Normal Review of Systems Template Examples

REVIEW OF SYSTEMS:
GENERAL/CONSTITUTIONAL:  The patient has been feeling more tired. Other than that, no other symptoms. No weight loss, no night sweats, no fever or chills.
CARDIOVASCULAR:  No prior history of any cardiac problem and no chest pain until last month.
PULMONARY:  No history of any lung problem, asthma, pneumonia or bronchitis.
GENITOURINARY:  No dysuria or hematuria.
GASTROINTESTINAL:  Has some acid reflux. No hematemesis or melena.
RHEUMATOLOGY:  The patient has history of osteoarthritis.
ENDOCRINE:  The patient has diabetes and has been on medication. She has been diagnosed with hypothyroidism and has been on Synthroid.
PSYCHIATRIC:  Mild depression.
NEUROLOGICAL:  Negative.

REVIEW OF SYSTEMS:
CONSTITUTIONAL:  Negative for fever, weight loss or weight gain.
HEENT:  Eyes:  Negative for glaucoma or cataracts. Ears:  Negative pain or loss of hearing. Nose:  Positive for nasal congestion. Negative for rhinorrhea or postnasal drip. Mouth:  Negative for false teeth. Throat:  Negative for masses or hoarseness. Positive for snoring.
CARDIOVASCULAR:  Negative for chest pain or palpitations.
RESPIRATORY:  See HPI.
GASTROINTESTINAL:  Negative for nausea, vomiting, diarrhea or heartburn.
GENITOURINARY:  Negative for dysuria.
MUSCULOSKELETAL:  Positive for osteoarthritis.
SKIN:  Positive for hives secondary to penicillin. Negative for rashes.
NEUROLOGIC:  Positive for occasional sinus headaches.
PSYCHIATRIC:  Positive for depression. Negative for daytime sleepiness or insomnia.
ENDOCRINE:  Negative for diabetes or thyroid abnormalities.
HEMATOLOGIC:  Negative for anemia or blood dyscrasias.

REVIEW OF SYSTEMS:
CONSTITUTIONAL:  Negative for any fever, weight loss or weight gain.
HEENT:  The patient has no visual problems. No sore throat. No sinus problems.
CARDIOVASCULAR:  The patient has been on Coumadin for atrial fibrillation. Has had no chest pain, no paroxysmal nocturnal dyspnea.
PULMONARY:  Denies any wheeze. Usually can ambulate a mile without shortness of breath. Infrequent bronchitis. Has no history of TB. Has never been told that he had asthma.
GASTROINTESTINAL:  Denies any nausea, vomiting, hematochezia, hematuria or constipation. Has not had any difficulty with his liver.
GENITOURINARY:  Denies any difficulty urinating.
NEUROLOGIC:  Denies any history of CVA, mental status changes or visual changes. Has not had any seizures or paresthesias. No neurologic changes.
ENDOCRINE:  Denies any diabetes or thyroid disease.
SKIN:  Denies any skin lesions, except he has had a discolored red area on his left shin for many years. Has had some petechial rash over bilateral shins but no pruritus and no other rashes.
PSYCHIATRIC:  Denies any psychiatric illness.
Rest of the review of systems was negative.

REVIEW OF SYSTEMS:
CONSTITUTIONAL:  No fever, no chills, no diaphoresis. Generalized weakness.
HEENT:  Blurred vision, chronic frontal headache with runny nose. No sore throat, no ear pain.
CARDIOPULMONARY:  Chest pain, shortness of breath on exertion, cough. Please see HPI. No orthopnea, no paroxysmal nocturnal dyspnea, no wheezing.
GASTROINTESTINAL:  Pleuritic pain. No nausea, no vomiting, no dysphagia, possible heartburn with chronic epigastric pain, no reflux, no regurgitation, no hematemesis, no abdominal pain, no constipation, no hematochezia, no melena. Diarrhea last night.
GENITOURINARY:  No dysuria, no hematuria, no flank pain, nocturia x4, no incontinence.
MUSCULOSKELETAL:  Lower back pain for 5 years.
NEUROLOGIC:  Numbness intermittently in both lower legs, not at the time of admission.

REVIEW OF SYSTEMS:
CONSTITUTIONAL:  The patient has not had recent weight change or fever.
CARDIOVASCULAR:  Had no chest discomfort, orthopnea, PND or edema.
RESPIRATORY:  Occasional cough. No wheezing or hemoptysis.
GASTROINTESTINAL:  No abdominal pain, nausea, vomiting, diarrhea, hematochezia or jaundice.
GENITOURINARY:  No frequent nocturia. No dysuria.
MUSCULOSKELETAL:  Occasional arthralgias. No major arthritis.
SKIN:  No rash, itching or suspicious lesions.
NEUROLOGIC:  Memory impairment is noted. No motor deficit, numbness or frequent headaches.
ENDOCRINE:  Denies polydipsia, polyuria, heat or cold intolerance.
HEMATOLOGIC:  No abnormal bleeding or bruising or lymphadenopathy.

