Colonoscopy and Polypectomy Medical Transcription Operative Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Screening examination.

POSTOPERATIVE DIAGNOSIS:  Multiple colonic polyps.

OPERATION PERFORMED:  Total colonoscopy and multiple polypectomies including snare polypectomy.

ENDOSCOPIST:  John Doe, MD

ANESTHESIA:  IV fentanyl, Versed and Phenergan in incremental doses.

DESCRIPTION OF PROCEDURE:  Digital examination and inspection was normal.  The Olympus colonoscope was introduced into the rectum.  The scope was advanced without difficulty to the cecum.  The appendiceal orifice was identified.  There was stool inspissated within the appendiceal orifice.  Attempts were made to wash the stool out; this was unsuccessful.  The scope was gradually withdrawn.  In the proximal ascending colon, 3 polyps were noted, 2 were pedunculated, each removed using snare cautery.  They were retrieved and sent for histopathologic analysis.  The scope was reintroduced to this point.  Hemostasis was good.  There was a 4 mm sessile polyp, which was removed in multiple pieces and multiple passes using the cold biopsy forceps technique.  The scope continued to be withdrawn.

In the distal transverse colon, there were 5 colon polyps; 3 were removed using snare and cautery.  They were retrieved and sent for histopathologic analysis.  A 6 mm sessile polyp was removed using a hot biopsy forceps technique and a 4 mm sessile polyp was removed using the cold biopsy forceps technique.  The scope continued to be withdrawn.  At 70 cm from the anal verge, in what appeared to be the hepatic flexure, near the splenic flexure, 3 polyps ranging in size from 8 mm to 6 mm were removed by snare and cautery and retrieved and sent for histopathologic analysis.  At 50 cm from the anal verge, there were 4 colon polyps ranging in size from 1 cm to 3 mm in diameter.

Snare polypectomy was performed, and a cold biopsy forceps polypectomy was performed.  The tissue was retrieved and sent for histopathologic analysis.  Good hemostasis was observed after all cautery.  Toward the end of the procedure, it was noted that the patient had some diminutive polyps in the rectum; however, he was becoming restless and combative, although he was well sedated until this point.  It was felt that it was not prudent to proceed with removing these polyps at this moment.  It was felt, given the multiplicity of polyps and the multiple polypectomies, that this patient will require an early followup colonoscopy to make sure that all more proximal polyps are removed and, at that time, the diminutive rectal polyps could be removed.  The patient was brought to the recovery area in good condition.

PLAN:  Check biopsy results.  Assuming there is no unusual dysplasia, I will repeat the colonoscopy on this patient in 3 months to make sure all polyps are removed.  Then, longer intervals between colonoscopies will be recommended.

Colonoscopy to Ileotransverse Anastomosis Medical Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  High-risk colon polyp surveillance status post right hemicolectomy with ileotransverse anastomosis for large tubulovillous adenoma of the transverse colon.
2.  History of small bowel carcinoid tumor.

POSTOPERATIVE DIAGNOSES:
1.  Small benign polyps and superficial, possibly ischemic, ulcers of the side-to-side ileotransverse colon anastomosis.
2.  Tiny benign rectosigmoid colon polyps.
3.  Moderate sigmoid colon diverticulosis with no acute diverticulitis.

PROCEDURES PERFORMED:
1.  Colonoscopy to ileotransverse anastomosis and into the distal ileum.
2.  Hot and cold biopsies of the ileotransverse anastomosis.
3.  Hot forceps polypectomy, rectosigmoid colon.

ENDOSCOPIST:  John Doe, MD

PREP:  Fleet Phospho-soda, with excellent prep and visualization entire extent of examination.

