Esophageal Motility / Esophageal Manometry and Bravo PH Study Medical Transcription Sample / Example Report

DATE OF PROCEDURE:  MM/DD/YYYY

PROCEDURE PERFORMED:  Esophageal motility.

PHYSICIAN:  John Doe, MD

INDICATION:  The patient is being evaluated for dysphagia. 

PROCEDURE AND FINDINGS:
1.  Lower esophageal sphincter:  Using the Medtronics esophageal manometry recording system, multiple circumferential measurements were taken of the patient's lower sphincter. The highest pressure obtained was a slightly elevated value at 37 mmHg. Relaxation during swallowing was definitely abnormal. Several swallows showed no relaxation at all, and in fact, there appeared to be a paradoxical increase in the lower sphincter pressure with swallowing. Most other contractions showed a brief, short duration relaxation towards the gastric baseline with the average relaxation duration being 6.5 seconds. The normal value is 11-12 seconds. Most significantly, there was an increased residual pressure with swallows where relaxation was present, with an average of 11.8 mmHg. The normal value is less than 8 mmHg. This patient's sphincter was 2.5 cm, of which 1.5 cm was intrathoracic. It was noted that the intraesophageal pressure was less than gastric pressure, which is the normal situation, and which is not typical of achalasia. 
2.  Esophageal contractions:  The contractions in this patient were abnormal, but not uniform. Frequent simultaneous contractions were definitely seen, but other contractions were undefined. With these contractions, there was the initial contraction in the proximal channel, and then shortly afterward, simultaneous contraction of the second and third channels. No normal peristalsis was seen during this examination. The average distal amplitude was approximately 50 mmHg, which is borderline normal.
3.  Upper esophageal sphincter:  A circumferential measurement of the upper sphincter was normal at 32.2 mmHg. There was normal relaxation to the esophageal baseline following a swallow and normal coordination of this sphincter with the pharynx during a swallow.

CONCLUSIONS:  The lower sphincter study in this patient is very typical of achalasia, but the body study is less so. Given all the findings, I suspect that this represents some variant of achalasia.

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DATE OF PROCEDURE:  MM/DD/YYYY

PROCEDURE PERFORMED:  A 48-hour Bravo pH study.

PHYSICIAN:  John Doe, MD

INDICATION:  The patient is being evaluated for acid reflux disease.

PROCEDURE AND FINDINGS:
1.  Reflux studies:  During the 2 days of this study, day #2 was the most significant with regard to the patient’s reflux. During the 22 hours and 45 minutes of this period, the patient experienced 54 episodes of reflux. This was slightly above the normal value of less than 46.8 reflux events. The reflux time in the supine position was elevated at 6.3%. The normal reflux time supine is less than 3.5%. The reflux time in the upright position was normal at 7.2%. For the total study, the reflux time was elevated at 6.9%. The normal value is less than 4.5%. There were a normal number of long reflux events at 3. However, the duration of the longest event was elevated at 30 minutes. Normally, the longest reflux event should not exceed 19.8 minutes.
2.  Symptom index:  Symptom index was calculated using the SAP table for the total procedure. For the complaint of heartburn, this occurred at the 99th percentile with respect to reflux giving a positive result. The complaint of regurgitation occurred at the 99.9th percentile giving also a positive result. The complaint of chest pain occurred at the 100th percentile giving a positive result. 

CONCLUSIONS:
1.  Positive reflux study.
2.  Positive symptoms index for heartburn, regurgitation and chest pain.

Bilateral Lower Eyelid Blepharoplasty Medical Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Aesthetic deformity of face.

POSTOPERATIVE DIAGNOSIS:  Aesthetic deformity of face.

OPERATIONS PERFORMED:
1.  Bilateral lower eyelid blepharoplasty.
2.  Open rhinoplasty.
3.  Fat transfer to bilateral nasolabial folds.

SURGEON:  John Doe, MD

ANESTHESIA:  General with endotracheal tube.

ESTIMATED BLOOD LOSS:  80 mL.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  After informed consent was obtained, the patient was marked in the upright position and was given intravenous antibiotics. The patient was subsequently taken to the operating room and placed in the supine position. Bilateral sequential compression boots were applied and the patient was placed under general anesthesia without difficulty. The face and central lower abdomen were then prepped and draped in the usual sterile manner.

We first performed the bilateral lower eyelid blepharoplasty. The bilateral lower eyelids were infiltrated with 1% lidocaine with epinephrine. We first worked on the right side. A subciliary incision was made with a #15 blade. Bleeding points were controlled with cautery. A skin-muscle flap was then raised to the level of the inferior orbital rim. The orbital septum was identified. Three small incisions were made in the medial, central and lateral aspects of the septum. The herniating fat pads from all three compartments were then removed with cautery without difficulty. Care was taken to avoid over-resection of these compartments. The skin-muscle flap was then redraped. Inferior traction was placed on the cheek and superior traction was placed on the eyebrow. A 2 mm wide aspect of the skin-muscle flap was then excised without difficulty.

We then moved to the left side. The mirror image subciliary incision was made with a #15 blade. Bleeding points were controlled with cautery. The skin-muscle flap was then developed to the level of the inferior orbital rim. The orbital septum was visualized and small incisions were made in the medial, central and lateral aspects of the septum. The fat pads were isolated in these areas and a similar excision was performed with cautery. Care was taken to avoid over-resection of these areas. After meticulous hemostasis had been achieved, the skin-muscle flap was redraped. Inferior traction was placed on the cheek and superior traction was placed on the eyebrow. A 2 mm strip of the skin-muscle was excised without difficulty. Both eyelid incisions were then closed with interrupted deep 5-0 Vicryl suture for the muscle followed by a running intradermal 6-0 Prolene suture for the skin. Steri-Strips were used to affix the edges of the suture.

