, chronic headaches and chronic pain syndrome, who was admitted to the hospital yesterday for increasing pain all over the body.  She has also expressed feelings of severe depression, and a psychiatric consultation was requested for evaluation of the same.  The patient reports that she had been going through a lot for the past few months.  She was referring to her medical problems, chronic obstructive pulmonary disease, especially the pain all over the body for which no clear organic reason has been found so far.  She says that she is hurting all the time, constantly.  She is tired of it.  She cannot take care of herself, and she was recently in the nursing home but had a bad experience over there, and she does not want to go back to the nursing home.  She was living with a man for 15 years, but he is not able to take care of her.  She was very helpless and hopeless, and she voices passive death wishes but denies any active intentions.  She says that she will never do that to her and her friend.  She does admit to having insomnia and extremely depressed crying episodes and reports very poor energy level, motivation, loss of interest and feeling sad and unhappy all the time.  She had some depression symptoms in the past, related to the medical problems, and was placed on Lexapro and Seroquel for sleep for the past few weeks, but it is not helping.  Seroquel helped for her sleep, but she does not want this medication as she knows this is an antipsychotic.  She denies any delusions or hallucinations.

PAST PSYCHIATRIC HISTORY:  No history of any psychiatric illness or psychiatric hospitalization or any suicidal attempts in the past.

PAST MEDICAL HISTORY:  As stated above.

CURRENT MEDICATIONS:  On admission, Protonix, Synthroid, Nitro-Dur patches, Tenormin 25 mg once a day, Ditropan, Atrovent, Nasonex, multivitamins, Os-Cal, Bumex, Imdur, Micro-K, Lexapro 10 mg daily, magnesium oxide, Klonopin 0.25 mg every 12 hours, Seroquel 100 mg nightly, Phenergan p.r.n., and Pulmicort inhaler.

ALLERGIES:  THE PATIENT IS ALLERGIC TO NONSTEROIDAL ANTI-INFLAMMATORY DRUGS AND SULFA DRUGS.

PSYCHIATRIC MENTAL STATUS EXAMINATION:  The patient is a thinly built female who appears to be in moderate distress from pain.  She is generally cooperative, pleasant, shows significant psychomotor retardation but no agitation.  She speaks in a very low volume voice.  She is alert and oriented in all three spheres.  Memory grossly intact in all modalities.  Speech is coherent.  Mood is depressed, tearful, constricted affect.  No evidence of any overt psychosis or hypomania.  She does have passive death wishes, however, denies any active suicidal intentions or thoughts.  Insight and judgment questionable.  Intellectual abilities in average normal range.

IMPRESSION:
Axis I:  Major depression, single episode, moderate to severe with anxiety component.
Axis II:  Deferred.
Axis III:  Chronic pain syndrome, narcotic dependence, chronic obstructive pulmonary disease, status post cerebrovascular accident, and seizure disorder.

RECOMMENDATIONS:  The patient does not appear to be responding to her current psychotropic medications, so I will discontinue the Lexapro and Seroquel.  Instead, we will use Effexor XR 37.5 mg once a.m. and also Desyrel 50 mg nightly.  We will continue to monitor the patient closely.

EEG (Sleep Medicine) Transcribed Medical Transcription Sample Report

DATE OF EEG:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

INDICATIONS:
A patient referred for the evaluation of possible seizures.

TECHNIQUE:
The 18-channel digital video and digital EEG monitoring was performed with conventional scalp electrode placement according to the 10-20 electrode convention.  The EEG was reviewed in bipolar and referential montages.

FINDINGS:
In the awake state, with the eyes closed, the dominant posterior rhythm consisted of well-formed, regular, medium amplitude 9 to 10 hertz alpha activity.  This was intermixed with low amplitude beta activity diffusely. Hyperventilation was performed and resulted in some increased amplitude and slowing of EEG activity.  The patient was "staring" after hyperventilation, but there were no epileptiform discharges. Intermittent photic stimulation was not performed. The entire sleep recording was scanned and reviewed.  Normal features of sleep were seen including vertex sharp transients, K-complexes, and sleep spindles.

In deeper stages of sleep, higher amplitude posterior slow waves were observed. There were no interictal abnormalities. More than 30 pushbutton events were recorded.  These consisted of various phenomena such as odd eye movements, staring, subjective changes, jumping episode, closing of the eyes, pressing on the eyes and eyelid blinking.  In addition, the patient self-induced several of the spells, where the patient arched his back and neck and stretched his neck.  None of these resulted in convulsion or loss of consciousness, but the patient said he felt dizzy.

In any case, no EEG changes of significance were seen with any of these phenomena at all.  There was considerable artifact occurring with many of these phenomena.

IMPRESSION:
Abnormal prolonged video EEG monitoring for age.  Normal awake and sleep features are seen.  No epileptiform discharges are observed.  None of the clinical events of concern were associated with EEG change of significance.

