Anterior and Posterior Colporrhaphy Colpoperineoplasty Medical Report Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Symptomatic second-degree cystocele and rectocele.
2.  First-degree uterine prolapse.
3.  Desire for maintenance of uterus.

POSTOPERATIVE DIAGNOSES:
1.  Symptomatic second-degree cystocele and rectocele.
2.  First-degree uterine prolapse.
3.  Desire for maintenance of uterus.

OPERATIONS PERFORMED:
1.  Anterior colporrhaphy.
2.  Posterior colporrhaphy and colpoperineoplasty.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  200 mL.

DESCRIPTION OF OPERATION:  In the operating room, the patient was placed under general anesthetic in lithotomy position. Examination revealed a widened introitus with a second-degree cystourethrocele and prolapse of the cervix at the outer third. The uterus is mid position and mobile. There is a second-degree rectocele. Rectovaginal confirmatory. After appropriate prep, the patient was draped in the usual manner for major vaginal surgery.

A weighted speculum was placed posteriorly and the vagina was retracted anteriorly with a Sims retractor. At the 10 and 2 o'clock positions, at the cervicovaginal mucosal junction, vaginal mucosa was grasped with an Allis clamp and intervening tissue excised. The vagina was then opened in the midline to within a centimeter of distal urethral meatus. The bladder was then sharply dissected free from the overlying vaginal mucosa. Pubovesical-cervical fascia was identified and an initial suture at the urethrovesical angle was placed using 0 Vicryl in a transverse position through that fascial plane. The remainder of the cystocele was reduced with several interrupted 0 Vicryl. Redundant vaginal tissue was excised and the vagina closed in midline with simple and figure-of-eight 0 Vicryl.

The bladder was then retracted superiorly. The hymenal ring was grasped at the 4 and 8 o'clock positions. A triangular incision was made to within a centimeter of the anus. The intervening tissue was excised. The vagina was then opened in the midline to within a centimeter of the cervix. An anchoring suture was placed superiorly. The perineal body was freed and the rectum freed from the overlying vagina. Three perineal sutures were placed at this point using 0 Vicryl for eventual reapproximation. Perirectal fascia was then transversely sutured in the midline with several interrupted 0 Vicryl for support.

Redundant vaginal mucosa was excised and the vagina closed in the midline in simple fashion with 0 Vicryl, grasping the fascia. Perineal sutures were then tied and the remainder of the perineal body reapproximated with several interrupted 3-0 Vicryl. Rectal exam was negative. Bleeding point was noted anteriorly, which was suture transfixed with 3-0 Vicryl. The patient tolerated the procedure well. A Foley catheter drained approximately 30 mL of clear urine. Rectal examination was negative. No packing was placed. The patient was sent to recovery in good condition.

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Repeat Low Transverse Cesarean Section of Twins Sample

PREOPERATIVE DIAGNOSES:

1.  A 37-week twin intrauterine pregnancy.
2.  Prior cesarean section x1.

POSTOPERATIVE DIAGNOSES:
1.  A 37-week twin intrauterine pregnancy.
2.  Prior cesarean section x1.

OPERATION PERFORMED:  Repeat low transverse cesarean section through a Pfannenstiel skin incision.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  Spinal with Duramorph.

ESTIMATED BLOOD LOSS:  800 mL.

COMPLICATIONS:  None.

DRAINS:  Foley catheter.

OPERATIVE FINDINGS:
1.  Twin A 2750 grams female infant with Apgars of 8 and 9 in the vertex presentation.
2.  Twin B 2195 grams female infant with Apgars of 8 and 9 in the vertex presentation,
3.  Normal placenta, uterus, tubes, and ovaries.

DESCRIPTION OF OPERATION:  The patient was taken to the operating suite. After appropriate level of spinal anesthesia with Duramorph, she was placed in the dorsal supine position with a left tilt. Foley catheter was inserted. She was then prepped and draped in sterile fashion. A Pfannenstiel skin incision was made through previous incision and it was extended out to the deeper layers with the second scalpel. Hemostasis was achieved with the Bovie. The fascia was incised horizontally from margin to margin. The rectus muscle was dissected off the fascia sharply, bluntly, inferiorly and superiorly. The rectus muscle was then bluntly and sharply dissected exposing the peritoneum below it and this layer was entered in its upper aspect and extended vertically avoiding the bladder inferiorly.

With appropriate retractors then put in place, the vesicouterine segment of the peritoneum was incised and the midline extended on either side. This layer was dissected off the lower uterine segment. A low transverse uterine incision was then made with the scalpel. The incision was extended with the operator's fingers and membranes of baby A were ruptured with clear fluid. The baby was delivered from the vertex presentation without difficulty. Mouth and nose were suctioned and the baby cried spontaneously. The cord was clamped and cut. The baby was handed off to the nurse after being shown to the parents. The baby was in good condition.

The second baby was also in the vertex presentation, followed easily after the first, and membranes on that sac were ruptured of clear fluid. The baby was delivered with fundal pressure without difficulty. The baby was obviously smaller, but did cry spontaneously after the mouth and nose were suctioned of clear fluid with bulb. The baby's cord was clamped and cut. The baby was shown to the parents after crying vigorously. After appropriate cord bloods were obtained from each placenta, the placenta was manually extracted from the uterus teasing the membranes with the Kelly clamp, exteriorizing the uterus while it was closed. The inside of the uterus was wiped clean with a dry lap.

The uterine incision was closed in two layers, first was a running interlocking 0 chromic. Hemostasis was deemed to be adequate; therefore, the vesicouterine segment of the peritoneum was closed with 2-0 Vicryl running sutures. Irrigation of the gutters was performed to remove blood and clots. The uterus was placed back into the abdominal cavity and contracted well. The inside of the uterus was wiped clean with a dry lap. The edges of the peritoneum were grasped and then this layer was closed with 0 Vicryl running sutures. A piece of Seprafilm was placed over the lower uterine segment peritoneum. The parietal peritoneum was closed with 0 Vicryl running sutures. Rectus muscle closed with 0 Vicryl interrupted sutures.

An On-Q pain buster with double lumen was placed. The first puncture site was used to place one just above the peritoneum and below the muscle and the second puncture site was used to place an Angiocath just above the muscle, below the fascia. After the rectus muscle was reapproximated, irrigation in the area was performed. The irrigant was removed and the fascia was then closed with 0 Vicryl running suture, one from either side, hanging to the midline. Subcutaneous fat layer was closed with 3-0 Vicryl running suture and the skin was closed with staples. The On-Q pain buster was steri-stripped and dressing placed and another dry sterile gauze dressing was applied to the incision proper. The uterus was expressed of a small amount of blood. Sponge, lap, and needle counts were correct x2. The patient was then transferred to the recovery room, again with her twin girls in good condition.

Open Chrisman-Snook Procedure Medical Transcription Operative Sample Report

PREOPERATIVE DIAGNOSIS:  Right ankle chronic lateral instability.

POSTOPERATIVE DIAGNOSIS:  Right ankle chronic lateral instability.

OPERATION PERFORMED:  Open Chrisman-Snook procedure.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, DO

ANESTHESIA:  General with an endotracheal tube.

SPECIMENS: None.

ESTIMATED BLOOD LOSS: Minimal.

DRAINS: None.