We then performed fat harvesting from the central lower abdomen. A 4 mm incision was made in the central pubic area. Tumescent solution containing 30 mL of 1% lidocaine and 1 ampule of epinephrine/liter of normal saline was utilized. A total of 300 mL was infiltrated into the central lower abdominal subcutaneous tissue. After approximately 10 minutes, syringe-assisted liposuction was performed in this area. Approximately, 100 mL of aspirate was removed. The aspirate was then placed into separate 10 mL syringes and was centrifuged for about 24 minutes. The abdominal incision was closed in one layer with interrupted 5-0 Prolene suture and sterile gauze dressing, and Tegaderm was then applied.

We then performed the open rhinoplasty. The nose was infiltrated with 20 mL of 1% lidocaine with epinephrine and the mucosal membranes were packed with 5% cocaine to facilitate vasoconstriction. A #15 blade was then used to make bilateral intercartilaginous incisions. These incisions were then connected with a transcolumellar incision performed in a stair-step manner. Low cautery was used to control bleeding points. The skin and soft tissue envelope was then elevated off the underlying lower lateral cartilages bilaterally with iris scissors. The skin envelope was also elevated off the upper lateral cartilages and off the nasal bone as well. Hemostasis was then achieved.

We first worked on the lower lateral cartilages. These cartilages were quite prominent and therefore cephalic trim was planned. The caudal 6 mm of cartilage was preserved bilaterally. The remaining portion was dissected off the posterior mucosal membranes and was then excised with sharp iris scissors. At this point in time, we performed bilateral nasal bone osteotomies to shift the nasal pyramid inward to decrease the nasal width. These osteotomies were performed intranasally with 2 mm osteotomes in a low-to-low manner. The osteotomies were performed without difficulty and the bones were shifted inward without difficulty. At this point, the tip complex was re-analyzed and was found to have a deviation towards the patient's right. Therefore, we planned to harvest septal cartilage to create a columellar strut. The lower lateral cartilages were retracted caudally and laterally. The anterior septal angle was exposed and bilateral mucoperichondrial flaps were elevated.

The entire septum was exposed and the submucous cartilage resection was performed. An L-strut was preserved which was 1 cm wide throughout. The remaining septum was excised sharply with a #15 blade and a swivel knife. The cartilage was then harvested and then cut to create a columellar strut graft measuring 3 x 25 mm. This strut graft was then placed in a soft tissue pocket between the medial crura of the lower lateral cartilages. The medial crura were then sutured with clear 4-0 PDS suture to the strut graft. At this point, the patient's dorsal hump was reduced with a combination of dorsal rasping and direct excision. The dorsal hump was taken down about 4 mm to create a nice dorsal profile to the nose. Finally, the middle crura were plicated to one another to narrow the tip further and to auto-rotate the tip upwards to about 2 mm.

The skin and soft tissues were then redraped over the nasal framework and all edema was squeezed out of the nose. It was found to have a good contour at this time. All internal incisions were closed with interrupted 5-0 chromic sutures. The transcolumellar portion of the incision was then closed with interrupted 6-0 Prolene suture. Internal nasal packings were placed bilaterally, which consisted of Adaptic coated in bacitracin ointment. An external Denver splint was also applied.

We then injected approximately 10 mL of fat into the nasolabial folds bilaterally. The initial labial folds were diminished in prominence after this was performed. The patient tolerated the procedure very well, was extubated without complication and transferred to the recovery area in good condition. The patient will go home today with prescriptions for both antibiotics and pain medications. The patient will then follow up with me in the office again tomorrow for evaluation and internal packing removal.

Plastic Surgery Operative Sample Reports   Plastic Surgery Operative Samples #2

Laparoscopic Inguinal Hernia Repair Medical Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY 

PREOPERATIVE DIAGNOSIS:  Bilateral inguinal hernia.

POSTOPERATIVE DIAGNOSIS:  Bilateral inguinal hernia, direct.

OPERATION PERFORMED:  Laparoscopic bilateral inguinal hernia repair.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  Minimal.

DESCRIPTION OF OPERATION:  With the patient under general endotracheal anesthesia, the abdomen was prepped with ChloraPrep solution and draped in the usual manner. A transverse skin incision was made below and to the right of the umbilicus to a length of approximately 4 cm. The incision was carried through the subcutaneous tissue. Bleeders were cauterized. The right rectus sheath was identified and incised lateral to the midline. The preperitoneal space was then developed following insertion of a Spacemaker balloon, which was inflated under direct vision.

Following removal of the Spacemaker balloon, a #10 trocar was placed in the preperitoneal space and the preperitoneal space was insufflated with CO2. Two #5 trocars were placed in the lower midline. Video laparoscope was inserted in the preperitoneal space. Landmarks including symphysis pubis, right Cooper ligament and right inferior epigastric vessels were identified. Dissection was then continued lateral to the transverse abdominis muscle. The internal ring was then explored for the presence of an indirect hernia sac. No indirect hernia sac was identified. The patient had a cord lipoma, which was reduced under direct vision. Exploration of the medial space showed a medial defect suggesting a direct hernia. A large size Bard 3D mesh was placed in the preperitoneal space and anchored to the symphysis pubis and anterior abdominal wall along the upper edge of the mesh with a stapler. The lower edge of the mesh was affixed to the abdominal wall with Tisseel fibrin glue.

Following this, the left preperitoneal space was explored in the same fashion. Landmarks including symphysis pubis, Cooper ligament and inferior epigastric vessels were identified. The dissection was continued laterally to the transverse abdominis muscle. The internal ring was then explored for the presence of an indirect hernia sac. No indirect hernia sac was identified. A cord lipoma was reduced. The patient was found to have a medial defect suggesting a direct hernia. A large size left 3D Prolene mesh was then placed in the preperitoneal space and placed over the floor of the inguinal canal and stapled to the symphysis pubis and anterior abdominal wall along the upper edge of the mesh with a stapler. 