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Cystoscopy and Left Ureterorenoscopy with Laser Lithotripsy and Stone Extraction/Stent Insertion Transcribed Medical Transcription Sample Report

PROCEDURE IN DETAIL: The patient was brought to the operative suite. Appropriate monitors were established and preoperative antibiotics were administered. The patient was prepped and draped in the low dorsal lithotomy position. Cystourethroscopy was performed and was characterized by an edematous left orifice and intramural ureter tunnel. There were no foreign bodies in the bladder. The bladder was otherwise normal. The patient had a Pollack catheter and Bentson guidewire readied and attempts were made to pass this past the stone; however, they proved futile and it was necessary to go to a combination glide and Bentson wire. This was successfully maneuvered past the calculus and allowed to rest in the pelvis of the kidney. The ureteroscope was then readied, and using saline as irrigant, was successfully passed into the orifice and the stone could be seen. Attempts were made to engage the stone with two different stone baskets; however, they kept collapsing and would not open enough to engage the stone. Accordingly, it was elected to employ the holmium laser and the laser fiber was introduced. It was then used to fragment the stone into several pieces, which were extracted from the ureter using the baskets. Several were retained for analysis. The guidewire was then backloaded through the cystoscope and a 6 x 20 double-J stent was readied and passed over the guidewire, positioned by fluoroscopic imaging as well as, visually, distally in the bladder and the suture was left on it. The guidewire was removed after satisfactory positioning of the stent had been achieved. The bladder was then drained and several more fragments were evacuated with blood clots. The suture was allowed to exit the urethra and was taped on the patient's thigh and the procedure terminated. The patient was taken to the recovery room in satisfactory condition.

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Cystoscopy, Retrograde Pyelogram and Right Ureterorenoscopy Transcribed Medical Transcription Sample Report

PROCEDURE IN DETAIL:  The patient was readied for cystoscopy. The patient received appropriate monitoring and general anesthesia. She was prepped and draped in the left dorsal lithotomy position. Cystourethroscopy was performed and effluxing urine was again seen from the right orifice. Reinspection of the bladder revealed no other diagnostic abnormalities. A Pollack catheter and Bentson guidewire were introduced into the right orifice and a retrograde pyelogram was done. This was completely normal throughout. There was no deviation of the caliber of the ureter. The diameter of the ureter was normal throughout. The pelvicaliceal system of the kidney looked perfectly normal. It was elected to then proceed with ureterorenoscopy which was done using the new mini ureteroscope. This was passed over the guidewire through the urethra, bladder, and into the orifice. There was no evidence of lesions within the ureter and the scope was gradually passed all the way back until the pelvis of the kidney was visualized and part of the interior of the kidney was noted. No diagnostic abnormalities or abnormal findings were appreciated. The water was turned off in order to try to tell where the bleeding might be coming from, but this was not successful. The scope was then slowly withdrawn reinspecting the ureter while doing so and again no abnormalities were noted.

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Neurologic Consultation Transcribed Medical Transcription Example Report


DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  Jane Doe, MD

CONSULTANT:  John Doe, MD

REASON FOR CONSULTATION/HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old right-handed male with history of hypertension, previous CVA, residual spastic left hemiplegia, seizures, alcohol abuse in the past, coronary artery disease status post coronary artery bypass graft, and most recent possible brainstem cerebrovascular accident about 8 months ago.  He was admitted to the hospital with confusion and was wandering around.  Reportedly, the patient was found wandering around on the road, in his car, driving erratically.  The patient has no clear recollection of events.  He was brought to the emergency room and was completely disoriented.  No reports of any complete loss of consciousness or any witnessed tonic-clonic seizure activity.  The patient states that he was taking his Dilantin, but he does not remember if he had any seizures.  He has no idea of how he got to the hospital.  At this time, the patient denies any new focal neurological symptoms.  CT of the head without contrast from the emergency room was reported as negative for any acute lesions.

PAST MEDICAL HISTORY:  Essentially as stated above.  He also had abdominal aortic aneurysm repair and left leg femoropopliteal bypass.

MEDICATIONS ON ADMISSION:  Neurontin 300 mg t.i.d., Plavix 75 mg once a day, Lanoxin, K-Dur, folic acid 1 mg once a day, vitamin B6 50 mg a day, TriCor 160 mg a day, multivitamins, Dilantin 250 mg a.m. and 300 mg nightly, Seroquel 25 mg nightly, Prozac 10 mg daily, Protonix 40 mg once a day, and Ativan 1 mg t.i.d.

ALLERGIES:  HE HAS NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY:  He smokes 3 packs a day.  He had a long history of alcohol abuse but claims that he quit.

FAMILY HISTORY:  Noncontributory.

PHYSICAL EXAMINATION:  General:  The patient is an averagely built male, who is not in acute distress.  Vital Signs:  Stable, as noted on the chart.  HEENT:  Examination unremarkable.  Neck:  Supple.  No carotid bruits.  Heart:  S1 and S2 are normal.  No murmur, gallop, or rub.  Lungs:  Clear.  Neurologic:  He is alert.  He knows he is in the hospital.  He has no recollection of events from yesterday, clearly.  He follows commands appropriately.  His speech is dysarthric, which is unchanged from his previous exams.  Pupils are 3 mm, round, reactive to light and accommodation.  No visual field defects.  Extraocular movements are full and no nystagmus.  Mild left facial weakness of central type is still seen, residual from previous stroke.  Auditory canals are intact.  He appears to be swallowing fairly well.  Motor examination reveals spastic left hemiparesis.  Strength is 0/5 in the left upper extremity and 3 to 4/5, left lower extremity, which is unchanged from previous one, 5/5 on the right side.  Generalized hyporeflexia.  Plantar response is downgoing on the right, upgoing on the left.