FINDINGS:
1.  Intact side-to-side ileotransverse colon anastomosis with postsurgical changes and a couple of small 2 to 3 mm hyperplastic-appearing polyps and a couple of small, less than 5 cm superficial ulcerations with white exudate base in the anastomosis blind pouch areas.  There was wide patency of the anastomosis ileal and colonic openings and lumen.
2.  Normal distal ileal mucosa.
3.  Moderate number of small as well as occasional large-mouth diverticula localized at the sigmoid colon with no acute diverticulitis.
4.  Two tiny 2 to 3 mm benign-appearing sessile proximal rectal and rectosigmoid area hyperplastic-appearing polyps removed with hot biopsy forceps.
5.  Normal colonic vascularity with no evidence of arteriovenous malformations.

ANESTHESIA:  Demerol 100 mg and Versed 10 mg, both slow IV push, titrated.

DESCRIPTION OF PROCEDURE:  After obtaining informed consent, the patient was placed on the left side and subsequently sedated with IV Demerol and Versed, titrated.  The external perineal area was inspected and appeared normal.  Digital rectal examination revealed no evidence of tenderness, masses or strictures.  The finger was used as a guide to insert the Olympus video colonoscope through the anus into rectum.  A small amount of air was insufflated to distend the lumen.  The scope was then easily advanced proximally using the push/pull technique all the way to the level of the transverse colon, where there was noted to be a side-to-side ileal Billroth II-appearing saddle-type anastomosis of the ileum and transverse colon that was widely patent.  The scope was advanced into the ileum proximal to the anastomosis and this was inspected and appeared normal.  The scope was then withdrawn back to the anastomosis where there were postsurgical changes with a couple of ischemic-appearing ulcerations that were small and shallow along with a couple of small hyperplastic and inflammatory polyps.  Cold biopsies were obtained of the ulcerated areas and hot biopsy forceps were used to remove a couple of these small polyps with an Endostat II power source with monopolar coagulation, current setting of 20.  Another couple of tiny polyps were also removed with hot biopsy forceps and the same current power setting from the rectosigmoid colon region.  No other biopsies were taken.  Prior to withdrawal of the scope from the patient, air was removed from the colon with the patient tolerating the procedure well with no evidence of immediate complication.  He was transferred to the recovery area in stable condition.

IMPRESSION:
1.  Some postsurgical mucosal changes seen in the area of the side-to-side ileotransverse colon anastomosis with some ischemic-appearing ulcerations.  There was no evidence of gross neoplastic changes involving the mucosa.
2.  The rectosigmoid polyps are also more likely to be hyperplastic.
3.  Moderate sigmoid colon diverticulosis.

RECOMMENDATIONS:
1.  High-fiber diet with avoidance of nuts, seeds and popcorn.
2.  Carcinoid screening workup to include a 24-hour urine collection for 5-HIAA, upper endoscopy down into the duodenum, barium small bowel follow-through x-ray examination, and nuclear medicine octreotide scan.
3.  Repeat colonoscopy in 3 years for colon polyp surveillance.

Orthopedic - Arthroscopy and Meniscectomy Medical Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Right knee lateral meniscus tear.

POSTOPERATIVE DIAGNOSES:
1.  Right knee lateral meniscus tear.
2.  Loose body.
3.  Lateral femoral condyle chondral lesion.

OPERATION PERFORMED:  Right knee diagnostic and operative arthroscopy with arthroscopic partial lateral meniscectomy, arthroscopic loose body removal and arthroscopic lateral femoral condyle microfracture.

SURGEON:  John Doe, MD

ANESTHESIA: General and local.

ESTIMATED BLOOD LOSS:  Minimal.

TOURNIQUET TIME:  None.

COMPLICATIONS:  None apparent.

DESCRIPTION OF OPERATION:  After the establishment of a general anesthetic, IV antibiotics were given.  The patient was positioned supine.  The right lower extremity was prepped and draped in the normal sterile fashion.  Using blunt trocars, superolateral and inferolateral portals were created.  A medial portal was created under direct vision to protect the medial meniscus.  Systemic evaluation of the knee was performed.  The suprapatellar pouch had no significant loose bodies or arthrofibrosis.  There was significant arthrofibrosis on the infrapatellar fat pad region and the medial and lateral gutters, which was debrided back to a stable base, freeing up the patellofemoral joint.  There was no significant further impingement on the medial and lateral condyles.  There were grade 2 changes on the undersurface of the patella diffusely, as well as in the trochlea, especially at 30-60 degrees of range of motion.