The lower edge was anchored to the abdominal wall with Tisseel fibrin glue. The preperitoneal space was then deflated. All trocars were withdrawn. The defect in the rectus sheath was closed with figure-of-eight 0 Vicryl suture. The skin incisions were closed with subcuticular 5-0 Monocryl suture. Sterile dressings were then applied. The patient tolerated the procedure well and was brought to the recovery room in stable condition. Needle and sponge counts were correct. 

Port-A-Cath Insertion Medical Transcription Sample / Example

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Lung cancer.

POSTOPERATIVE DIAGNOSIS:  Lung cancer.

OPERATION PERFORMED:  Right internal jugular dual-lumen Port-A-Cath insertion.

SURGEON:  John Doe, MD

ANESTHESIA:  Local anesthesia with sedation.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room. Consent was obtained. Sedation was achieved by the anesthesiologist. The patient’s left neck was prepped and draped in the usual standard sterile fashion. The intention was on placing the Port-A-Cath in the left neck, given that this is the side of the patient's pathologic lung, and we did not want to risk him having a pneumothorax in his right lung. With this in mind, local anesthetic was infiltrated into the region under the left subclavian. A needle was passed with no difficulty in one pass into the subclavian vein. A wire was then advanced; however, we felt some resistance. Using fluoroscopy, we noted the wire was turning back up into the left jugular region. Under fluoroscopic guidance, we manipulated the wire somewhat further; however, we were unable to get it to head toward the right side of the heart, and this approach was abandoned. The left neck had already been prepped and was included in our draping. Using ultrasound guidance, we passed a needle into the left internal jugular with one pass. Again, the wire had some difficulty passing, and under fluoroscopic guidance, we were able to get the wire to head in the direction of the heart; however, it was unable to make the left-handed turn down the superior vena cava. The wire continuously traversed the vena cava and either headed back up or made a U turn. This approach did not lead to success and it was again abandoned.

At this point, we considered that there was a very low likelihood of the patient having an iatrogenic pneumothorax given that only two passes had been made, both in very straightforward fashion, and the patient has had a pleurodesis on the left and likely has a trapped lung already. We undraped, reprepped and redraped the right side, and we interrogated the right internal jugular with ultrasound. This vein did seem patent. It was easy to compress, and again, with local anesthetic and one pass of the needle, we were able to enter the internal jugular vein. On this attempt, the wire passed very easily. There were PACs noted on the electrocardiogram tracing, and with fluoroscopic guidance, we noted that the wire had actually passed the heart and was in the inferior vena cava. The wire was pulled back somewhat so that it was in approximately the right position. We then secured the wire to the bed and administered some local anesthetic into the right chest to create the port. The skin was incised with a knife and Bovie electrocautery. A subcutaneous port was made. There was no evidence of any ischemia at the completion of the case in this area. The port was noted to fit in the cavity with no difficulty. There was no evidence of any hemorrhage.

An 11 blade was used to widen the wire insertion site, and a 9.5 French dual-lumen Groshong catheter was fed retrograde from the wire insertion site to the port site. A dilator was then placed over the wire. The wire and the obturator were removed, and the catheter was inserted through the peel-away sheath. The peel-away sheath was then separated. The wire was maintained in position. Using fluoroscopy, we determined that the catheter was slightly low and this was pulled back to what appeared to be the SVC/right atrial junction region. There was no evidence of any cardiac arrhythmia in the position of the catheter. The catheter was then cut and secured to the port. The lock was applied and the port was inserted into the pocket. The pocket was then irrigated. Again, there was no evidence of any bleeding. It was closed with a combination of 3-0 Vicryl and 4-0 Monocryl. The wire site was also closed with a 4-0 Monocryl. Steri-Strips were applied covered by a dry sterile dressing. The patient tolerated the procedure well. A chest x-ray will be obtained in the recovery room.

Endoscopic Maxillary Antrostomy / Ethmoidectomy / Frontal Sinusotomy / Sphenoidotomy ENT Medical Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Chronic sinusitis, nasal polyposis.

POSTOPERATIVE DIAGNOSIS: Chronic sinusitis, nasal polyposis.

OPERATIONS PERFORMED:  Bilateral endoscopic maxillary antrostomies, bilateral endoscopic complete ethmoidectomies, bilateral endoscopic frontal sinusotomy, bilateral endoscopic sphenoidotomies and fluoroscopy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  Approximately 40 mL.

FLUIDS:  Crystalloid.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed on the operating room table in the supine position. General endotracheal anesthesia was then induced. The 4% cocaine-soaked cottonoid pledgets were then placed in the patient's nasal cavity for decongestion. The patient was then draped. After 5 minutes, the cottonoid pledgets were removed. The left nasal cavity was addressed first. A 0 degree nasal endoscope was used to visualize the left nasal cavity as well as the sinuses. Xylocaine 1% with epinephrine was infiltrated into the base of the middle turbinate anteriorly and posteriorly for further decongestion as well as hemostasis. A Freer elevator was used to medialize the middle turbinate. A Freer elevator was then used to take down the uncinate process. The uncinate process was then excised using Blakesley forceps. The maxillary sinus ostia were visualized and it was enlarged using the microdebrider. There was polypoid tissue in the maxillary antrum and this was removed using the microdebrider. The ostia were opened widely. The bulla ethmoidalis was then taken down using the microdebrider. Anterior and posterior ethmoid air cells were then opened completely using the microdebrider. The patient had polypoid changes in the ethmoid mucosa.