LABORATORY DATA:  Laboratories on admission; blood gases show pH 7.40, PCO2 41.6, PO2 62.2.  O2 saturation 91.9.  Urine drug screening came back positive for benzodiazepines and cannabinoids.  CK, myoglobin was elevated.  Troponin was normal.  CBC shows WBC 6900, H and H 12.4 and 39.  Platelets normal at 262,000.  Chemistry profile on admission shows sodium 144.  Rest of the electrolytes are normal.  BUN, creatinine, and blood sugar were normal.  Liver profile was unremarkable.  Dilantin level on admission was 4.3.

CT head without contrast, no acute focal lesions.

IMPRESSION:
1.  Altered mental status, confusion, could be metabolic encephalopathy, rule out sepsis versus seizure, in postictal state.
2.  Old brainstem cerebrovascular accident and also spastic left hemiparesis, nonplegic, residual from previous stoke.
3.  Seizure disorder with subtherapeutic Dilantin level.
4.  History of alcohol abuse in the past but sober now.
5.  Multiple medical problems including cardiac and peripheral vascular disease.

RECOMMENDATIONS:  We will give extra Dilantin bolus of 500 mg intravenous piggyback today and check the level in the morning.  He denies doing any drugs.  However, his urine drug screen tested positive for marijuana.  Protonix sometimes gives false-positive results for marijuana.

Thank you, Dr. Doe, for the consult.  We will follow the patient with you.

Neurology Consultation Transcribed Medical Transcription Example Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  Jane Doe, MD

CONSULTANT:  John Doe, MD

REASON FOR CONSULTATION/HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old right-handed female with a history of hypothyroidism, who was admitted to the hospital last night with severe headache, sudden onset, localized to right frontoparietal area, radiating to the back.  Neurological consultation requested for evaluation of the same.  The patient reports having developed sudden headache on the right side, throbbing in nature, last night, localized to the right parietal and frontal areas, radiating to the back of the head and right side of the neck.  It is severe associated with nausea, but no vomiting.  The patient does report blurred vision and photophobia.  No speech difficulties or any diplopia, dysphagia or any focal neurological symptoms.  She denies any vertigo.  She states that, later, she did have possible hyperventilation and also complained of numbness in the lips and fingers but that resolved.  She was brought to the emergency room.  CT of the head without contrast was reported as unremarkable.  Her blood pressure in the emergency room was 192/102 and pulse 72 per minute.  She was given a dose of Demerol, which did help her, and was admitted for further management.  At this time, she is feeling much better.  She still has the headache but not as bad as last night.

PAST MEDICAL HISTORY:  Hypothyroidism, allergies, and intermittent bifrontal headaches from allergies in the past.  She has no history of increased hypertension, diabetes, TIA, severe seizures or any cardiac disease.

MEDICATIONS:  Synthroid and Allegra.

ALLERGIES:  SHE HAS NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY:  She smokes 5 to 6 cigarettes a day.  She drinks alcohol socially.

FAMILY HISTORY:  Noncontributory.

PHYSICAL EXAMINATION:  General:  The patient is a well-built female not in acute distress.  Vital Signs:  Her blood pressure today is 142/78, pulse 68 per minute and regular, and she is afebrile.  HEENT:  Examination unremarkable.  Neck:  Showed some muscle tenderness on the right side.  Full range of motion.  No carotid bruit.  Heart:  S1 and S2 normal.  No murmur, gallop or rub.  Lungs:  Clear.  Neurological:  She is alert and oriented in all three spheres.  Normal speech and language function.  Memory is intact in all modalities.  Pupils are 3 mm, round, and reactive to light and accommodation.  No visual field defects.  Extraocular movements are full.  No nystagmus.  She does have mild photophobia.  No facial asymmetry.  Cranial nerves are intact.  Muscle bulk and tone are within normal limits.  No evidence of any focal motor deficits.  Sensory examination is unremarkable.  Deep tendon reflexes 2+ and symmetrical.  Plantar response is downgoing bilaterally.  Finger-to-nose test did not show any ataxia.  Gait not tested at this time.

LABORATORY DATA:  Chemistry profile on admission showed sodium 136 and potassium 3.4.  Glucose, BUN, and creatinine normal.  Liver profile was normal.  PT and PTT within normal limits.  WBC 11,200, H and H 14.2 and 41.4, and platelets 350,000.  CT of the head without contrast as discussed above and was reported as negative.

IMPRESSION:
1.  Sudden onset of right parietal headache, nonfocal neurological examination, no signs of any meningeal irritation.  Most likely etiology is vascular headache versus related to uncontrolled hypertension.  Possibility of an intracranial lesion cannot be ruled out completely.
2.  She does have mild cervical strain, mostly in the right side.  This might contribute to headaches.

RECOMMENDATIONS:  We will get MRI of the brain with contrast.  MRA of circle of Willis was just completed.  I will also get C-spine x-rays, ESR, and continue symptomatic treatment.  We will continue to monitor closely.

Thank you, Dr. Doe, for the consult.  We will follow the patient with you.