COMPLICATIONS: None.

TOURNIQUET TIME:  Approximately 50 minutes.

DESCRIPTION OF OPERATION:  After being properly identified by Anesthesia, in the same day surgery suite, the patient was transported to the operative theater. The patient was then transferred to the operating table and placed in the supine position. All bony prominences were well padded. The patient received 1 gram of preoperative antibiotics. After confirming the correct surgery site, which was confirmed to be the right ankle, the patient was put to sleep using a general endotracheal tube. A thigh-high tourniquet was placed on the patient's right lower extremity. The patient's leg was then prepped and draped in the usual sterile fashion.

A marking pen was used to delineate the incision at the lateral right ankle. The area was then injected with lidocaine. An Esmarch was then used to exsanguinate the right lower extremity. The tourniquet was inflated to 300 mmHg. The incision was made. This was approximately 15 cm in length, staying just posterior to the fibula and then curving distally around the lateral malleolus. The incision was then carried down to the level of the fascia. The sural nerve was then identified and protected throughout the entire case using a vascular loop. The peroneal tendons were then identified at their anatomical landmarks. This was just distal to the lateral malleolus. A knife was then used to free up both the peroneal brevis and peroneal longus tendons from the underlying scar tissue.

At that time, the peroneus longus was identified and a #10 scalpel was used to dissect this tendon in half. The tendon stripper was then used to dissect a portion of the peroneal longus tendon. At that point, all muscle was removed from the tendon and a marking suture was then placed. Attention was paid to drilling the holes anatomically in the lateral malleolus and the calcaneus, fused and sutured. Tendon passers were used to pass the graft through these tunnels, which were created using the bur on the lateral aspect of the ankle. The tendon was then brought through these tunnels and wrapped around the remaining portion of the peroneus longus tendon with good fixation. At that point, testing showed that the ankle was tight, free of any instability. The tendon was then sutured down using 0 Vicryl sutures. The tendons were shown to be in their anatomic position and showed again that the ankle was tight.

At that time, the sural nerve was then placed back in its anatomical landmark with attention paid to the lateral ankle to suture the subcuticular layer of skin back using 3-0 Vicryl sutures. The superficial layer of skin was sutured back using a 4-0 Monocryl. This was done in a running fashion. Steri-Strips were then placed over the incision to approximate it. The wound was then dressed with Adaptic, sterile 4x4s, and sterile Webril. It should be noted that a posterior splint was then applied to the patient's right lower extremity with the ankle in neutral position. This was done using plaster of Paris, and two 4-inch Ace wraps were used to hold the splint in place, again making sure that all bony landmarks were well padded. The tourniquet was then let down and the patient was extubated. The patient was then taken to the PACU and noted to be in stable condition.

Left Heart Catheterization Ventriculogram MT Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

 PROCEDURES PERFORMED:
1.  Left heart catheterization.
2.  Left ventriculogram.
3.  Selective coronary angiography.
4.  O2 saturation monitoring.
5.  IV sedation.
6.  Percutaneous transluminal coronary angioplasty with bare-metal stent of the right coronary artery.
7.  Postintervention angiography x1.

DESCRIPTION OF PROCEDURE:  After informed consent was obtained, the patient was taken to the catheterization lab where he was sedated with IV Versed and fentanyl. O2 saturation and hemodynamics were monitored throughout the procedure. The patient was sterilized and draped in the usual manner. Access was obtained via the right femoral artery using a 6 French sheath.

Selective coronary angiography was performed using JR4, JL4, 6 French diagnostic catheters and left ventriculogram using a 6 French angled pigtail catheter. After review of the films, it was determined that there was a significant, approximately 70-80% stenosis of the mid right coronary artery, which most likely was the cause of the patient's anginal symptoms.

Angiomax was administered. We chose not to use 2b/3a. Secondary to the patient's risk of bleed due to esophageal varices, a JR4 catheter without side holes was placed in the ostium of the right coronary artery. The lesion was crossed with the BMW wire. We primarily stented the lesion with a 3.0 x 12 mm Liberte bare-metal stent to a total of 14 atmospheres.

Post-intervention angiography revealed 0% residual stenosis. The patient did have reproduction of chest pain and ST-segment elevation during deployment of the stent, which resolved post deflation of the balloon. The patient was then transferred to the holding area in stable condition.

PROCEDURE FINDINGS:
1.  Left main coronary artery:  The left main coronary artery has less than 20% atherosclerosis.
2.  Left anterior descending artery:  The left anterior descending artery has diffuse atherosclerotic disease. In the mid portion, the artery is relatively small at about 2 to 2.5 mm in diameter and there is about a 50% focal stenosis. There is a diagonal artery that comes off near this stenosis, but has about 50% ostial stenosis.
3.  Left circumflex artery:  The left circumflex artery has diffuse nonobstructive coronary artery disease
4.  Right coronary artery:  The right coronary has a focal 70-80% stenosis in the mid segment.
5.  Left ventriculogram:  The left ventricle shows uniformly normal wall motion with an ejection fraction of 50-55%.

CONCLUSIONS:
1.  Successful angioplasty of the right coronary artery with reduction of stenosis from 70-80% down to 0% after placement of a 3.0 x 12 mm Liberte bare-metal stent.
2.  Moderate stenosis of the left anterior descending artery consisting of a 50% mid left anterior descending artery and 50% ostial diagonal artery stenosis.
3.  Preserved left ventricular systolic function.

PLAN:
1.  The patient will remain in the hospital overnight for observation of potential complications.
2.  Should be loaded with Plavix 300 mg and continue 75 mg daily for one month, at which time he can discontinue Plavix.
3.  He will be treated with aspirin 81 mg daily and Toprol 25 mg daily.
4.  Due to his alcohol consumption and liver abnormalities, we will not use statin therapy and treat his hyperlipidemia with Zetia 10 mg daily.


Otolaryngology ( ENT ) Medical Transcription Operative Sample Report / Example

PREOPERATIVE DIAGNOSIS:  Recurrent respiratory papillomatosis.

POSTOPERATIVE DIAGNOSIS:  Recurrent respiratory papillomatosis

PROCEDURES PERFORMED:
1.  Direct laryngoscopy.
2.  Suspension microlaryngoscopy with shave excision of papillomas.

SURGEON:  John Doe, MD

COMPLICATIONS:  None.

SPECIMENS:  Laryngeal papilloma.

ESTIMATED BLOOD LOSS:  Approximately 100 mL.

IV FLUIDS:  Lactated Ringer's.

COMPLICATIONS:  None apparent.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operative suite and placed in a supine position. A combination of IV and inhalational agents were used to bring the patient to an adequate plane of general anesthesia while breathing spontaneously. The patient was then rotated 90 degrees in appropriate position and the airway was turned over to the otolaryngology service. At this point, a time-out was performed and verified with all operative room personnel. Next, a moist gauze was placed over the maxillary alveolus and a Dedo laryngoscope was carefully inserted. The patient was noted to have significant bulky disease of the supraglottis and glottis with complete occlusion of the glottic introitus. With further expansion anteriorly, a small opening was able to be identified. This patient was then intubated with a 5.0 uncuffed endotracheal tube. The Dedo was removed and the airway was secured.