There were no grade 3 to 4 changes in this region.  The medial femoral condyle had minimal grade 1 to 2 changes at medial tibial plateau, but no formal grade 3 to 4 changes were noted.  The medial meniscus was stable per palpation without evidence of tear.  The PCL was intact.  The ACL had some looseness.  Did have a firm endpoint with anterior drawer.  Importantly, though, there was a large loose body anterior to the ACL, impinging into the notch, which was minimally scarred down to the ACL, impinging the notch with flexion, extension.  This was removed with a basket after the medial portal was enlarged carefully and noted to be approximately 1 cm in length.  Pictures were taken before and after this and anterior drawer was performed.  There was a firm endpoint approximately 4-5 mm and stable per palpation.

Upon entrance of the lateral joint line, there was an anterolateral meniscus tear, which was gently debrided back to a stable base.  There was significant synovial hypertrophy in this region over the lateral femoral condyle, which was gently debrided.  The remaining portion of the anterior mid body was intact.  There was a posterior horn lateral meniscus tear with instability, which was gently debrided back with a combination of baskets and shaver.  Care was taken to protect the articulated surfaces.  The lateral femoral condyle had demyelinating articular cartilage.  This was down to bone and grade 4 in nature.  There was delaminating cartilage around this.  All loose cartilage was removed.  The anterior weightbearing portion was inspected.  Pictures were taken and followed by microfracture technique in approximately 3 mm increments.  A microfracture awl was used to penetrate some chondral bone.  Bleeding was achieved after the pump was turned off.  Pictures were taken.  The scope was removed.  The knee was evacuated.  The portals were closed with buried sutures, followed by Steri-Strips and the insertion in the portals and in the knee of 0.5% Marcaine with epinephrine for a total of approximately 25 mL.  No apparent complications.

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Hand Surgery Medical Transcription Transcribed Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Right small finger flexor tendon contracture.
2.  Proximal interphalangeal joint contracture.
3.  Distal interphalangeal joint contracture.

POSTOPERATIVE DIAGNOSES:
1.  Right small finger flexor tendon contracture and adhesions.
2.  Proximal interphalangeal joint contracture.
3.  Distal interphalangeal joint contracture.
4.  Flexor tendon rupture.

OPERATIONS PERFORMED:  
1.  Right small finger flexor tendon tenolysis.
2.  Proximal interphalangeal joint capsulectomy and complete joint release.
3.  Distal interphalangeal joint capsulectomy and complete joint release.
4.  Flexor tendon repair to the distal phalanx.

SURGEON:  John Doe, MD

ANESTHESIA:  General anesthesia.

ANESTHESIOLOGIST:  Jane Doe, MD

FLUIDS:  600 mL of lactated Ringer's.

ESTIMATED BLOOD LOSS:  Minimal.

TOURNIQUET TIME:  86 minutes.