Left Ring Trigger Finger Release Medical Transcription Operative Sample

OPERATION IN DETAIL:  The patient was brought to the operating room and laid supine on the operating room table. Ten mL of a mixture of Marcaine and lidocaine was injected at the level of the distal flexion crease in line with the ring finger. Next, a tourniquet was placed on his left forearm. The left upper extremity was prepped and draped in the usual sterile fashion. An Esmarch bandage was used to exsanguinate the left upper extremity, and the tourniquet was inflated to 250 mmHg. Next, a transverse incision approximately 2 cm in length was made just distal to the distal flexion crease, in the palm, in line with the ring finger. Dissection was carried down through the subcutaneous fat down to the level of the tendon sheath. The A1 pulley was identified and incised with a 15 blade. After incision of the A1 pulley, the finger was taken through a full range of motion. No further triggering was noted. There was no further locking. The patient was asked to actively flex and extend his fingers, and he did not note any catching or locking. The wound was then thoroughly irrigated with normal saline. The tourniquet was deflated. The skin was closed with 5-0 nylon suture in horizontal mattress fashion. Sterile dressings were applied. The patient was then transferred back onto a stretcher and taken to Same Day Surgery.

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Open Reduction and Internal Fixation of Left Humerus MT Sample Report

OPERATION IN DETAIL:  The patient was brought to the operating room and laid supine on the OR table. After general anesthesia was induced, the patient was turned over to the lateral decubitus position. The left upper extremity was prepped and draped in the usual sterile fashion. A standard posterior approach to the humeral shaft was performed. Dissection was carried down through the subcutaneous layer. The interval between the long and lateral heads of the triceps was identified and the triceps tendon was incised in the midline distally. Careful dissection was carried out to expose the radial nerve and the neurovascular bundle. This bundle was encased in a scar tissue and careful dissection was performed to free up the bundle from the eschar. Penrose drains were placed around the neurovascular bundle before the fracture was exposed. Next, the fracture callus was identified and taken down. The bone graft from the callus was saved for later bone grafting. Next, the humeral shaft nonunion was exposed and cleaned with a curette and rongeurs, after the fractured ends were thoroughly exposed. Next, a 12-hole LCDC plate was contoured to the posterior aspect of the humerus. Compression was obtained across the fracture. Four screws were placed proximal and four screws distal to the fracture. Compression was applied to eccentric positioning of the screws. After excellent reduction was obtained, bone graft from the callus was then packed around the fracture site. This was done after the wound was thoroughly irrigated with normal saline. Next, the fascia was closed with a running 2-0 Vicryl suture. The subcutaneous layer was closed with 3-0 Vicryl suture followed by staples for the skin. Sterile dressings were applied and the patient was then turned over to the supine position, extubated, and awakened from anesthesia. The patient was transferred onto a stretcher and taken to the PACU for recovery.

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Open Reduction and Internal Fixation of Left Calcaneal Tuberosity Fracture and Repair of Left Achilles Tendon Transcribed Sample Report

OPERATION IN DETAIL:  The patient was brought to the OR and laid supine on the OR table. After general anesthesia was induced, the patient was turned over to the prone position. All bony prominences were well padded. A tourniquet had been placed high up on the left thigh prior to the patient being turned prone. The left lower extremity was then prepped and draped in the usual sterile fashion. Esmarch bandage was used to exsanguinate the left lower extremity and the tourniquet was inflated to 300 mmHg. Next, a 12 cm incision longitudinally was made just medial to the Achilles tendon. The Achilles tendon was identified. Next, the fracture through the calcaneal tuberosity was identified and this area was cleaned of fibrin clots and all bullet fragments were removed. Next, the patient's foot was placed into plantar flexion. A transverse incision was made through the heel pad. Two drill holes were passed from the plantar aspect of the calcaneus up through the fractured surface. Next, Ti-Cron sutures were passed with a straight needle through these holes. Next, a Krackow-type suture was performed extending approximately 4 cm up into the Achilles tendon substance. These sutures were then brought back down and passed through the drill holes that were made in the calcaneus and brought out through the plantar aspect of the calcaneus using a straight needle. The foot was placed into full plantar flexion and suture was tied down tightly. Excellent fixation of the Achilles tendon into the calcaneus was obtained after final tightening. Next, there was noted to be a bone fragment with the Achilles tendon attached to which a screw could be placed for additional fixation. Therefore, a 35 mm partially threaded cortical screw was placed into the calcaneus fixating this bone fragment. Next, the wound was thoroughly irrigated with normal saline and the tourniquet was deflated and hemostasis was obtained. The wound was closed using a 2-0 Vicryl suture for the subcutaneous layer followed by staples for the skin. Sterile dressings were applied and the patient was placed into a splint in plantar flexion. The patient was then awakened from anesthesia and taken to the PACU for recovery.

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Left Hip Hemiarthroplasty Medical Transcription Operative Sample Report

OPERATION IN DETAIL:  The patient was brought to the operating room and laid supine on the OR table. After general anesthesia was induced, the patient was turned to the left lateral decubitus position. The patient was on a bean bag. Next, the left lower extremity was prepped and draped in the usual sterile fashion. Approximately, a 15 cm incision was made directly overlying the greater trochanter. A direct lateral approach to the hip joint was performed. The gluteus medius and minimus were elevated off the greater trochanter in separate layers. The capsule was opened and retractors were positioned. The femoral head was then removed using a corkscrew. Next, the femur was then prepared for the implant. The canal finder was used followed by the lateralizing reamer. Then, broaching was initiated and the size 14 broach was determined to be the appropriate size. Next, trials were performed for the femoral head size and a size 52 hemiarthroplasty head was chosen. Next, a trial reduction was performed and excellent range of motion and stability was noted with a 52 head and the standard femoral neck. Next, the broach was removed and the canal was then prepared for cementing. A cement restrictor was placed. The canal was then irrigated with pulsatile lavage. Next, cement was injected in retrograde fashion into the femoral canal. Next, the implant was positioned in neutral into the medullary canal. Next, a standard femoral neck size with a 52 head was then positioned and the hip was reduced without any difficulty. This was done after the cement had hardened. Once the hip was reduced, excellent range of motion and stability were noted. Next, the joint was thoroughly irrigated with normal saline. Next, the gluteus medius and minimus were reattached to the greater trochanter in their respective positions. The iliotibial band was closed using figure-of-eight suture of 0 Vicryl. A Hemovac drain was placed and the subcutaneous layer was closed with 2-0 Vicryl suture in an inverted fashion. Staples were used to close the skin. Sterile dressings were applied. The patient was awoken from anesthesia and was then transferred over to the bed and an abduction pillow placed. The patient will be sent to the MICU for further care.