The area of the frontal recess was then cleaned out using the microdebrider. The frontal recess was then visualized with 0 degree nasal endoscope and the frontal sinus catheter guide was placed in the area of the frontal recess. A wire guide was then threaded up into the frontal sinus and the position of the wire guide was confirmed using fluoroscopy. A 7 mm balloon was then passed over the wire guide up into the frontal recess and frontal sinus ostia. This was inflated to 8 atmospheres. The position of the balloon was confirmed using fluoroscopy. The balloon was then deflated and the wire guide, the catheter guide, as well as the balloon were removed. Next, the sphenoid recess was visualized using the 0 degree nasal endoscope. The sphenoid ostia were identified and this was enlarged further using microdebrider. The sphenoid sinus ostia were widely opened. There was purulent material in the sphenoid sinus, which was released. The nasal endoscope was then removed from the left nasal cavity.

Next, the right nasal cavity and sinuses were addressed. Again, the right sinuses and nasal cavity were visualized using a 0 degree nasal endoscope. Xylocaine 1% with epinephrine was infiltrated into the base of the middle turbinate anteriorly and posteriorly for hemostasis as well as decongestion. A Freer elevator was used to medialize the middle turbinate. There was a large polyp obstructing the maxillary ostia on the right side and this was taken down using the microdebrider. An uncinectomy was then performed using the Freer elevator. The uncinate process was then removed using Blakesley forceps. The maxillary sinus ostia were opened widely using the microdebrider. There was thick mucoid material in the maxillary sinuses, which was suctioned out. The bulla ethmoidalis was then taken down using the microdebrider. The anterior and posterior ethmoid air cells were then opened widely using the microdebrider. There were polypoid changes to the ethmoid sinus mucosa. This was taken down using the microdebrider.

The frontal recess was then visualized using a 0 degree nasal endoscope and cleansed using the microdebrider. A sinus catheter guide was then placed up into the frontal recess. A wire guide was then threaded through the sinus catheter guide up into the frontal sinus. The position of the wire guide was confirmed using fluoroscopy. A 7 mm balloon was then guided over wire guide up into the frontal sinus ostia. The balloon was then inflated to 8 atmospheres. The position of the balloon was confirmed using fluoroscopy. The balloon was then deflated. The balloon, the wire guide, as well as the sinus catheter guides were then removed. The sphenoid ostia were then visualized using a 0 degree endoscope. A sinus catheter guide was then placed in the area of the sphenoid ostia. A wire guide was then threaded into the sphenoid sinus and the position was confirmed using fluoroscopy. A 7 mm balloon was then guided over the wire guide and into the sphenoid ostia. The balloon was then inflated to 8 atmospheres. The position of the balloon was confirmed using fluoroscopy. The balloon was then deflated. The wire guide, the sinus catheter guide, as well as the balloon were then all removed. Stammberger sinus gel was then placed in the middle meatus bilaterally for postoperative hemostasis. The patient was then awakened from anesthesia and taken to the recovery room in stable condition.

Removal of Penile Prosthesis Medical Transcription Sample / Example

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Eroded penile prosthesis. 
2.  Traumatic hypospadias.
3.  Peripheral vascular disease.
4.  Severe diabetes mellitus.

POSTOPERATIVE DIAGNOSES:
1.  Eroded penile prosthesis. 
2.  Traumatic hypospadias.
3.  Peripheral vascular disease.
4.  Severe diabetes mellitus.

OPERATION PERFORMED:
1.  Removal of complete 3-piece penile prosthesis.
2.  Cystotomy and suprapubic tube insertion.
3.  Cystoscopy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room suite. He had preoperative antibiotics. The patient was given anesthesia and prepped and draped in the dorsal lithotomy position. The patient had his Foley catheter removed and a clean catheter was placed in the field. His penile and scrotal region was shaved with a sterile razor. A transverse scrotal incision was made, and using the Lone Star retractor, blunt and sharp dissection was used to dissect down to the scrotal tubing and dissect the corpora. Care was taken to prevent any injury to the urethra in the midline. Cautery was used to dissect onto the tubing for the pump. The pump was pulled up and completely freed. This was followed across to the right side where the reservoir was dissected.

Once the tubing had been dissected, this was clamped and cut and the reservoir was drained. Cautery was used at the neck of the reservoir and the reservoir was removed. The tubing was then all separated and the pump was also separated and handed off the field. A piece of tubing was found to the corpora on each side. The corpora were opened laterally in a lengthwise incision with electrocautery. Care was taken to avoid the midline. A right angle was then used and passed around the corporal pontoon. This was removed and a rear tip extender was noted. The left side was then removed in a similar fashion and the rear tip extender was also removed. The patient had very minimal bleeding from this. The corpora were then reapproximated on each side with interrupted figure-of-eight PDS sutures with 2-0 suture. The patient had these areas irrigated, specifically on the left side, where he had the large erosion. He then had a Penrose drain placed and the subcutaneous tissue was reapproximated with interrupted sutures. The skin was then closed with a running 4-0 Vicryl suture. The Penrose was brought out through a separate stab incision and secured to the skin using Vicryl loose suture.

The patient then had a cystoscopy revealing moderate BPH. His bladder appeared normal; although, there was some inflammation, likely from the indwelling Foley catheter. This was then removed. The patient then had a Lowsley retractor passed through his urethra. This was retracted to the anterior wall. A knife was used and an incision was made in the midline. The patient had a cystotomy created and the Lowsley retractor was passed through this. The Lowsley retractor was opened and a 16 French Foley catheter was then grasped and brought into the bladder. The balloon was inflated with 10 mL of sterile water. This was noted to drain the bladder. Cystoscopy was used to confirm the balloon location in the bladder. This was secured to the skin using a figure-of-eight silk suture and this was tied around the catheter. The patient had fluff dressings placed and was taken to the recovery room in stable condition.