Next, the Dedo was carefully reinserted and the patient was suspended from the Mayo stand. The shaver was then brought up onto the field and was used to begin removing the supraglottic component of the papilloma. There was a significant amount noted on the posterior glottic region, right greater than left. This was aggressively debulked. Once an opening to the glottis was identified, the ET tube was pulled out and the shaver was used to remove the obstructing portion of the papillomas. This allowed identification of the remnant right true vocal cord. There was significant involvement of the ventricle and false cords, which was taken down. There was also significant amount in the anterior commissure, which was debrided on the right side, but the left portion was left intact. This provided an adequate airway and the endotracheal tube was easily able to pass through the glottic introitus. Next, the laryngoscope was readjusted to focus on the right piriform sinus/aryepiglottic fold as well as the postcricoid region. There was noted to be significant bulky disease in this region, which was partially debrided. Significant bleeding ensued with this; therefore, Afrin pledgets were intermittently used to stop the bleeding. This was then completed and the ET tube was removed and a 0-degree Hopkins rod was used to evaluate the distal airway. Because the patient was in suspension, only the proximal trachea and subglottis were able to be visualized and there was noted to be no significant disease distal to the glottis.

Therefore, given the concern for worsening airway edema and the significant improvement in the glottic airway, it was decided to terminate the procedure. Adequate hemostasis was again verified. The patient was then intubated with a cuffed endotracheal tube and the patient was then taken out of suspension. The patient was then returned to anesthesia. Once the patient was awake and breathing spontaneously with the endotracheal tube in place, the patient was extubated in the operating room. The patient tolerated this well and was breathing spontaneously without any difficulty. Therefore, the patient was transferred to the PACU.


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Neurosurgery Medical Transcription Transcribed Operative Sample Report

PREOPERATIVE DIAGNOSES:
1. Cervical degenerative disk disease at C5-C6 and C6-C7.
2. Left-sided disk herniations at C5-C6 and C6-C7 with accompanying cervical radiculopathy.

POSTOPERATIVE DIAGNOSES:
1. Cervical degenerative disk disease at C5-C6 and C6-C7.
2. Left-sided disk herniations at C5-C6 and C6-C7 with accompanying cervical radiculopathy.

OPERATIONS PERFORMED:
1.  Decompressive anterior cervical diskectomies at C5-C6 and C6-C7.
2.  Microdissection using operating room microscope.
3.  Anterior cervical arthrodesis at C5-C6 and C6-C7.
4.  Placement of HSR cages packed with bone morphogenic protein-soaked sponges into the C5-C6 and C6-C7 interspaces.
5.  Placement of Sofamor Danek cervical spine locking plate from C5 through C7.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room, placed under general anesthesia, and then placed supine on the operating room table. The neck was placed in gentle extension to optimize cervical lordosis. The anterior cervical area was then prepped and draped in the usual sterile fashion. Using a #15 blade knife, the skin was incised in a horizontal fashion over the target interspaces. Monopolar cautery was used to dissect the platysma and blunt dissection was used to develop the avascular plane between the sternocleidomastoid and the medial strap muscles exposing the vertebral space. The longus colli muscles were elevated adjacent to the target interspaces and a self-retaining TrimLine retractor was placed. Lateral fluoroscopic imaging confirmed proper localization at the target interspaces.

A 15 blade knife was used to incise each interspace and the disk was grossly removed with pituitary forceps. The endplates were prepared for arthrodesis by removing all cartilaginous endplate material. The microscope was brought into the field and used to assist with performing a microsurgical decompression of the dorsal structures at C5-C6 and C6-C7. The posterior longitudinal ligament was opened with a micro nerve hook at both levels. There was an obvious free disk fragment at both levels on the left side, in particular at C6-C7, where there was a quite large free disk fragment. The fragments were grasped with a 2 mm punch and removed. The posterior longitudinal ligament was opened and further fragments were found and removed.

A foraminotomy on the left side was performed at both levels to adequately visualize both exiting nerve roots and confirm decompression. The wound was then irrigated with antibiotic solution. The interspaces were sized and two HSR cages of appropriate size were packed with bone morphogenic protein-soaked sponges and carefully impacted into the target interspaces. A Sofamor Danek cervical spine locking plate was then placed from C5 through C7 with screws placed at each vertebral body level. The wound was then closed in the usual fashion using a running 3-0 Vicryl suture in the platysma and a running 4-0 Monocryl in the subcuticular layer followed by Dermabond dressing. The patient was extubated in the operating room and transferred to the recovery room in stable condition. There were no complications.

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Left Heart Catheterization, Selective Coronary Cineangiography Medical Transcription Transcribed Sample Report

PROCEDURES PERFORMED:
1.  Left heart catheterization.
2.  Selective coronary cineangiography of the right and left coronary arteries.
3.  Selective angiography of the LIMA and saphenous vein graft.

DESCRIPTION OF PROCEDURE:  The patient was brought to the cardiac catheterization lab. The right femoral area was prepped and draped in the usual sterile fashion. After anesthetizing the area with 2% lidocaine, a 5 French sheath was placed in the right femoral artery using Seldinger technique. Subsequently, selective coronary cineangiography of both the left and right coronaries was performed in multiple projections. This was performed using 5 French JR4 and JL4 diagnostic catheters. Left heart catheterization was performed but no left ventriculogram was performed in an effort to conserve contrast. This was performed using the 5 French JR4. Selective injection of the saphenous vein graft was performed using the JR4 diagnostic. Attempts were made to sub-selectively engage the LIMA graft with the JR4 diagnostic catheter, but we were unable to do this. It was selectively engaged with a 5 French LIMA diagnostic catheter. The patient tolerated the procedure well and no complications were encountered. The right femoral arterial sheath was removed and hemostasis was obtained using closure pad.

RESULTS/FINDINGS OF PROCEDURE:

HEMODYNAMICS:  Left ventricular end diastolic pressure equals 10 to 12.

There was no significant gradient across the aortic valve by pullback post cineangiography.

LEFT VENTRICULOGRAM:  No left ventriculogram was performed to conserve contrast.

LEFT MAIN:  The left main had mild diffuse disease but no significant focal obstructive lesions.

LEFT ANTERIOR DESCENDING:  The LAD coursed to and wrapped partially around the apex. There was competitive flow in the distal LAD from the LIMA graft. There is diffuse disease, especially in the mid vessel of the LAD. It appeared to approach 60% at the level of the diagonal branch. The diagonal branch itself had diffuse proximal disease with an area approaching 60% in the proximal diagonal branch.

LEFT CIRCUMFLEX:  The circumflex had diffuse disease throughout. It gave rise to a small first marginal branch followed by a moderate sized second marginal branch. There were two areas of narrowing through the proximal portion of the marginal branch approaching 70 to 80% in each area. There was competitive flow from the graft distally. There was also retrograde filling of the radial T-graft through injection of the native coronary artery.

RIGHT CORONARY ARTERY:  The right coronary artery is the dominant vessel. It gives off a moderate-sized bifurcating PDA. There is diffuse disease throughout the PDA, including in each bifurcation in the distal vessel. There is an area in the mid PDA approaching 60 to 70%. The distal posterolateral branch has diffuse disease with an area in the proximal portion approaching 50%. There is competitive flow in the distal portion of the posterolateral branch. There is diffuse disease throughout the body of the right coronary artery but no focal obstructive lesions.