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Open Reduction and Internal Fixation of Right Calcaneus Operative MT Sample Report

OPERATION IN DETAIL:  The patient was brought to the operating room and laid supine on the operating table. After general anesthesia was induced, the patient was turned to the lateral decubitus position. All bony prominences were well padded. A tourniquet was placed high upon the right thigh and the right lower extremity was prepped and draped in the usual sterile fashion. Next, an L-shaped incision was made, performing a standard lateral approach to the calcaneus. Full-thickness skin flaps were raised. Subperiosteal elevation of the anterior flap was performed using sharp dissection. Care was taken to protect the peroneal nerves as well as the sural nerve and the peroneus tertius tendon distally. The calcaneus fracture was exposed. The lateral wall was removed. Next, a Steinmann pin was placed into the calcaneal tuberosity through the heel through a separate stab incision. Next, the fracture was opened using a combination of elevators and Cobbs. Next, the calcaneal tuberosity was brought into valgus. Preoperative plain films showed a significant fracture deformity of the hindfoot. This was corrected intraoperatively using the Schanz pin. Next, attention was turned to performing reduction of the posterior facet. With direct visualization, the posterior facet was reduced. Two 2.0 K wires were placed from posterior to anterior, holding the posterior facet reduced. C-arm fluoroscopy was used to confirm good restoration of the hindfoot alignment, which was taken out of varus and brought into neutral alignment. The facet was reduced under direct visualization. It was difficult to reduce the anterior process of the calcaneus, as any attempt at reduction of this anterior portion would lead to gapping of the posterior facet. Therefore, we decided to perform an anatomic reduction of the posterior facet and accept the upward tilt of the anterior process of the calcaneus. As mentioned, the varus deformity was corrected intraoperatively. Next, a calcaneal plate from the DePuy set was selected and fashioned to the lateral aspect of the calcaneus. Two screws were placed distal into the calcaneal tuberosity and two screws under the facet joint. Another screw was placed in the calcaneus. C-arm fluoroscopy was used to confirm good length of all screws. Final reduction was checked under C-arm fluoroscopy as well and was felt to be acceptable. Next, the wound was thoroughly irrigated with normal saline. A drain was placed and brought out the dorsum of the foot. Next, 0 Vicryl suture was used to close the flaps. The skin was closed using 3-0 nylon suture using a corner stitch fashion throughout the incision. Sterile dressings were applied. The patient was placed into an AO splint. The tourniquet was deflated prior to closure and hemostasis was obtained. The patient was then turned to the supine position and was extubated in the operating room and taken to the PACU for recovery. There were no complications.


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Open Reduction and Internal Fixation of Right Ankle Fracture MT Operative Sample

OPERATION IN DETAIL:  The patient was brought to the operating room and laid supine on the operating room table. General anesthesia was induced. A tourniquet was placed high up on the right thigh but was never inflated during the procedure. Next, the right lower extremity was prepped and draped in the usual sterile fashion. A longitudinal incision was made with a standard approach to the lateral malleolus. Dissection was carried down to the level of the fracture, which was noted to be highly comminuted in several pieces. Dissection was carried out proximally, and the superficial peroneal nerve was identified and protected during the remainder of the procedure. The fracture fragments were then provisionally reduced and held with a 1.6 mm K-wire. Two lag screws were placed from anterior to posterior, obtaining fixation of one of the fragments more proximally. These lag screws were inserted in standard AO fashion. Next, the distal malleolar piece was reduced. The distal lateral malleolus was fragmented into two large pieces. Another lag screw was inserted from anterior to posterior, obtaining fixation of the distal malleolar tip. Next, a 10-hole LCDC plate was then fashioned to the distal fibula. The plate was contoured to fit the mold of the fibula. Next, three cortical screws were placed proximal to the fracture and three cancellous screws were placed at the distal lateral malleolus. The comminuted fragment was spanned with the plate. The plate essentially functioned as a bridge plate spanning the comminuted segment. After all screws were tightened, C-arm fluoroscopy was used to confirm good reduction of the fracture as well as restoration of length of the fibula. Next, attention was directed to the medial malleolus. A standard medial approach was performed, taking care to protect the greater saphenous vein. Next, the medial malleolar fracture was identified. The fracture was cleaned of periosteum. A tenaculum was used to hold the fracture reduced. Two 4.0 mm cancellous screws, partially threaded, each 45 mm in length, were then inserted in standard fashion from the tip of the distal malleolus up into the tibial metaphysis. The fracture was held reduced while the screws were being inserted. C-arm fluoroscopy was used to confirm excellent reduction of the fracture and positioning of the screws. Next, plain films were obtained in the operating room and the fixation was felt to be adequate. The ankle mortise was symmetric. All screws on both the medial and lateral sides were of adequate length. Next, both wounds were then thoroughly irrigated and closed with 2-0 Vicryl suture in the subcutaneous layer followed by staples in the skin. Next, a sterile dressing was applied and the patient was placed into an AO splint. The patient was then awakened from anesthesia, transferred back onto stretcher, and taken to the postanesthesia care unit for recovery.