Extracapsular Cataract Extraction Medical Transcription Sample

DATE OF OPERATION:
MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Mature traumatic cataract, right eye.

 POSTOPERATIVE DIAGNOSIS:
Mature traumatic cataract, right eye.

OPERATION PERFORMED:
Planned extracapsular cataract extraction with posterior chamber intraocular lens implant, right eye.

SURGEON:
John Doe, MD

 ASSISTANT:
None.

ANESTHESIA:
General.

COMPLICATIONS:
None.

DESCRIPTION OF OPERATION:
The patient arrived in the operating room after adequate preoperative sedation, intravenous line and cardiac monitor initiated. The patient was prepped and draped in the usual sterile fashion after smooth induction of general endotracheal anesthesia. Attention was directed to the right eye, where a chalk-white cataract was noted.

A Lieberman wire lid speculum was placed between the lids of the right eye. A fornix-based conjunctival flap to the superior 3 o'clock was fashioned with Westcott scissors using blunt and sharp dissection. Hemostasis was obtained with wet-field cautery. Initially, this procedure was approached as a phacoemulsification case. A 3 mm limbal wound was fashioned with a 69 Beaver blade in partial thickness fashion. A crescent knife was used to dissect a scleral tunnel anteriorly into clear cornea.

A superotemporal paracentesis stab was performed with a 75 Beaver blade. The anterior chamber was deepened with Viscoat. The scleral tunnel was then completed with a 2.8 mm keratome into the anterior chamber. A bent 25 gauge needle cystotome and a Viscoat syringe introduced into the anterior chamber and an attempt was made to perform a continuous tear capsulorrhexis. In the light of the mature white lens, as well as flocculent material, visualization of the anterior capsule was extremely difficult and a continuous tear capsulorrhexis could not be performed. 

It was elected at this point to convert to a can-opener capsulotomy through 360 degrees and convert to an extracapsular cataract extraction. The 3 mm limbal wound was extended 1 o'clock on either side with corneoscleral scissors, first passing nasally then temporally. A traction suture was placed into the 12 o'clock cornea, and with gentle pressure from above and below the lens, nucleus was expressed from the eye uneventfully. The limbal wound was secured with 3 interrupted 8-0 Vicryl sutures.

Irrigation/aspiration handpiece was introduced into the anterior chamber. Cortical cleanup was performed uneventfully. A good red reflex was noted. The posterior capsule remained intact. The limbal wound was secured nasally and temporally with interrupted 10-0 nylon sutures whose knots were buried to 12 o'clock. Vicryl suture was removed. The capsular bag was filled with Provisc.

A 21.5 diopter posterior chamber intraocular lens implant was inspected under the operating microscope and found to be free of defect. The lens implant was placed in the eye with the inferior J-loop being reposited behind the iris leaflet and within the capsular bag. Using a one-handed maneuver, the superior J-loop was placed behind the iris leaflet within the capsular bag. The lens was rotated such that its major axis was from the 3 to 9 o'clock positions. The lens was noted to be well centered and stable.

The limbal wound was secured with an additional 6 interrupted 10-0 nylon sutures whose knots were buried. Viscoelastic was removed from the anterior chamber. The chamber was deepened with balanced salt solution and the wound was tested and found to be watertight. Subconjunctival gentamicin and Solu-Medrol were administered. Maxitrol ointment was instilled. The lid speculum was removed. The eye was patched. The patient was extubated uneventfully.

Ophthalmology Operative Samples # 1             Ophthalmology Operative Sample Reports #2

Bilateral TMJ Arthroplasty / Mandibular Coronoidectomy / Maxillomandibular Fixation Transcribed Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Bilateral degenerative disease affecting mandibular condyles, temporomandibular joint.

POSTOPERATIVE DIAGNOSES:  Degenerative joint disease involving bilateral condyles, mandible, with heterotopic bone formation and fibrous ankylosis.

OPERATIONS PERFORMED:  
1.  Bilateral temporomandibular joint arthroplasty. 
2.  Bilateral mandibular coronoidectomy.
3.  Application of maxillomandibular fixation using Ivy loop wires and elastic traction.

SURGEON:  John Doe, MD

ANESTHESIA:  General via nasal intubation.

DESCRIPTION OF OPERATION:  The patient was brought to the operating suite, and following administration of a general anesthetic utilizing nasotracheal intubation, the patient was prepared and draped in a manner appropriate for extraoral surgical reconstruction of the jaws. Intraoral procedure was started by placement of Ivy loop 25 gauge wires about the maxillary and mandibular teeth for intraoperative surgical traction. Elastic bands will be placed at the mid point of the operation. In the patient's left lower abdomen, in the outer aspect of the lower quadrant, a 2 cm incision was made through the skin entering into the subcutaneous tissues and approximately 5 to 6 mL of subcutaneous fat tissue was harvested for later use. This tissue was placed in saline-soaked gauze and the incision was checked for hemostasis and then closed utilizing 3-0 Vicryl suture and skin staples. A Tegaderm dressing was placed and then attention was directed to the jaw areas. 

The patient was re-prepared and draped in a manner appropriate for external approach to the mandible. The patient's head was turned to the left side and local anesthesia of 0.25% Marcaine with epinephrine was infiltrated into the preauricular area of the face overlying the temporomandibular joint and along the inferior border of the jaw in the angle area for hemostasis and pain control. A preauricular incision utilizing a previously made skin closure was accomplished as well as a modified Risdon incision, which was approximately 2.5 cm in length. Both incisions were carried down through the skin and subcutaneous tissue until the fascia plane was encountered. In the Risdon incision, the fascia was dissected, paying attention to preserve nerve tissue that may be in the area and retracting the mandibular branch of the facial nerve inferiorly away from the incision line. Once the masseter-pterygoid sling was encountered, this was exposed and incised sharply at the angle and the masseter muscle was reflected from the lateral aspect of the mandible. The preauricular incision was carried down until reaching the lateral aspect of the joint capsule. This later was easily determined because the underlying metallic fossa eminence implant was visible through the overlying fascial tissue.