SVG TO THE POSTEROLATERAL BRANCH OF THE RCA:  This vein graft is widely patent. Anastomoses into a small bifurcating vessel.

LIMA TO THE LAD:  The LIMA to the distal LAD is widely patent. There is brisk competitive flow with only mild filling of the distal LAD.

RADIAL T-GRAFT TO DIAGONAL/OBTUSE MARGINAL:  There is diffuse disease throughout the entire radial T-graft. At the ostium of the radial T-graft, there is a 75 to 80% narrowing. This is diffusely diseased to the diagonal branch and the subsequent limb to the marginal branch is severely, diffusely diseased with multiple areas approaching 80%. As noted, it is diffusely diseased and of an extremely small caliber. There is actually relatively brisk competitive flow from the native vessels.

IMPRESSION:
1.  Severe multivessel native coronary artery disease as described.
2.  Widely patent vein graft to distal right coronary artery.
3.  Widely patent left internal mammary artery to the left anterior descending.
4.  Radial T-graft failure to obtuse marginal branch.
5.  Recommend medical therapy.

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Left Hip Open Reduction and Internal Fixation Medical Transcription Transcribed Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left hip intertrochanteric three-part fracture.

POSTOPERATIVE DIAGNOSIS:  Left hip intertrochanteric three-part fracture.

OPERATION:  Left hip open reduction and internal fixation.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  Regional lumbar plexus block and local.

SPECIMENS:  None.

ESTIMATED BLOOD LOSS:  200 mL.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  The patient was taken to the operative room and he received preoperative antibiotics intravenously prior to skin incision.  A lumbar plexus block was administrated by the anesthesia team prior to entrance into the operating room.  The patient was then placed on the fracture table.  The right lower extremity was well padded and abducted.  The left lower extremity was placed in traction.  The left hip three-part intertrochanteric hip fracture was reduced, verifying with fluoroscopy in the AP, lateral, and oblique planes.  

The left hip was prepped and draped in the normal sterile fashion.  A 1 inch incision was made just proximal to the greater trochanter.  Dissection was carried down to the fascia, which was incised in line with the skin incision.  The guide pin was then placed in the appropriate starting point on the greater trochanter and was passed into the proximal femur.  This was followed by the 17 mm cannulated proximal drill to make the entrance for the TFN nail.  The nail preselected was then inserted with ease into the proximal femur.  The lateral jig was then placed for the lag screw.  A small skin incision was made.  The trocar was inserted down to the lateral femur.  The guide pin was then inserted into the center of the femoral head and measured for length.  The appropriate sized lag screw was then inserted, after drilling through the lateral cortex.  Good placement was verified in the AP, lateral, and oblique planes.  At this point, the guide for distal locking screw was placed.  A small skin incision was made.  The trocar was inserted down to the lateral femur and the drill was used to drill for the distal locking screw.  The screw was measured and placed.

Again, fluoroscopic views were obtained of the construct, which showed reduction of the fracture and proper placement of the hardware in multiple views using fluoroscopy.  The wounds were then irrigated with copious irrigation solution.  The fascia proximally was closed with 2-0 Vicryl, subcutaneous tissue with 2-0 Vicryl and 3-0 Monocryl, and the skin with Dermabond.  Sterile dressing was applied.  The patient tolerated the procedure well.  Sponge and instrument counts were correct at the end of the case.

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Sleep Study / Polysomnography Medical Transcription Transcribed Sample Report

DATE OF STUDY:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

BRIEF HISTORY:  This patient is being referred for evaluation for clinical suspicion of sleep apnea.

SLEEP STATUS:  Total time in bed 389 minutes.  Total sleep time 347 minutes.  Sleep latency 17 minutes.  REM latency 226 minutes.  Sleep efficiency of 89%.

SLEEP STAGES:
1.  Stage I:  7%.
2.  Stage II:  64%.
3.  Stage III and IV:  13%.
4.  REM of 14%.

The patient did have sleep fragmentation and disruption of sleep architecture with an arousal index of 19 per hour.  Some periodic limb movements were also seen though they were mild in intensity and frequency.  Oxygen desaturations were down to lowest of 88%.  The patient had a total apnea-hypopnea index of 9 per hour, but during REM sleep, this was 17 per hour.  In the supine position, this was 15 per hour.  The patient slept 34% of the time in the supine position, 25% on the right side and 40% on the left side.

Since the events were much more pronounced in the supine position, the overall data could have underestimated the severity of this patient's sleep disordered breathing.

IMPRESSION:
1.  Overall the patient's polysomnographic data depicts mild sleep disordered breathing with apnea-hypopnea index of 9 per hour.  During REM sleep, this was 17 and during supine position 15 per hour.  Since the patient only slept 34% of the time in the supine position, the overall data could have underestimated the severity of this patient's sleep disordered breathing.
2.  Oxygen desaturation down to lowest of 88%.
3.  Sleep fragmentation and disruption of sleep architecture with the arousal index of 19 per hour.

RECOMMENDATIONS:  In light of the above findings, I would consider inviting this patient back to the sleep center to undergo a second night study with CPAP/BiPAP titration, as this patient appears rather symptomatic though the polysomnographic data is mild.  The patient will be requested to come back to sleep center for a second night's study with CPAP/BiPAP titration.

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EMG/Nerve Conduction Study Medical Transcription Transcribed Sample Report

REFERRING PHYSICIAN:  John Doe, MD

STUDY:  Bilateral lower extremity EMG/nerve conduction study.

INDICATION:  Right hip/thigh pain.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old right-handed male who complains of right thigh pain. The patient had a right total hip arthroplasty and notes inability walking on that leg secondary to pain. The patient notes that with standing, he has a lot of pain in the anterior and lateral aspect of the right thigh; it does not go down below the knee. He said that he has had fairly extensive workup including multiple x-rays and even a second opinion. There is no evident fracture or dislocation of the hardware. He does describe weakness in his right lower extremity. The patient went to physical therapy for 8 weeks and really has not gotten much better. He has no symptoms in his left lower extremity. The patient reports that in the remote past he did have a right L5-S1 herniated disk and had a discectomy. At that time, he did have some weakness in the right lower extremity. He feels that has subsequently improved. He has no upper extremity symptoms. He has had no other trauma that he can identify.

On examination, the patient has 2+ knee jerks, 1+ ankle jerks bilaterally. Motor strength in the lower extremities, knee extensors, dorsiflexors, and plantar flexors appear essentially without functional limitation. Light touch is grossly preserved. The patient identifies an area over the distal lateral right thigh, which is hyperpathic.

NERVE CONDUCTION STUDIES:

Right Lower Extremity:  Sural, sensory, and tibial motor studies are essentially within normal limits. The standard right peroneal motor study was not reliably recorded; however, with stimulation to the right tibialis anterior muscle, the study is considered normal. A right tibial F-wave was also within normal limits.

Left Lower Extremity:  The peroneal sensory study is within normal limits. The left tibial motor study is within normal limits. The left peroneal motor study also has similar findings with difficulty in picking up the peroneal study to the extensor digitorum brevis muscle (EDB). However, with pickup over the left tibialis anterior, the peroneal motor study is normal around the fibular head. Attention was placed to the left lateral femoral cutaneous nerve (LFCN). This study is considered easily obtainable and reproducible with a distal latency of 1.8 milliseconds and an amplitude of 21 microvolts (normal being less than 2.5 and greater than 4 microvolts respectively). Again, the left LFCN is well within normal limits and easily obtainable.