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Repair of Chronic Right Patellar Tendon Rupture MT Sample Report

OPERATION IN DETAIL:  The patient was brought to the operating room and laid supine on the OR table. General anesthesia was induced. Right lower extremity was prepped and draped in the usual sterile fashion, after tourniquet was placed high on his right thigh. An Esmarch bandage was used to exsanguinate and tourniquet was inflated to 200 mmHg. Next, a standard anterior approach to the knee joint was performed. The patellar tendon rupture was identified. The tendon was debrided and freshened up using 11 blade. Next, a #5 Ti-Cron suture was passed using Krackow-type suture. Two #5 Ti-Cron sutures were passed to the patellar tendon and brought out through the tendon end. Next, a Beath needle was used to make three drill holes from distal to proximal in the patella. Next, the suture ends were brought out through the drill holes at the proximal end of the patella. Next, an 18-gauge wire was passed through the quadriceps tendon just superior to the superior pole of the patella. The drill hole was made from the medial to lateral and the tibial tubercle. The 18-gauge wire was passed through this drill hole and the knee was placed into hyperextension and the 18-gauge wire was then tightened. As the 18-gauge wire was tightened, the Ti-Cron sutures were securely tied at the superior pole of the patella and buried underneath the quadriceps tendon. Next, the final clamping of the wire was performed. Excellent repair was obtained; although, it was very tight due to the chronic nature of the rupture. Next, the wound was thoroughly irrigated with normal saline. The retinaculum on either side was closed with #1 Ethibond suture in a figure-of-eight fashion. The 0-Vicryls were used to sew over the superficial layer of the tendons to retinaculum of the patella. Next, the subcutaneous layer was closed with 2-0 Vicryl suture in an inverted fashion followed by staples for the skin. Prior to closure, the tourniquet was deflated and hemostasis was obtained. Next, sterile dressings were applied after staples were placed on the skin and the patient was placed into the knee immobilizer. He was then awakened from anesthesia and transferred back on to the stretcher and taken to the PACU for recovery.

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Cardiac Catheterization Medical Transcription Example Report

PROCEDURE PERFORMED:  Cardiac catheterization. 

INDICATION FOR PROCEDURE:  Unstable angina and abnormal stress test. 

DETAILS OF PROCEDURE:  The patient was taken to the cardiac catheterization lab and prepped and draped in the usual sterile fashion. The patient was sedated with Versed and fentanyl and the right groin was infiltrated with 2% lidocaine. A 5 French sheath was placed in the right common femoral artery. Judkins left 4, 3DRC and pigtail catheter as well as an Amplatz right modified catheter were used for the diagnostic portion of the procedure. 

FINDINGS: The right coronary artery is a dominant vessel and gives off a couple of RV marginal branches that are severely, diffusely diseased and 100% occluded in its mid portion. There is a widely patent saphenous vein graft anastomosed to the posterior descending artery with good flow into the posterior descending and no significant disease seen distal to the anastomosis in the posterior descending. The left main is relatively free of disease. It bifurcates into a nondominant circumflex and left anterior descending. The circumflex gives off a high first marginal, which is a bifurcating vessel and is 100% occluded proximally. It fills faintly from left collaterals. The second marginal is a moderate-sized branch with a 50% proximal stenosis and trivial disease elsewhere. The AV groove vessel is 100% occluded. There is a widely patent saphenous vein graft attached to the distal circumflex, just prior to it, giving a bifurcating posterolateral. Immediately distal to the anastomosis, the vessel is approximately a millimeter in caliber and there is a 90% stenosis just after the bifurcation of the obtuse marginal with the lateral branches. Neither of them supplies a very large territory. The larger of the two posterolaterals is the one with the lesion in it proximally. There is a significant mismatch between the size of the distal vessel with a poststenotic dilatation in the proximal vessel. The left anterior descending wraps around the apex and bifurcates. There is a mid diagonal with a 99% proximal stenosis and an 80% stenosis in the left anterior descending. There is a widely patent saphenous vein graft attached to the diagonal with a proximal stenosis. It fills this diagonal well. The diagonal is a millimeter or less in caliber throughout its course. There is a widely patent left internal mammary artery anastomosed to the mid left anterior descending. Approximately a centimeter or two distal to the anastomosis, there is 90% stenosis in the left anterior descending before it wraps around the apex and bifurcates distally and is a millimeter or less in caliber and diffusely diseased. Injection of the right groin revealed the sheath to be in the common femoral artery. 