Staying in this plane, dissection was carried inferiorly approximately 1 to 1.5 cm, thereby allowing good visualization of the lateral aspect of the temporomandibular joint capsule. The joint capsule itself was infiltrated with the local anesthetic solution and then sharply incised horizontally entering into what remained of the joint space. Significant scar tissue had formed as well as a fair degree of heterotopic bone on the medial aspect of the residual portion of the condyle. The condyle was grossly deformed and flattened and heterotopic bone, approximately 1 cm AP x 5 to 7 mm medially, was encountered that was firmly fibrosed to the medial connective tissues. The condyle could not be manipulated within the glenoid fossa until the adhesive quality of this heterotopic bone was released. Using direct visualization and micro reciprocating saws, a coronoidectomy of the right mandible was accomplished and the specimen placed aside. The condyle was also removed using the micro reciprocating saw as previously determined by 3-dimensional model reconstructive surgery. After the condyle was resected, the glenoid fossa was inspected. The implant previously placed a number of years ago was stable. A layer of bone had started to creep across from the medial aspect. This was debrided and hemostasis of the surgical site was accomplished. Sponge dressings were placed within the two incisions and the patient's head was then turned to the right side, exposing the patient's left side. Similar incisions were made and coronoidectomy and condylectomy were accomplished. A similar finding of heterotopic bone on the medial aspect of the remaining portion of condyle was also visualized. Both specimens were to be submitted and photographed. 

After completion of the bilateral condylectomy, arthroplasty and coronoidectomy, the patient's mandible was placed into a normal occlusion related to the maxilla. Direct fixation was accomplished using elastic traction across the numerous maxillary and mandibular Ivy loop wires. After traction was applied, the patient's head was turned to the left side and the prosthetic condyle was placed into the incision directly against the fossa eminence implant and stabilized using one screw at the bottom of the device. The same procedure was carried out on the patient's left side. With the patient's two prosthetic devices initially stabilized, the mandible was checked for reasonable occlusion. Such was found to be in existence and the traction which had been removed was replaced. The additional six screws were placed to rigidly stabilize each of the prosthetic devices and all screws were tightened by hand without stripping of any of the screw holes or the screws themselves. Good rigid fixation of both condyle prosthetic devices was found to be present. The previously harvested abdominal fat at this time was divided into two parts and this fat was then placed into the space around the prosthesis and within the confines of the overlying fascial covering and joint capsule. Obliteration of the residual joint space was accomplished and also agent preventing scar formation about the device.

After the fat grafts were placed bilaterally, deeper wound closure was accomplished utilizing interrupted 3-0 chromic sutures as well as subcutaneous closure and then running 6-0 nylon sutures were used for the skin closures. After closure of all four incisions, the patient's occlusion was checked and found to be as predicted. Two elastic bands remained between the maxillary and mandible on each side. The patient's fascial area incisions and area was cleansed. These incisions were dried and then Mastisol and Steri-Strip dressings were placed on both incisions on each side of the face. After wound closure and dressing, the patient was awakened. The patient was extubated and taken to the recovery room in a reactive, responsive condition. The patient tolerated the procedure without complications. Estimated blood loss was 200 mL. The patient was taken to the recovery room and will be admitted for observation.

Postpartum Curettage Medical Transcription Sample / Example

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Routine products of conception.

POSTOPERATIVE DIAGNOSES:
1.  Routine products of conception.
2.  Presumed placenta accreta.

PROCEDURES PERFORMED:
1.  Postpartum curettage.
2.  Uterine packing.

SURGEON:  John Doe, MD

SEDATION:  Mask, general, converted to a general endotracheal tube.

PROCEDURE FINDINGS:  A 14-week size uterus with heavy vaginal bleeding. Cervix open, 2 cm, small amounts of adhered placental fragments and ruddy, rough texture in the body of the uterus consistent with placenta accreta.

SPECIMENS:  Endometrial curetting.

ESTIMATED BLOOD LOSS:  1000 mL.

COMPLICATIONS:  Presumed placenta accreta.

FLUIDS:  Two liters of crystalloids, one unit of Hespan and two units of packed red cells.

INDICATIONS AND DESCRIPTION OF PROCEDURE:  The patient is a (XX)-year-old G3, P3-0-0-3 female status post vaginal delivery, who has had postpartum bleeding since the delivery. The patient was seen in the emergency room approximately 2 days prior to admission this time, with heavy vaginal bleeding. Her hemoglobin at that time was approximately 11.8. She was seen by the ER physician without a great deal of bleeding and the ultrasound did not show significant amount of placental tissue left in the uterus and so the decision was made to discharge her home on Methergine. She was given Methergine and antibiotics and had continued vaginal bleeding. She called today with passage of large amounts of clots and was sent back to the emergency room. In the emergency room, she was seen and had an open cervical os with a great deal of bleeding. She was, therefore, consented for D and C for removal of placental fragments as the presumed cause of her postpartum bleeding. She was consented for D and C and brought to the operating room. General anesthesia was initiated with mask general. She was prepped and draped sterilely. Straight catheterization of the bladder was obtained. A weighted speculum was placed in the vagina and a great deal of bleeding was noted, heavy brisk vaginal bleeding. The anterior lip of the cervix was grasped with ring forceps and the cervix was opened 2 cm wide. A banjo curette was used to curette via the uterus and a small amount of placental fragments were obtained. There was still active bleeding and clots expelled from the uterus. Because of this, a suction curettage with a 12 mm curette was used to evacuate the uterus, but the bleeding persisted. This was attempted once as the curettage was re-performed using the banjo curette to attempt to remove the products of conception. Intravenous Pitocin and intramuscular Methergine were used to cause uterine contractions. The uterus appeared firm at approximately 12-14 week size; however, the bleeding continued briskly.