The right lateral femoral cutaneous nerve study is simply not recordable despite exhaustive attempts. A side-to-side comparison using the same anatomic landmarks was obtained as compared with left and the study is not recordable.

EMG of the right lower extremity including multiple femoral innervated muscles demonstrated no acute abnormalities. Mechanical insertional activity is within normal limits. There was no abnormal spontaneous activity appreciated. The right vastus medialis and rectus femoris muscles are considered normal with no evidence of active and no evidence of acute denervation/reinnervation. Interestingly, multiple right lower extremity muscles did demonstrate abnormally large amplitude motor units without active denervation. Corresponding right lower extremity paraspinal muscles are within normal limits.

IMPRESSION:
1.  Abnormal study.
2.  There is electrodiagnostic evidence suggestive of a right lateral femoral cutaneous nerve palsy. This was a technically challenging study. On the left (normal) side, it was easily obtainable. The response is absent on the right side. Of note, the patient did state that approximately 24 hours earlier, he had a block with local anesthetic. This could alter the study, but since most local anesthetics only last for several hours, this would seem less likely to be the reason for this abnormality.
3.  Most importantly, there is no electrodiagnostic evidence of a right lower extremity mononeuropathy otherwise. In particular, there is no active femoral nerve palsy, no active peroneal nerve palsy, and no evidence of tibial nerve/sciatic nerve injury. There is no evidence of a superior gluteal nerve acute injury either. Again, there is no evident active denervation and no active reinnervation in any muscles in the right lower extremity.
4.  There is electrodiagnostic evidence of a chronic inactive process, which appears to be involving the right lower extremity. In particular, the right tibialis anterior and right medial gastrocnemius muscles demonstrate abnormally large motor units suggestive of chronic reinnervation. This would seem unrelated to the patient's current symptoms.
5.  There is no electrodiagnostic evidence to suggest a peripheral polyneuropathy.
6.  There is no electrodiagnostic evidence to suggest a myopathic process.

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Electrophysiology Study, Radiofrequency Catheter Ablation, Intracardiac Mapping Medical Transcription Procedure Sample Report

PROCEDURES PERFORMED:
1.  Electrophysiology study.
2.  Radiofrequency catheter ablation.
3.  Intracardiac mapping.

INDICATION:  Atrial flutter.

FINDINGS OF ELECTROPHYSIOLOGY STUDY:
1.  Slow atrial flutter at baseline.
2.  Pacing from the IVC, tricuspid valve isthmus does demonstrate participation of the floor of the right atrium in the arrhythmia circuit.
3.  Sluggish AV conduction.

RADIOFREQUENCY CATHETER ABLATION RESULTS:
1.  Successful ablation of IVC - tricuspid valve isthmus.
2.  Isthmus conduction was slow at baseline related to previous ablation attempt and presence of flecainide.

DESCRIPTION OF PROCEDURE:  After informed consent was obtained, the patient was brought to the cardiac electrophysiology laboratory in a fasting state. The patient was prepared for the procedure by application of ECG electrodes and an automated blood pressure cuff. Pacing and fibrillation patches were applied to the chest in the anterior-posterior orientation. The right and left groin were shaved and prepared with antibacterial soap and the patient was draped in a sterile fashion. He received IV midazolam and IV fentanyl for sedation. Local anesthetic was infiltrated into the skin above the right and left femoral veins. The right and left femoral veins were cannulated with a thin-walled 18-gauge needle through which a J-tipped guidewire was passed. Two guidewires were placed in the left femoral vein and two guidewires were placed in the right femoral vein. Two 7 French introducers were advanced over the guidewires in the left femoral vein. Two 8 French introducers were advanced over the guidewires in the right femoral vein. The guidewires and dilators were removed. The introducers were aspirated and flushed carefully and placed on a continuous infusion of heparinized saline. Three standard quadripolar electrode catheters were introduced in the left femoral vein and advanced to the heart under fluoroscopic guidance. These catheters were placed in the right ventricular apex and across the tricuspid valve to record His bundle potential. Steerable decapolar electrode catheters were introduced into the left femoral vein and advanced to the heart under fluoroscopic guidance. These catheters were positioned along the posterolateral aspect of the tricuspid valve annulus. A steerable quadripolar electrode catheter was introduced into the right femoral vein and advanced to the heart under fluoroscopic guidance. This catheter was placed in the proximal coronary sinus. After the catheters were determined to be in stable position, the ablation catheter was introduced. This was a 3.5 mm irrigated tip catheter. This was initially used to perform entrainment mapping along the posterolateral aspect of the tricuspid valve annulus. Several sites were identified, most of which had returned cycle length within 15 milliseconds of the tachycardia cycle length. Mapping was then performed along the previous ablation line. Some sites were identified, which had some early activity during atrial flutter. A series of radiofrequency energy lesions were applied. The atrial flutter was observed to terminate quite promptly. The patient from the coronary sinus, however, did demonstrate some residual isthmus conduction. A series of radiofrequency energy lesions were placed, which did interrupt the isthmus conduction. Several consolidative lesions were then placed using irrigated tipped catheter technology. Programmed stimulations were performed after restoration of sinus rhythm. After 60 minutes of observation, there was still no isthmus conduction and the lesion seemed quite solid. The procedure was then considered complete. The catheters were removed. Venous introducers were removed. Firm manual pressures were applied over the venous puncture sites until adequate hemostasis was achieved. The patient tolerated the procedure well. There were no apparent complications.


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Fiberoptic Bronchoscopy and Left Lower Lobectomy Medical Transcription Transcribed Sample Report

PREOPERATIVE DIAGNOSIS:  Carcinoma, left lower lobe of lung.

POSTOPERATIVE DIAGNOSIS:  Carcinoma, left lower lobe of lung.

OPERATION PERFORMED:  Fiberoptic bronchoscopy and left lower lobectomy.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endobronchial.

ANESTHESIOLOGIST:  Bradford Doe, MD

DESCRIPTION OF OPERATION:  After percutaneous radial artery line and general endobronchial anesthesia was obtained, fiberoptic bronchoscope was passed via the endobronchial tube and all the segmental orifices visualized.  In the left lower lobe particularly, there were no endobronchial lesions or central extension of the tumor.  No deviation of the airways was noted to suggest adenopathy.  The other segmental orifices of the upper lobe and right segmental orifices were all normal.  Accurate positioning of the double endobronchial tube was also assured and then the patient was positioned in the right lateral decubitus position.

After prepping and draping, a posterolateral left thoracotomy was done sparing the serratus anterior muscle.  Partially resected fifth rib posteriorly was used for mobilization, and other than a few scattered adhesions at the apex, no adhesions were present.  The mediastinum was inspected for adenopathy and none found.  Also, the hilar nodes were also very soft and small, not suspicious for any extension centrally.  The lesion could be seen umbilicating the surface of the superior segment of the left lower lobe.  The major fissure was very poorly developed.  Initially, the perihilar structures were mobilized circumferentially around the left lower lobe and then posteriorly the left pulmonary artery identified and dissected.