DESCRIPTION OF OPERATION:  Following informed consent, administration of IV antibiotics and site marking of the right small finger and forearm of the right arm, the patient was taken to the operating room and placed supine on the operating table. Following site verification and time-out of the right small finger, the hand, and forearm, the patient was placed under general anesthesia and the right arm was placed on the hand table. The operating table was turned 90 degrees and a nonsterile tourniquet was placed in the proximal right arm and the right arm and hand were sterilely prepped and draped in the usual fashion. The right arm was wrapped in Esmarch and tourniquet was inflated and left inflated a total of 86 minutes. Following inflation of the tourniquet, a Brunner incision extending from the mild pulp of the distal aspect of the right small finger and extending down the length of the finger down into the palm proximal to the A1 pulley Brunner incisions, zig-zag type incision was made. A sharp dissection was carried through skin and dense scar to the flexor tendon. The A3 pulley that was really just a scar tissue was elevated off of the flexor tendon. The neurovascular bundles, both radial and ulnarly, were left undisturbed during the procedure. The A3 pulley was opened. The flexor tendon was observed. The flexor digitorum superficialis tendon was noted to not be intact. The patient had a single flexor digitorum profundus tendon to the right small finger. There was noted to be sutures distal to the A4 pulley, where the tendon repair had been repaired to a very small stump at the distal attachments of the flexor digitorum profundus tendon at the base of the distal phalanx. Again, the A3 pulley was opened. The A2 and A4 pulleys were left intact. The A4 pulley was very small, but it was intact. The A2 pulley was intact. The A1 pulley was intact as well. The flexor digitorum superficialis tendon was retracted from the proximal interphalangeal joint.

Using the Beaver blade, a capsulectomy of the volar aspect of the proximal interphalangeal joint releasing the collateral ligaments was performed as well as the volar plate and the proximal interphalangeal joint could be extended to full extension. Attention was then turned to the distal interphalangeal joint. Again, the flexor tendon was retracted. A capsulectomy and complete collateral ligament release of the distal interphalangeal joint was performed in a complete extension, to 0 degrees of the distal interphalangeal joint was possible. The joints appeared to be normal with normal articular cartilage. The skin and subcutaneous tissues were dissected free from the tendon proximal to the A1 pulley. The tendon was noted to be intact. Using a Freer, adhesions were broken up surrounding the flexor digitorum profundus tendon through the A1 and A2 pulleys. In the process of doing that, the distal attachment repair site of the flexor digitorum profundus tendon completely ruptured. The flexor tendon was completely released from adhesions down into the mid palm through the pulley system in the finger, and it was noted to have full free movement of the flexor digitorum profundus tendon with complete release of all adhesions through the pulley system, as well as to the bone and surrounding soft tissue.

The distal flexor tendon was then repaired to the base of the distal phalanx. The prior sutures were removed. The micro-Mitek suture anchor was drilled into the base of the distal phalanx and the suture was used to reapproximate the flexor digitorum profundus tendon to the base of the distal phalanx with an intact A4 pulley. The #4 Ethibond sutures were used to secure the distal tendon to the surrounding tissue, and then, using two Keith needles, these were drilled through the distal phalanx exiting through the proximal aspect of the nail dorsally and 3-0 Prolene suture in a Bunnell-type suture pattern was sutured to the distal flexor digitorum profundus tendon, passed through the Keith needles through a button on the dorsum of the nail of the right small finger and tied in place to further secure the attachment of the flexor digitorum profundus tendon to the distal phalanx. The flexor digitorum profundus tendon was noted to be intact and held in its position. The right small finger could be fully extended. The metacarpophalangeal and proximal interphalangeal joints and distal interphalangeal joint could be extended to approximately flexion of about 30 degrees before tension on the flexor digitorum profundus tendon was noted. The finger could be completely flexed by pulling on the tendon proximal to the A1 pulley down into a fully flexed position touching the palm with the tip of the small finger.

The tourniquet was deflated at 86 minutes. Hemostasis was achieved. The distal finger had capillary refill less than 2 seconds. The wound was copiously irrigated and the skin was closed with interrupted 5-0 nylon sutures. A sterile soft dressing and a dorsal hood splint with the right small finger, the wrist flexed approximately 20 degrees, metacarpophalangeal joint flexed approximately 20 to 30 degrees, the proximal interphalangeal joint flexed about 20 degrees and the distal interphalangeal joint flexed about 45 degrees, was placed. The patient was extubated in the operating room and taken to the recovery room in stable condition.