After feeling digitally into the uterus because of the continued bleeding, a fine ruddy texture was noted throughout the body of the uterus and the majority of the area, except for the anterior surface of the uterus, which felt rough, but the roughness was at the same level as the uterus and not protruding out signifying a possible placenta accreta. Given that the patient is (XX) years of age and the active bleeding, she was given volume expanders, crossed for 4 units of blood and uterine packing was performed as a stop-gap measure prior to possible need for hysterectomy, uterine artery ligation or hypogastric artery ligation to prevent any further hemorrhage and bleeding. While we were waiting for the blood products to be obtained to the operating room for transfusion prior to laparotomy, it was noted that her bleeding from the uterus with the packing had almost completely stopped. The decision was made to leave the pack in place, pack the vagina, leave a Foley in place and observe for bleeding. She was observed in the operating room for approximately another 30 minutes with no further bleeding noted to the pack. Her vital signs remained stable after volume expanders and decision was made to transfer the patient to the recovery room for further observation in case of possible need for laparotomy. The decision by the anesthesiologist was to leave the patient intubated so as to prevent the need for further intubation if need be. Sponge, lap, needle and instrument counts were correct x2. Following the procedure, the patient was taken intubated to the recovery room.

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Wound Care Medical Transcription Sample Reports

DATE OF SERVICE:  MM/DD/YYYY

HISTORY OF PRESENT ILLNESS: This patient returns to wound clinic for followup on chronic ulceration in the plantar and lateral aspect of left foot. She missed her last appointment. She denies new complaints at this visit. Denies nausea, vomiting, fever or chills. The patient is continuing dressings with Prisma on the medial aspect of the left foot and Panafil on the outside of her left foot. She denies new complaints.

PHYSICAL EXAMINATION: Reveals ulcerations present on the patient's left foot and the medial ulceration measured 2.5 x 1.5; this is on the medial left foot. There is no sinus tract or tunneling. There is small amount of undermining noted at 2 to 5 o'clock. There is a large amount of serous drainage coming from the wound. There is large amount of red granulation tissue with the large amount of hyperkeratotic tissue surrounding the wound. No black or necrotic tissue. No exposed tendon or bone. There is no periwound edema, erythema or malodor. On the left plantar second metatarsal head, there is also an ulceration measuring 0.6 x 0.6 x 0.2. Again, there is no sinus tract or tunneling. No undermining. There is moderate amount of serous drainage coming from the wound. There is a large amount of red granulation tissue with small amount of fibrous tissue. No black or necrotic tissue. No exposed tendon or bone. No periwound edema, erythema or malodor. There is an ulceration present in the lateral aspect of the left foot measuring 1.3 x 1.3 x 0.2. There is no sinus tract or tunneling. No undermining. There is a moderate amount of serous exudate coming from this wound with small amount of pale granulation tissue with large amount of yellow slough and fibrous tissue. No black or necrotic tissue. No exposed tendon or bone. No periwound edema, erythema or malodor.

 On vascular examination, she has +1/4 palpable pedal pulses bilaterally. Capillary fill time less than 3 seconds x5 bilaterally. On neurological examination, she has decreased sensation to Semmes-Weinstein monofilament of 5.06 to the level of the malleoli bilaterally.

ASSESSMENT:
1.  Grade 2 Wagner ulceration on the medial aspect of the patient's left foot, a grade 2 Wagner ulceration on the lateral aspect of the patient's left foot, and a grade 2 ulceration on the planter second metatarsal head, left foot.
2.  Peripheral neuropathy.
3.  Diabetes mellitus.

PROCEDURE PERFORMED: I examined and evaluated the patient. I discussed the etiology of these ulcerations and treatment protocol. I aggressively debrided these ulcerations into the subcutaneous layer of the wound involving all fibrous and nonviable tissue. I applied Panafil to the outside of the left foot and Prisma to the plantar and medial aspect of the left foot.

PLAN: I advised the patient to continue doing daily dressing change and to return to the wound clinic in 1 week for followup visit. Continue the off-loading device in her shoe.

 DATE OF SERVICE:  MM/DD/YYYY

 This patient has a dehisced midline wound, which we have been treating on an outpatient basis with the wound VAC. There has been substantial improvement in the wound. There still is undermining on the patient's right upper quadrant, of this wound, of 3 cm for a maximum of 5 cm 12 o'clock on the left upper hemisphere. This also had been undermined last week and now appears to be adherent. The overall cutaneous wound is smaller, and the wound is contracting with much better looking granulation tissue. There is no longer the thick white slough, which had been present at the beginning. So overall, there is continued improvement. The patient's general sense of health and well-being has been good as well. The patient indicates that wound VAC has been able to stay in place, which had been a problem for the first couple of weeks. That is no longer an issue.

 We have curetted the wound base and the sides, including curetting the undermined area, into bleeding subcutaneous tissue. Hemostasis was achieved with pressure. We will continue to use the wound VAC. We have increased it to 150 cm. Continue at this point. We will try to stimulate further contraction. We will continue to see the patient on a weekly basis.

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Electrophysiologic (EP) Study Medical Transcription Example

DATE OF PROCEDURE:  MM/DD/YYYY

PROCEDURES PERFORMED:
1.  Comprehensive electrophysiologic study with programmed stimulation and induction of arrhythmia with cannulation of the coronary sinus.
2.  Detailed mapping of the tachycardia focus.
3.  Radiofrequency catheter ablation for typical atrioventricular nodal reentry tachycardia.
4.  Programmed stimulation after intravenous drug infusion with isoproterenol.