An obvious branch immediately going to the superior segment was visualized and divided between 2-0 silk ligatures and 3-0 silk suture ligatures.  One could then appreciate the normal branches extending to the upper lobe and also main trunk, extending to the lower lobe proper leading us to believe the anatomy is quite usual.  The branch of the left lower lobe basal segment was divided between 2-0 silk ligature and 3-0 silk suture ligatures and then the perihilar structures dissected posteriorly and the inferior pulmonary vein circumferentially freed up.

At this point, just superior to the inferior pulmonary vein, one could appreciate another large arterial structure, surprisingly large, considering that we probably had divided the usual branches to the lower lobe already, but on tracing this back proximally, was a very large anomalous branch that passed anterior to the lower lobe bronchus or to the mediastinal aspect of the lower lobe bronchus, which was very unusual.  This was traced and followed as it entered the lower lobe, and reflecting the completely freed-up hilum, one could see that no branches were passing superiorly toward the upper lobe from this large anomalous branch.  The venous anatomy was normal in the anterior hilum, and after we suture ligated this large branch to the lower lobe basal segments, we then divided the inferior pulmonary vein between 2-0 silk ligatures and 3-0 silk suture ligatures.

Reflecting the lung further upwards, one could now see the previous branch that had been ligated to the basal segments.  Indeed, several branches were going to the lower lobe anteriorly, but also a moderate-size branch was crossing the fissure into the lingula in addition to several other lingular branches, which were seen previously near the fissure and preserved.  Since the main trunk of this vessel had already been divided, we may have devascularized the very distal most portion of the lingula, but this does not seem to be of any consequence.  The bronchus to the left lower lobe was seen dividing quite early to this superior segment and to the basal segments and we carefully freed up this to make certain there was not a bronchus crossing the fissure to the upper lobe and lingula.

At this point, there was so much tissue in the area of the fissure, one could not appreciate whether there was any ventilation from this lower lobe bronchus.  For this reason, we temporarily pinched the lower lobe bronchus major orifice and reventilated the left lung.  It appeared the entire lingula was ventilating well without delay, and therefore, we felt safe in dividing the basal segment bronchus separately from the superior segment bronchus which was done initially before ascertaining the anatomy.

At this point, we could then carefully divide the fissure with a GIA-75 stapler.  It was observed that the upper lobe bronchus was very close to the fissure and was carefully preserved as was the superior pulmonary vein, both structures of which seemed to deviate somewhat below the surface markings of the fissure.  It was possible to place it so that these structures were carefully preserved.  After stapling and dividing the fissure in this manner, the lower lobe was sent to pathology.  The bronchial resection was nowhere near the vicinity of the tumor such that we felt a very adequate resection was obtained.  A few small interlobar lymph nodes, which have been freed up during the dissection of the bronchi, were submitted separately, but they were totally innocent and tiny.  The lung was then tested for air leaks.  There was small air leak from the anterior portion of the lingula; it was sutured with fine 6-0 Prolene with good effect.

Hemostasis was checked and found adequate.  Chest was then drained with 28 French catheters, one anteriorly and one posteriorly extending up to apex.  Several side holes being added to the lower aspect of the posterior tube to provide good dependent drainage.  These were brought out through separate skin sites below the incision and sutured with #1 silk suture.  At this point, pericostal sutures of #1 Vicryl were placed passing subperiosteally around the inferior rib to avoid nerve impingement.  Once these were tied down, the left lung was expanded again with normal ventilation.  The serratus fascia was next approximated with continuous 0 Vicryl, latissimus fascia with continuous 0 Vicryl, subcutaneous with 2-0 Vicryl, and skin with 3-0 Vicryl subcuticular and Steri-Strips.  The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.

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General Surgery Medical Transcription Transcribed Operative Sample Report

PREOPERATIVE DIAGNOSIS:  Lung cancer.

POSTOPERATIVE DIAGNOSIS:  Lung cancer.

PROCEDURE PERFORMED:  Subcutaneous port central venous catheter placement via the right internal jugular vein with Site-Rite ultrasound guidance for venous access and fluoroscopic guidance for catheter placement.

SURGEON:  John Doe, MD

ANESTHESIA:  Local with MAC.

DESCRIPTION OF PROCEDURE:  After obtaining informed consent and identification of the patient, the patient was transported to the operating room where monitoring and sedation was provided by the anesthesia service.  The patient was placed supine with the head turned somewhat to the left, prepped with DuraPrep and draped exposing the right side of the neck and upper chest area.  The Site-Rite ultrasound was draped sterilely and used to image over the right side of the neck identifying the internal jugular vein with the transducer observing the vein, the skin above and adjacent to the transducer was anesthetized with local anesthetic.

An 18 gauge thin-wall needle was introduced through the skin and advanced until the vein was penetrated observing penetration with the ultrasound and noting free return of blood.  The syringe was removed from the needle and the guidewire passed without resistance.  The ultrasound was used to image over the vein and could visualize the guidewire within the vein.  Fluoroscopy was then used to image over the lower neck and chest and confirm the guidewire directed into the superior vena cava.  The guidewire was secured and then a skin marker used to outline a planned course for the catheter and pocket location over the upper chest.  Additional local anesthetic was infiltrated along the catheter course, and at the pocket location, a small incision was made adjacent to the guidewire.

Then, another incision was made at the location for the port site.  Dissection at the port site created a pocket on the pectoralis fascia for the port placement.  Next, a tunneler was used to create a tunnel from the port site up to the neck wound site and the catheter was drawn through the tunnel.  A catheter introducer was then passed over the guidewire and observed to enter the superior vena cava under fluoroscopy.  The dilator and guidewire were removed and the catheter passed through the introducer, and the introducer then split and withdrawn.  The catheter position was observed with fluoroscopy with the catheter secured and pulled to length with the tip of the catheter in the superior vena cava near the junction with the right atrium.  The loop of the catheter was secured under the skin in the neck.

Two 3-0 Prolene sutures were placed in the pectoralis fascia and brought through the securing sites on the edges of the port.  Then, the catheter was cut at the port site and connected to the port securely.  The port was then placed within the pocket and the Prolene sutures secured into the pectoralis fascia.  Then, a Huber needle was passed through the skin overlying the port into the port.  Aspiration noted free return of blood and the port was flushed with sterile saline.  Then, the entire course of catheter was observed under fluoroscopy and noted to have a smooth curve to the catheter and the tip remaining in the superior vena cava near the junction with the right atrium.

The subcutaneous tissue at both incision sites was closed with 3-0 Vicryl suture and the skin closed with subcuticular 4-0 Vicryl sutures.  Steri-Strips and dressings were applied over the wounds.  Aspiration on the port again noted free return of blood.  It was flushed again with saline followed by heparinized saline and then a dressing was placed over the needle entry site.  The patient tolerated this procedure well and was returned to the same day surgery unit in apparently good condition.


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ENT Medical Transcription Transcribed Surgical Sample Report

PREOPERATIVE DIAGNOSES:
1.  Nasal airway obstruction.
2.  Hypertrophic nasal turbinates.
3.  Nasal fracture.

POSTOPERATIVE DIAGNOSES:
1.  Nasal airway obstruction.
2.  Hypertrophic nasal turbinates.
3.  Nasal fracture.