Total Knee Arthroplasty Medical Transcription Operative Sample Report

PREOPERATIVE DIAGNOSIS:  Left knee degenerative joint disease.

POSTOPERATIVE DIAGNOSIS:  Left knee degenerative joint disease.

OPERATION PERFORMED:  Left total knee arthroplasty.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  50 mL.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  Once consent was obtained, the patient was given preoperative antibiotics based on his allergy profile and then he was brought to the operative theater by the anesthesia team and anesthetized in the usual fashion. A well-padded tourniquet was placed on the left proximal thigh and then the left lower extremity was prepped and draped in sterile fashion. After Esmarch exsanguination, the tourniquet was inflated and a midline incision was made followed by a medial parapatellar incision and eversion of the patella. Visualization of the distal femur with distal femoral intramedullary guide placed in the appropriate position and then a 5 degree valgus cut was made on the distal femur, resecting 9.5 mm of bone. This was followed by sizing the femur, which was a size 6, and placement of the size 6 distal femoral cutting guide and then the anterior-posterior cuts were made followed by the chamfer cuts.

Once this was completed, the size 6 distal femoral trial was inserted with excellent fit. The posterior cruciate ligament retractor was inserted. The proximal tibia was retracted. The patient's patellar tendon was intact. Once the proximal tibia was exposed, extramedullary proximal tibial guide was placed and 9 mm was taken off the lateral side on this varus osteoarthritic patient. Once this was done, a size 4 tray was pinned into place. A drop rod was placed down the front of the tibial tray and found to go right down the tibia, indicating no varus-valgus malalignment. The tibial tray was found to be in good position. A 9 mm trial insert was placed and the knee was reduced. There was full extension, greater than 120 degrees of flexion, with no excess varus-valgus or anterior-posterior instability.

Once this was completed, the patella was resurfaced using the appropriate patellar resurfacing guides and then the patellar surface was peg drilled and a 38 mm tri-peg patellar component was inserted and reduced into the trochlea. The knee was brought through a full range of motion. There was no instability of the patella. There was slight lateral patellar tracking. A lateral release was performed. All components were then removed. The proximal tibia was punched. All bony surfaces were copiously irrigated with normal saline, pulsatile lavage and then dried. Then, the tibial component was cemented into place followed by cementation of the patellar component and finally cementation of the Oxinium distal femoral component polyethylene 9 mm insert, was placed, and the cement was allowed to dry. Once the cement was dry, the knee was brought through full range of motion. There was no instability. There was full range of motion and excellent patellofemoral tracking. The excess cement had been removed prior to drying. The components and soft tissue were copiously irrigated with normal saline and the medial parapatellar incision was closed with Ethibond interrupted figure-of-eight sutures.

The Hemovac drain was inserted prior to closure for postoperative swelling control. The subcutaneous layer was closed with Vicryl in interrupted inverted mattress sutures and the skin was approximated with staples. The wound was cleansed and dressed using Adaptic, 4 x 4s, ABD, Webril, Polar Care pack and Ace bandage followed by a knee immobilizer. The tourniquet was deflated prior to dressing placement. There was no excessive bleeding. Toes were pink and warm with excellent capillary refill and pulses.  The patient was awakened by the anesthesia team, extubated, and moved to the postanesthesia care unit in stable condition. There were no complications.

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Austin Bunionectomy Medical Transcription Transcribed Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Hallux abductovalgus deformity, left first metatarsal.

POSTOPERATIVE DIAGNOSIS:  Hallux abductovalgus deformity, left first metatarsal.

OPERATION PERFORMED:  Austin bunionectomy with internal fixation, left first metatarsal.

SURGEON:  John Doe, D.P.M.

HEMOSTASIS:  Pneumatic ankle tourniquet set at 250 mmHg.

ANESTHESIA:  MAC with local.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS: None.

PROPHYLAXIS: Ancef 1 gram 30 minutes prior to incision.