REVIEW OF SYSTEMS:
CONSTITUTIONAL:  Has a subjective fever, but no chills, no weight loss, no change in her appetite. No night sweats.
SKIN:  There is a wound to her left foot. There were no other skin rashes.
HEENT:  Negative for URI symptoms, conjunctivitis, eye pain, sinus tenderness, runny nose, sore throat or lymph node enlargement. No mass in her neck. Hearing and vision have been normal.
CARDIOVASCULAR:  Denied any chest pain, palpitation, orthopnea or dyspnea. Did have left leg edema and swelling, but normal to the right side.
RESPIRATORY:  Denied any cough, hemoptysis, wheezing, history of asthma or any shortness of breath. Denies any history of tuberculosis.
GASTROINTESTINAL:  Denied nausea, vomiting, abdominal pain, bloody stool, melena or hematochezia.
GENITOURINARY:  Denied any dysuria, urgency, any leukorrhea or any abnormal vaginal discharge.
MUSCULOSKELETAL:  Denied any joint pain or joint swelling except to the left foot, which has overall pain and is tender since the injury.
NEUROLOGIC:  Denied any focal muscle weakness, neurological or sensation abnormalities. No loss of consciousness. No chronic headache. No other neurological deficit. No history of seizure.

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ACL Reconstruction Revision Medical Transcription Example

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Failed left anterior cruciate ligament reconstruction with persistent chronic lateral ligament laxity.

POSTOPERATIVE DIAGNOSIS:
Failed left anterior cruciate ligament reconstruction with persistent chronic lateral ligament laxity.

OPERATION PERFORMED:
Revision of left anterior cruciate ligament reconstruction using patellar tendon autograft, removal of hardware and open lateral ligament reconstruction using anterior tibialis tendon allograft and Pegasus graft augmentation.

SURGEON:  John Doe, MD

ANESTHESIA:  General laryngeal.

TOURNIQUET TIME:  120 minutes.

ESTIMATED BLOOD LOSS:  Minimal.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room. In the holding area, the patient's left knee was scrubbed with Betadine. The patient was given 2 grams of Ancef IV piggyback and was then brought in to the operating room and placed in the supine position on the operating room table. General laryngeal anesthesia was administered by the anesthesia staff.  The patient had examination of the knee under anesthesia and had a 2+ Lachman and 3+ pivot shift. The patient had no valgus laxity, but 3+ varus laxity. A tourniquet was placed high on the left thigh. An Esmarch tourniquet was used to exsanguinate the left lower extremity and the tourniquet was elevated to 300 mmHg. The left lower extremity was then placed in a leg holder and flexed to 90 degrees. The inferior pole of the patellar tendon joint lines was marked with a sterile marking pen. The anterolateral port was made with a #11 blade and the arthroscope was carefully placed into the intercondylar notch of the suprapatellar pouch without difficulty and the knee was instilled with Ringer's lactate solution. The suprapatellar pouch was inspected and noted to be free of loose bodies. The patella and femoral trochlea were then inspected and noted to be without gross degenerative changes. The medial compartment was entered. The patient had some fraying of the medial and lateral meniscus and subtotal medial and lateral meniscectomies were completed. The intercondylar notch was entered and the patient had a full-thickness failure of the ACL. This was debrided with a 5.5 resector shaver. 

The arthroscope was removed at this point and a straight midline incision was made from the inferior pole of patella to the tibial tubercle. Sharp dissection was made down through the paratenon isolating the patellar tendon and using #10 graft at middle third of patellar tendon with a 2.5 cm block of bone from the patella and tibial tubercle were isolated. Using an oscillating saw, mallet and osteotome, the patellar tendon graft was removed without difficulty and passed to another sterile table and prepared for passing. The tibial guide was then placed through the anteromedial portal and Steinmann pin retrograde through the original incision.

At this point, we thought that the post of the tibial side would be in the way for our tunneled site, so using an extra small stab incision, that screw was removed without difficulty. Then, the tibial cut was made with a #11 reamer and the tibial plane was prepared with a rasp and shaver. The over-the-top guide was then placed through the tibial tunnel at approximately the 1 o' clock position. A large Beath pin was exited anterior to the thigh. A #11 reamer of the Beath pin and the femoral tunnel was prepared with the rasp and shaver. The graft was pulled through retrograde pulling the Beath pin through the anterior thigh. Then, with the knee in full flexion through an extra small stab incision through the fat pad, a guide pin was placed between the femoral bone block and the femoral tunnel. A 8 x 23 mm biodegradable screw was used to fix the femoral bone block to the femoral tunnel. The notch was very sclerotic with bone, possibly because of the two previous ACL reconstructions, and we thought for better fixation, we would use a metallic screw, so a 7 x 23 mm metallic screw was used adjacent to the biodegradable screw with excellent fixation of the graft. Then, with the knee at 30 degrees of flexion and slight external rotation and full tension on the graft and the posterior drawer, a 9 x 28 mm biodegradable screw was used to fix the tibial bone block to the tibial tunnel. Final arthroscopic visualization revealed excellent tension of the graft with no evidence of impingement and good tension. The arthroscope was then removed.