OPERATIONS PERFORMED:
1.  Radiofrequency reduction of the bilateral infranasal turbinates.
2.  Nasal airway reconstruction.
3.  Open reduction of nasal fracture with columellar graft and dorsal grafts.

SURGEON:  John Doe, MD

ESTIMATED BLOOD LOSS:  100 mL.

COMPLICATIONS:  None.

ANESTHESIA:  General endotracheal.

OPERATIVE FINDINGS:
1.  Severely convoluted nasal septum and asymmetric nasal dorsal hump.
2.  Hypertrophic nasal turbinates.
3.  Poor tip and dorsal support.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed in the supine position.  After successful general endotracheal anesthesia was established, an oropharyngeal pack was placed.  Cocaine and 1% Xylocaine with 1:100,000 epinephrine were placed in the usual fashion for nasal surgery.  The patient was draped.  We injected 3 mL of saline into the hypertrophic left inferior turbinate and we placed 300 joules of radiofrequency energy posteriorly and 300 joules anteriorly in the contralateral hypertrophic turbinate.  We injected 3 mL of saline and placed 300 joules of radiofrequency energy posteriorly and 300 joules anteriorly.  We then made a standard left Killian incision.  The mucoperichondrium and mucoperiosteal flaps were elevated.  The quadrangular cartilage was disarticulated from the bone and septum posteriorly, and the obstructive portion of the bony septum was conservatively resected.  A thin strip of inferior quadrangular cartilage was resected.  The obstructing portion of the maxillary crest was cleared of its mucoperiosteum and then conservatively resected.  Both inferior turbinates were laterally outfractured.  These maneuvers greatly served to improve the airway.  Plain suture on the Keith needle was used circumferentially to reapproximate the mucoperichondrial flaps; two of these sutures were placed. 

With a fresh #15 blade, we made a left intercartilaginous incision.  Soft tissue was elevated off of the cartilaginous and bony dorsum, and we then incrementally lowered the asymmetric cartilaginous nasal dorsum with a #15 blade under direct vision with an Aufricht.  We then freshly sharpened osteotomes and removed the asymmetric nasal dorsal hump.  When doing this, there was minimal tip support and dorsal support was insufficient.  We then formed a precise pocket in the columella with retrograde dissection and shaped and sized a columellar graft, which was placed into the columella and sewn into place with 4-0 chromic in an interrupted fashion.  We then, with great care, requiring extra time and dissection, fashioned a dorsal graft from the cartilage.  Two pieces were sewn into place with 4-0 clear nylon, knot was buried, the edges were beveled, and this graft was placed overlying the inadequate nasal dorsum.  We then removed the graft.  Medial and lateral osteotomies were performed, serving to narrow the asymmetric nasal dorsal hump.  We then replaced the nasal dorsal graft, requiring extra time and some manipulation, the dorsal graft was placed into excellent position, providing excellent support of the nasal dorsum.  Tip support was excellent.

The incision was closed with 3-0 chromic in running and interrupted fashion.  Cosmesis was excellent.  Profile alignment was excellent.  The nasal dorsum was narrowed from its widened asymmetric preoperative position and the profile alignment was excellent.  Telfa and bacitracin were placed bilaterally intranasally.  A mustache dressing was placed externally.  A Denver splint was placed very carefully over the nose after careful taping.  The previously placed oropharyngeal pack was removed.  Estimated blood loss was 100 mL.  There were no surgical complications.

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Diagnostic Arthroscopy and ACL Reconstruction Medical Transcription Transcribed Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Anterior cruciate ligament deficient left knee, status post repair of posterolateral corner injury.

POSTOPERATIVE DIAGNOSIS:  Anterior cruciate ligament deficient left knee, status post repair of posterolateral corner injury.

OPERATIONS PERFORMED:
1.  Diagnostic arthroscopy of the left knee.
2.  Anterior cruciate ligament reconstruction with tibialis anterior allograft.
3.  EZLoc femoral fixation device and WasherLoc screw for the tibia.

SURGEON:  John Doe, MD

FIRST ASSISTANT:  Jane Doe, PA-C

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  Minimal.

DESCRIPTION OF OPERATION:  The patient was taken to the OR and general anesthesia was given by the anesthesiologist.  The patient had already been given 1 gram of intravenous Ancef.  The knee was examined under anesthesia and had full range of motion with positive Lachman, anterior drawer, and mild pivot shift.  The patient had a 1+ varus laxity but no valgus laxity.  A high thigh tourniquet cuff was placed.  The entire left lower extremity was prepped with DuraPrep.  The standard inferolateral and superomedial portals were made using prior incisions.  Arthroscope was placed.  Diagnostic arthroscopy of the knee was performed.  A probe was placed in the inferomedial portal.  The suprapatellar pouch and gutters showed no abnormalities.  No loose bodies were identified.  The patella and trochlear groove were without abnormality.  The medial joint was pristine, without evidence of meniscal tear.  The ACL had scarred down to the PCL.  There was no evidence of attachment to the lateral wall.  The lateral joint showed no abnormality. 

At this point in time, the first assistant went to the back table to prepare the tibialis anterior allograft.  I brought the table up and flexed the knee to 90 degrees.  I brought in a large size shaver, debrided the stump of the remaining portion of the ACL.  The PCL was intact.  We then brought in the Howell tibial guide and put this at approximately 65 degrees to the joint surface, drilling a K-wire up into the tibia.  A skin incision was made along the proximal anteromedial aspect of the tibia.  The guidewire entered at the knee joint anterior to the PCL and just between the tibial spines.  We had measured the tibialis anterior allograft and it fell into the 9 mm category.  We therefore drilled a 9 mm tibial tunnel, debrided the margins of the above.  I placed the impingement rod.  There was no evidence of impingement with full knee extension.  I removed a minimal portion of the medial wall of the lateral distal femur.  A roof plasty was not required.  I cleaned off the older top position. 

We used the transtibial femoral guide, placed a guidewire through the tibia from distal lateral to proximal lateral through the lateral cortex, then obtained a 9 mm reamer and reamed our femoral tunnel at the 1:30 position up through the lateral cortex of the femur.  We measured the length of the femoral tunnel and it measured 40 mm.  We then obtained the EZLoc femoral fixation device and placed the tibialis anterior allograft.  We then brought this through the tibial tunnel into the femoral tunnel, putting the pointed guide pin through the skin proximal and lateral.  We pulled the EZLoc device through the femoral tunnel, bringing the reconstructed ACL graft into the femoral tunnel.  The lever arm was lateral and came out through the tunnel into the soft tissue.  I then removed the passing wire after cutting the suture and pulled on the suture proximal and then distal to deploy the lever arm.  This caught on the lateral cortex of the femur, so I was unable to bring the EZLoc device or the reconstructed ACL back through the femoral tunnel.  Prior to this, we had drilled the counter-bore for the WasherLoc device aiming towards the fibula.  We obtained an extended spike WasherLoc and got this ready to fix the tibialis anterior allograft to the tibia. 