DESCRIPTION OF OPERATION:  The patient was placed on the operating room table in the supine position. Following adequate sedation, a Mayo block was performed utilizing 10 mL of 0.5% Marcaine plain around the first metatarsal. The pneumatic ankle tourniquet was then placed around a well-padded left ankle. The left lower extremity was then scrubbed, prepped, and draped in the usual sterile fashion. Attention was directed to the left and an Esmarch was then utilized for exsanguination. The pneumatic ankle tourniquet was then inflated on the left lower extremity to 250 mmHg. A 6 cm linear longitudinal incision was then made medial and parallel to the extensor hallucis longus involved with the contour deformity. The incision was then deepened through the subcutaneous tissues using sharp and blunt dissection. Care was taken to identify and retract all vital neurovascular structures. All bleeders were electrocauterized as necessary.

At this time, a linear capsulotomy was then performed over the dorsal aspect of the first metatarsophalangeal joint. The periosteal and capsular structures were then carefully dissected free of their osseous attachments and reflected medial and laterally exposing the head of the first metatarsal at the operative site. A sagittal bone saw was then utilized to resect all noted medial prominence. Attention was then directed to the first interspace by the original skin incision, where the extensor hallucis longus was observed and retracted out of the way, exposing the extensor hallucis brevis, which was identified and retracted out of the way. Dissection was then continued deep using blunt dissection down to the level of the fibular sesamoid, which was freed from its soft tissue attachments proximally, laterally, and distally. The conjoined tendon of the abductor hallucis muscle was then identified and resected at its attachment to the base of the proximal phalanx at the hallux. At this time, the level of the contracture present on the hallux was noted to be reduced and the sesamoid apparatus was noted to flow in a normal corrected position.

At this time, attention was directed to the medial aspect of the first metatarsal head at which time a 0.45 inch K-wire was then driven from the medial to lateral in a perpendicular fashion across the head of the first metatarsal, being perpendicular to the line of the second metatarsal with no dorsiflexion or plantarflexion noted. At this time, a V-type osteotomy was created in the metaphyseal region of the bone utilizing a sagittal bone saw. After this was created and placement of the guidewire, the apex of the deformity was pointed distally and the arms were approximated plantarly and proximal, dorsally. Upon completion of the osteotomy, the capital fragment was distracted and shifted laterally into a more corrected position impacted on the first metatarsal shaft. At this time, a 0.45 inch K-wire from the DePuy screw set was then driven from dorsal to plantar across the osteotomy site to serve as temporary fixation.

Following standard AO technique procedures, one 20 x 2.7 mm FRS DePuy bone screw was then inserted and placed across the osteotomy site with excellent compression noted. At this time, the K-wire was then removed and attention was then directed to the medial bone shelf, which was resected utilizing a sagittal saw and passed from the operative site. A power rasp was then utilized to smooth all bony prominences. Correction of the deformity was then reassessed at this time, both clinically and utilizing intraoperative fluoroscopy, and the position of the screw and correction of the deformity was noted to be excellent. The wound was then flushed with copious amounts of sterile normal saline and a medial capsulorrhaphy was then performed. The capsule and the periosteal structures were then reapproximated utilizing 4-0 Vicryl. The subcutaneous layer was then reapproximated utilizing 4-0 Vicryl and the skin was closed in a subcuticular stitch fashion using 4-0 Monocryl. Benzoin and Steri-Strips were then applied.

Upon completion of the procedure, the incisions were then dressed with dilute Betadine-soaked Adaptic covered with dilute Betadine-soaked gauze, Kling, Kerlix and Coban. The pneumatic ankle tourniquet on the left ankle was then rapidly deflated with a prompt hyperemic response noted to all digits of the left foot. A DonJoy ice dressing was then incorporated into the wound dressing, after initial dry sterile dressings. The patient tolerated the procedure and anesthesia well and was transferred to the recovery room in satisfactory condition with vital signs stable and vascular status intact to all digits bilaterally.

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