IMPRESSION:  Severe native multivessel disease as described above with widely patent grafts as described above. There are several territories where the patient could be ischemic, including in the territory of the ungrafted 100% occluded first marginal, in the territory of the distal posterolateral after the anastomosis with the saphenous vein graft and in the territory of the distal left anterior descending where again the patient has disease after the anastomosis of the mammary. Her ischemia was in the inferior apex, likely in the territory where the patient's distal left anterior descending lesion is; this is clearly not revascularizable. The patient could potentially have a posterolateral revascularized; however, not sure of the benefit. The patient still has several other ischemic territories and the ischemia was in a different distribution and this would be a high risk procedure for the patient. At this point, recommend medical management.

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Cardiac Catheterization Percutaneous Revascularization Sample Report

PROCEDURES PERFORMED:  Cardiac catheterization and percutaneous revascularization of left anterior descending artery, circumflex, and right coronary artery. 

INDICATION FOR PROCEDURE:  Recent non-ST elevation infarct. 

DETAILS OF PROCEDURE:  The patient was taken to the cardiac catheterization lab, prepped and draped in the usual sterile fashion, sedated with Versed and fentanyl. The right groin was infiltrated with 2% lidocaine. A 6 French sheath was placed in the right common femoral artery.

For the diagnostic portion of the procedure, an XB 3.5 guide and 3DRC guide were utilized. For the intervention on the circumflex, an XB 3.5 guide was utilized for intervention on the LAD. Judkins left 3.5 guide was utilized for the intervention on the right coronary artery. Multiple catheters were utilized. The only one that seated reasonably was internal mammary artery guide with side holes.

For the interventions on the left coronary, Balance Middle Weight wire was utilized for the right coronary artery. A Choice PT floppy was utilized. 

FINDINGS: 
1. The left main is free of disease and bifurcates to a nondominant circumflex and LAD. Circumflex gives off a large marginal with a 90% stenosis in its mid section. 
2. LAD wraps around the apex and bifurcates. It gives off a large first diagonal with an ostial 70% stenosis and a 70% stenosis 1 cm thereafter. The LAD then has a likely 70% stenosis in its mid section. 
3. Right coronary artery is a dominant vessel, gives off posterior descending and posterolateral branches and has a 50% proximal lesion and 80% lesion in its mid portion approximately 1 cm downstream from this 70% proximal lesion. The posterior descending and posterolateral branches have no significant disease. 
4. The left ventricular end-diastolic pressure is 20 mmHg. Ejection fraction is 55% with no segmental wall motion abnormality. No gradient across the aortic valve. No mitral regurgitation. 

For the intervention, the patient was given weight-based heparin and Integrilin. Balance Middle Weight wire was used to cross the lesion in the circumflex and this was primarily stented with a 3.5 x 20 mm Taxus drug-eluting stent.

Subsequently, the LAD was intubated and the lesion in the LAD was primarily stented with a 2.5 x 20 mm Taxus drug-eluting stent. Subsequently, the right coronary artery was intubated. The more distal lesion was ballooned with a 2.5 x 12 mm balloon to a residual 70% stenosis. This was moderately calcified and difficult to intubate.

A 20 mm stent would not make it around the turn and get into this lesion. Subsequently, a 3.0 x 12 mm Taxus drug-eluting stent was deployed in the lesion to a residual 0% stenosis and then another Taxus 3.0 x 12 mm drug-eluting stent was deployed in the more proximal lesion to a residual 0% stenosis.

Of note, there was extensive spasm of the distal LAD. During the LAD intervention, this was relieved by withdrawing the wire and giving the patient 300 mcg of intracoronary nitroglycerin. 

IMPRESSION: Successful revascularization of left anterior descending artery, circumflex, and right coronary artery. The diagonal was left alone given its ostial nature. Recommendation would be to maintain the patient on medical therapy. Continue aggressive medical therapy.