I cycled the reconstructed ACL with 10 flexion/extension arcs.  We put the knee into full extension, placed tension on the sutures holding the ACL graft, and then impacted the WasherLoc device pointing towards the fibula.  I then drilled through the drill guide, measuring the depth of the tibial drill hole and it measured 58 mm.  This was a very long tunnel for the tibia, therefore, I brought in the mini C-arm to confirm that this was not too long, but it did measure 58 mm, coming out just along the posterolateral cortex of the tibia.  I obtained a 58 mm screw and we had excellent bite with the above, stabilizing the reconstructed anterior cruciate ligament using our tibialis anterior allograft.  We put the arthroscope into the knee joint, confirming that the reconstructed ACL with the tibialis anterior allograft was in excellent position.  There was no Lachman or pivot shift.  We had excellent fixation both to the femoral site and the tibial site. 

Therefore, I irrigated the knee joint copiously with irrigation solution.  Multiple pictures were taken during the operative procedure.  We cut off the long portion of the graft distal to the WasherLoc device.  Multiple pictures were taken during the operative procedure.  We irrigated the wounds copiously, as noted.  The portals were closed with staples, and the subcutaneous for our tibial graft site was closed with 2-0 Vicryl followed by staples.  The skin was cleansed, followed by a dry sterile dressing, followed by a knee brace in full extension.  A femoral nerve block was performed by Anesthesia.  Tourniquet was let down at 80 minutes.  We had good capillary refill of all toes and normal dorsalis pedis and posterior tibial pulses.  The patient was reversed from anesthesia and taken to the recovery room awake and in stable condition.

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Initial Office Visit / Chart Note Medical Transcription Transcribed Sample Report

SUBJECTIVE:  This is a (XX)-year-old male with multiple past medical history including arrhythmia, which most likely is paroxysmal atrial fibrillation, currently in sinus rhythm with PVCs, status post pacemaker placement and ICD; this was subsequently revised.  History of CAD, status post CABG with two-vessel disease; status post MI x1; hypertension; hyperlipidemia; hypothyroidism; status post CVA with initial residual deficit in the right eye which has resolved; BPH; B12 deficiency; status post surgery for peptic ulcer disease, most likely with perforation; status post spinal surgery x2; status post TURP for BPH.  The patient came for initial visit complaining of vertigo/generalized dizziness for the last two weeks.  This usually is precipitated during change in position from supine to upright but without any preceding or accompanying signs or symptoms like headache or amaurosis fugax.  No presyncope or syncopal episode.  No focal deficit.  The patient denied any tinnitus, although with some aural fullness or decreased aural acuity.  The patient has seen his former PCP and was given meclizine, which relieved the symptoms, but then it caused the patient to be more lethargic and the patient decided to stop the medication.  Currently, the patient's vertigo or dizziness has markedly improved.

PAST MEDICAL/SURGICAL HISTORY:  As mentioned above.

FAMILY HISTORY:  Significant for cancer.  No other heredofamilial diseases noted.

SOCIAL HISTORY:  The patient denied recreational drugs.  He used to smoke, but quit many years ago.  Denied any heavy alcohol use.

MEDICATIONS AT HOME:  Warfarin 5 mg one-half tablet on Monday, Wednesday, Friday, and one tablet on Tuesday, Thursday, Saturday, Sunday; potassium 10 mEq two tablets once a day; lisinopril 20 mg daily; simvastatin 40 mg at bedtime; levothyroxine 0.05 mg daily; meclizine 25 mg b.i.d. p.r.n.; promethazine 25 mg one-half tablet to one tablet q.6h. p.r.n.; clindamycin as SBE prophylaxis for any procedures, especially dental procedures; Betapace 80 mg b.i.d.; betamethasone lotion 0.1% b.i.d. p.r.n.; magnesium; and zinc.

ALLERGIES:  THE PATIENT IS ALLERGIC TO PENICILLIN.

REVIEW OF SYSTEMS:  HEENT:  Unremarkable.  CENTRAL NERVOUS SYSTEM:  As mentioned, vertigo.  This was followed by generalized dizziness.  CARDIOVASCULAR:  Unremarkable.  PULMONARY:  Unremarkable.  GASTROINTESTINAL:  Nausea, but this was associated with the vertigo.  No abdominal pain.  Occasional episodes of vomiting with the nausea.  No change in bowel habits.  No melena.  No hematochezia.  No hematemesis.  Mild anorexia, but no weight change.  GENITOURINARY:  Unremarkable.  MUSCULOSKELETAL:  Unremarkable.  INTEGUMENTARY:  Unremarkable.

PHYSICAL EXAMINATION:
GENERAL:  The patient is a well-nourished, well-developed male.  Alert and oriented x3, not in acute distress, ambulatory.
VITAL SIGNS:  Temperature 98.4, blood pressure 138/92, pulse 66, respirations 22, and weight 180 pounds.  Height 5 feet 4 inches.
HEENT:  Normocephalic.  Pupils equally reactive to light and accommodation.  Anicteric.  Pink conjunctivae.  No nasal or pharyngeal congestions.  No oral lesions.  Otoscopy:  There is a mild effusion behind the right tympanic membrane, but no erythema and no discharge.
NECK:  Supple.  There is no mass.  No palpable cervical lymph nodes.  No carotid bruit.  No evidence of jugular venous distention.
LUNGS:  Clear to auscultation.
HEART:  Normal rate.  Regular rhythm.  There is no gallop.  There are premature beats intermittently.
ABDOMEN:  Soft and flabby.  Presence of bowel sounds.  Presence of abdominal scar.  There is no bruit.  No hepatojugular reflux.  Nontender.
EXTREMITIES:  Equal radial and pedal pulses.  There is about +1 pitting leg edema.  There is no cyanosis, no petechiae, no hematoma.
NEUROLOGIC:  There is no focal deficit.

ASSESSMENT AND PLAN:
1.  Vertigo/generalized dizziness, most likely this is secondary to orthostatic hypotension by history, although have to rule out any other cause, especially vertebrobasilar insufficiency.  The patient does have very high risk for arteriosclerosis.  Unlikely benign positional vertigo.  Can be secondary to labyrinthitis.  Plan is to continue with the same medication.  We will get a carotid ultrasound.  We will refer the patient to Neurology for further evaluation and management.
2.  History of pacemaker placement as well as AICD.  Continue observation.  The patient needs to be referred back to Cardiology for a pacemaker as well as defibrillator check.
3.  History of CAD, status post CABG with two-vessel disease and status post MI x1.  Continue with the same management and risk modification factors.
4.  History of arrhythmias, most likely secondary to paroxysmal atrial fibrillation, currently in sinus rhythm.  Continue with the same medications, especially with Betapace.  The patient will need cardiology followup as well.
5.  History of hyperlipidemia.  Continue with the same treatment and diet.  Need to recheck the lipid profile and LFTs.
6.  Hypertension, currently fairly controlled.  Continue with the same treatment and diet.  Recheck the blood pressure on the next followup.
7.  Hypothyroidism.  Continue with the same treatment.  Need to recheck the TSH level.
8.  History of CVA with no residual deficit.  Continue with the same management and risk modification factors.
9.  History of B12 deficiency.  Need to check B12 level and folic acid level.  We will continue with the B12 shot monthly.
10.  History of BPH, status post TURP.
11.  History of peptic ulcer disease, status post surgery, currently resolved.  We will just observe.
12.  Health maintenance screening, which would include a PSA level.  We will get the result of both the upper endoscopy and the colonoscopy per GI, which was done not too long ago.  The patient will also be advised about pneumonia vaccine at the next followup.
13.  The patient will be advised to follow up in about a month.

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