SURGEON:  John Doe, MD

PROCEDURE IN DETAIL:  The patient was brought to the electrophysiology laboratory in a fasting state. The patient was prepped and draped in the usual sterile fashion. Lidocaine 1% was used for local anesthesia, and fentanyl and Versed were administered in divided doses using the conscious sedation protocol. The 8 French and 7 French sheaths were placed in the right femoral vein, two 7 French sheaths were placed in the left femoral vein, and a 7 French sheath was attempted to be placed in the right internal jugular vein. The guidewire could be inserted into the right internal jugular vein but could not be advanced into the right atrium. Contrast, 20 mL, was injected revealing anomalous drainage of the subclavian vein. A decision to forego right internal jugular vein cannulation was made and an extra 7 French sheath was placed in the left femoral vein using the modified Seldinger technique. Through the groin sheaths, a Cordis Webster deflectable decapolar catheter was positioned in the coronary sinus, a fixed curve Bard quadripolar catheter was positioned in the atrioventricular junction, a fixed curve Bard quadripolar catheter was positioned in the high right atrium and right ventricular apex under fluoroscopic guidance. The patient's coronary sinus was extremely large. Thresholds were measured.

The baseline rhythm was normal sinus. The following conduction intervals were recorded including the basic cycle length of 1024 milliseconds, a PR interval of 150 milliseconds, QRS duration of 120 milliseconds, a QT interval of 441 milliseconds, an AH interval of 88 milliseconds, and a HV interval of 46 milliseconds. Atrial pacing to assess sinus node function was performed. The longest corrected sinus node recovery time was 242 milliseconds at a pacing cycle length of 600 milliseconds. Atrial pacing was performed to assess AV node function. AV Wenckebach occurred at a pacing cycle length of 430 milliseconds. Single premature stimuli were delivered in the atrium. The effective refractory period of the AV node was 400 milliseconds at pacing cycle length of 600 milliseconds and the effective refractory period of the atrium was 240 milliseconds at a pacing cycle length of 600 milliseconds. There was no AH jump at the baseline state. Ventricular pacing was performed. VA conduction was present and concentric. VA Wenckebach occurred at a pacing cycle length of 420 milliseconds. Single premature stimuli were delivered in the ventricle. VA conduction was decremental. The effective refractory period of the AV node in the retrograde direction was 360 milliseconds at 600 milliseconds and the effective refractory period of the ventricle was 260 milliseconds at 600 milliseconds.

Because there was no SVT induced at the baseline state, isoproterenol at 1 mcg and then 2 mcg per minute was infused. After a resultant increase in heart rate, programmed stimulation was performed. At a cycle length of 500 milliseconds and a coupling interval of 250 milliseconds, a 100 millisecond AH jump was recorded. Double premature stimuli were delivered in the atrium at a cycle length of 500 milliseconds and a coupling interval of 320, 260 milliseconds. Supraventricular tachycardia was induced at a cycle length of 410 milliseconds. PVCs were delivered spanning systole and diastole. PVCs that were synchronous to His bundle depolarization were analyzed. These PVCs did not delay or pre-excite the atrium. Ventricular pacing was performed during tachycardia. The tachycardia was entrained. With termination of ventricular pacing, the response was VA and VA. During tachycardia, the VA time measured 16 milliseconds. All these maneuvers confirmed the diagnosis to be typical AV nodal reentry tachycardia. The tachycardia was terminated with overdrive ventricular pacing. The tachycardia was reproducibly inducible with an AH jump using double premature stimuli in the atrium. The tachycardia was also induced with burst atrial pacing at 310 milliseconds. A decision to proceed with radiofrequency catheter ablation was made.

The 8 French sheath was replaced with an SR0 long sheath under fluoroscopic guidance. Through this long sheath, an EPT large curve 4 mm mapping and ablation catheter was positioned in the slow pathway area of the AV node. Detailed mapping of the slow pathway region was performed. Radiofrequency energy was delivered at appropriate sites for 20 seconds with a maximum power of 50 watts, temperature of 60 degrees for 20 seconds. If junctional rhythm was not seen, RF energy delivery was discontinued. In this fashion, four RF lesions were administered. The first two lesions did not elicit junctional rhythm. The latter two lesions elicited junctional rhythm and RF energy was delivered for a total of 60 seconds each. There was no heart block seen during RF energy delivery. The patient tolerated radiofrequency ablation well.

The catheter was withdrawn from the ablation site. Isoproterenol at 1 mcg and then 2 mcg per minute was infused. Programmed stimulation was performed after ablation. VA Wenckebach occurred at a pacing cycle length of 310 milliseconds. AV Wenckebach occurred at a pacing cycle length of 330 milliseconds. Single and double premature stimuli were delivered in the atrium. A single echo beat was elicited with a long escape junctional beat to follow. Isoproterenol was discontinued and programmed stimulation was performed. There were no inducible arrhythmias at the end of the procedure. The AH interval measured 100 milliseconds. The HV interval measured 40 milliseconds. The catheters and sheaths were removed and direct pressure was applied to obtain hemostasis. The patient tolerated the procedure well without complications and was sent to the holding area in stable condition.

PROCEDURE FINDINGS:
1.  Normal sinus node function.
2.  Normal atrial function.
3.  Abnormal AV node function with dual pathways in the AV node and inducible typical AV nodal reentry tachycardia.
4.  Normal His-Purkinje function.
5.  Normal ventricular function.
6.  Anomalous drainage of the superior vena cava into the right atrium.

RESULTS:  Successful radiofrequency catheter ablation with slow pathway of the AV node to treat typical AV nodal reentry tachycardia.

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