Total Knee Arthroplasty Medical Transcription Sample

DESCRIPTION OF OPERATION: After suitable general anesthesia, the patient’s right lower extremity, with a tourniquet cuff in place, was prepped and draped in the usual sterile fashion.  The outline of the skin incision was marked out.  This was centered over the patella and extended distally, longitudinally, to the tibial tuberosity.  Proximally, it followed the previous skin scar in the suprapatellar area which was in a slightly oblique fashion towards the lateral side.  Next, the tourniquet cuff was elevated to 300 mmHg after exsanguination of the extremity with the help of the Esmarch bandage.  A skin incision was made and then deepened.  The blood vessels were cauterized as the dissection proceeded.  On the anterior aspect of the patella, the patellar retinaculum was noted to be markedly scarred extending proximally from its previous injury.  A medial flap was dissected and then the knee joint was entered by standard medial parapatellar incision.  A fair amount of clear straw-colored synovial fluid was removed.  The incision extended distally along the medial side of the patellar ligament to the level of the tibial tuberosity and, proximally, it was carried into the tendon of the quadriceps for short distance.  After suitable dissection, the patella was everted and the knee joint was then opened by flexing the knee.  There was noted to be marked osteoarthrosis involving all the knee joints.  There were prominent osteophytes around the margins of the patella as well as the femoral and the tibial condyles.  The articular cartilage of the joint including the patella, femoral, and tibial condyle was noted to be absent down to subcondylar bone in the majority surface of the joint.  The menisci were noted to be very degenerative and absent in places.  The anterior cruciate ligament was also noted to be very degenerative.  First, the osteophytes on the margin were trimmed, some osteophytes in the intercondylar notch were also removed as well as the anterior cruciate ligament.  Then, a drill hole was made in the center of the distal femoral condyle just anterior to the intercondylar notch.  The femoral canal was opened and then the T-handle was passed to further open it proximally.  Next, the distal femoral cutting jig was placed in position and aligned properly and then fixed.  The distal femoral cut was then made and checked for smoothness, then the jig too was placed in position and sizing was done, and it was seen that it would require a large prosthesis.  Following this, after making the drill hole for the peg hole for the prosthesis, the second sizing block was placed in position, and using the instrumentation, it was confirmed that a large prosthesis was the most adequate size as an extra large prosthesis would cause notching of the distal femur.  Next, the 4-in-1 cutting block was placed in position, and after protecting the posterior tissues, the anterior-posterior femoral cuts and the anterior-posterior chamfer cuts were made and checked for smoothness.  After these cuts were made, there were noted to be multiple loose bodies posterior to the femoral condyles, which were removed.  There were also osteophytic ridges posteriorly, which were removed with the curved osteotomes.  Next, the large size femoral prosthesis was taken and placed over the prepared distal end of the femur and packed in position and found to be an excellent fit.  Following this, peg holes for the prosthesis were made.  At this point, the remnants of the meniscal cartilage were removed as well as further osteophytes.  Then, preparation of the proximal tibia was done.  The tibial cutting jig was taken, assembled and then placed in satisfactory alignment, and after double checking its alignment, the proximal tibial cut was made after protecting posterior tibial tissues.  Care was taken not to cut the posterior cruciate ligament.  Next, the cut surface was checked for smoothness and further small loose and semi-attached osteophytic bodies were removed from behind the tibia.  Next, sizing of the proximal tibia was done and it was seen that an L2 tibial trial base plate afforded the best coverage.  This was then fixed in position after double checking its alignment.  At this point, the femoral trial prosthesis was again placed back in position and then first an 11 mm tibial trial insert was placed in position and the knee reduced by extending it. However, it was seen that it was slightly loose in extension; therefore, this was removed and the 13 mm tibial trial insert was placed with the base plate and the knee joint reduced, and it was seen that it could be extended to 0 degree and flexed fully with the prosthesis remaining stable.  There was no laxity of the collateral ligament.  At this point, it was decided that these were the proper size components.  Next, preparation of the patella was done.  The synovium around the margin was incised for a short distance and then the thickness of the patella was measured with a caliper and then the patellar cutting jig was placed in position and set to remove about 10 mm of the joint surface.  Following the cutting process, it was seen that there was still about 1 mm thickness remaining from the previous measurements, so this was removed by free hand sawing.  Next, the peg holes for the patellar prosthesis was made in the proper alignment and sizing, and it was seen that the medium size patella afforded the best coverage.  At this point, since most of the bony cuts were made, the trial prosthesis was removed, and before the tibial base plate was removed, the cruciform cut was made.  Next, the tourniquet cuff was released and the knee joint was irrigated.  The bleeding points were then controlled with electrocautery, and after hemostasis had been obtained and the limb had been perfused for about 12 minutes or so, the tourniquet cuff was again elevated to 300 mmHg after exsanguination of the extremity with the help of Esmarch bandage.  The knee joint was then again opened up, and then using the SysTec lavage, the prepared bony ends were thoroughly cleaned out and dried.  Next, implantation of the prosthesis was done in the following sequence.  First, the methyl methacrylate cement was mixed and while in the low viscosity stage was applied over the prepared surface of the tibia and some was also applied over the tibial base plate, which was then taken and in the correct alignment and orientation introduced down the cruciform cut and impacted in position.  Excess cement from the margin was quickly removed.  Following this, the 13 mm tibial insert was placed over the base plate and locked in position.  The femoral trial prosthesis was placed over the femur and the knee joint was then reduced and held in the reduced position till the cement had cured.  Following this, the knee joint was then again opened and checked for any loose pieces of cement, none were found.  Next, another batch of methyl methacrylate cement was mixed and then applied over the prepared distal femur and hand packed in the peg holes.  Some cement was also applied over the posterior skids of the femoral prosthesis, which was then taken and aligned in the peg holes and impacted in position.  Excess cement around the margin was removed.  The knee joint was then reduced by extending the knee and held in that position.  Some cement was also placed over the patellar surface and the patellar prosthesis, which was then taken and placed in the position and held in place with a patellar clamp.  Excess cement around the margin was removed.  After the cement had cured, the patellar clamp was removed.  The knee joint was opened up and checked for any loose fragments of cement.  Next, patellar tracking and range of motion was done and was found to be satisfactory.  The knee joint could be extended to 0 degree and flexed to 120 degrees and the patella was noted to be tracking well.  At this point, the knee joint was again thoroughly irrigated. Hemovac was placed in the lateral parapatellar gutter area and brought out through a separate stab incision situated proximally.  Next, the synovium capsule retinacular layer was closed with a single layer using interrupted sutures of #1 Vicryl.  The incision in the quadriceps, proximally, and the retinacular layer, distally, was also closed with interrupted sutures using #1 Vicryl.  The subcutaneous tissue was closed with interrupted sutures using a combination of #0 and #2-0 Vicryl and finally the skin with staples.  Xeroform and a bulky knee dressing were applied.  The tourniquet cuff was released with good flow to the lower extremity.  The patient was then awakened and transferred to the recovery room in a stable condition.  The first tourniquet time was 80 minutes, second tourniquet time was 81 minutes.  Needle and sponge counts were correct at the end of the procedure.

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