Our attention was drawn posterolaterally. A curvilinear incision was made posterolaterally from the Gerdy's tubercle proximally approximately 8 to 10 cm. Sharp dissection was made down to the iliotibial band. Moderate medial and lateral skin flaps were made sharply. Then, the plane between the iliotibial band and the biceps femoris was isolated. We identified the peroneal nerve just posterior to the biceps femoris tendon and this was dissected out of the way to the fibular neck, and very carefully, a Penrose drain was placed around the peroneal nerve and it was reflected posteriorly out of the way. There essentially was no lateral collateral ligament remaining, so I thought that a posterolateral reconstruction with an anterior tibial tendon allograft would be used. A guidepin was placed through the fibular head with complete visualization of the fibular head. From anterior to posterior, a 7 mm reamer was placed over the guidepin. The tunnel was rasped and the anterior tibial tendon allograft was then passed through this in a figure-of-eight and was passed underneath the iliotibial band. A 10 mm reamer was then used just at the lateral femoral epicondyle. The graft was placed into this 10 mm hole and a 9 x 28 mm Delta biodegradable screw was used to affix this. There was excellent fixation of the lateral ligament reconstruction. A Pegasus graft was then placed over this area and sutured in with a FiberWire for augmentation. This allowed for excellent position and excellent reconstruction of the lateral ligaments.

The wound was copiously irrigated with arthroscopic irrigation. An On-Q pain pump was placed into the suprapatellar pouch. All incisions were closed with the deep fascia closed with #1 Vicryl figure-of-eight suture, subcutaneous tissue with a 2-0 Vicryl undyed interrupted suture and the skin was closed with staples. Then, 30 mL of 0.5% Marcaine was injected around the incisions. Sterile dressings were applied. Compressive-type Ace bandage from toe to the groin was placed over a hot ice pad. Range of motion brace from 0 to 60 degrees was placed. Tourniquet was released. Tourniquet time was 120 minutes.  The patient was then awakened and taken to the recovery room in stable condition.

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Quadriceps Tendon Repair Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY 

PREOPERATIVE DIAGNOSIS:  Left quadriceps tendon rupture.

POSTOPERATIVE DIAGNOSIS:  Left quadriceps tendon rupture.

OPERATION PERFORMED:  Repair of left quadriceps tendon rupture.

SURGEON:  John Doe, MD 

ANESTHESIA:  General with postoperative femoral block.

ESTIMATED BLOOD LOSS:  Minimal.

URINE OUTPUT:  Zero.

FLUIDS:  1250 mL of crystalloid.

TOURNIQUET TIME:  60 minutes.

DESCRIPTION OF OPERATION:  The patient was seen in the preoperative holding area where the left lower extremity was marked as the correct site per the preoperative protocol. The patient received IV Ancef for antibiotic prophylaxis. He was then brought back to the operating room where he underwent general anesthesia per the anesthesia service without complications.

The left lower extremity was prepped and draped in the usual sterile fashion. The leg was exsanguinated and tourniquet was inflated to 250 mmHg. A midline incision was made curving just slightly medial to distal extent. Sharp dissection was performed down through the skin and subcutaneous tissues. There was noted to be a complete rupture of the quadriceps tendon just proximal to the insertion. There was extension to both the medial as well as the lateral retinacula. There was a moderate amount of hematoma noted, which was expressed from the joint and lavaged with sterile saline. There was mild to moderate articular cartilage. No fractures were noted. At that point, the tendon edges were gently debrided several millimeters down, back to healthy-appearing tissue. The superior pole of the patella was then prepared using rongeur and a curette down to the bleeding bony surface. At that point, #5 Ethibond x2 were used to run a total of 4 strands of suture coming out distally in a running locking-type stitch. There was excellent tension taken up in the sutures with no gapping noted. 

At that point, Beath needles were then placed in a staggered fashion through the patella, coming out near the inferior extent. Each of these was separated by a little bit more than a centimeter. The middle two sutures were then passed through the middle hole, followed by the medial and lateral sutures, out through their respective holes. Hemostats were then placed and we felt the repair to take up excellent tension without undue stress to about 30 degrees of knee flexion. At that point, the knee was then extended and the Ethibond sutures were tied. It should be noted that there was excellent stability of the patella within the trochlea without subluxation noted. The repair was reinforced with #1 Vicryl as well as the retinacular extension both medial and lateral. We felt we had an excellent repair. Again, the extremity flexed easily at 30 degrees without undue tension on the repair.

Subcutaneous tissues were closed with 2-0 Vicryl followed by running 3-0 Prolene suture for the skin. Steri-Strips were applied. A sterile dressing followed by an Ace wrap was then applied, followed by a knee immobilizer locked in extension. Tourniquet was deflated after 60 minutes. The patient was then given a femoral block by the anesthesia service. The patient was then awakened in the operating room, extubated and transferred to postanesthesia recovery in stable condition.

Lumpectomy / Sentinel Node Biopsy Medical Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Right breast cancer.

POSTOPERATIVE DIAGNOSIS:  Right breast cancer with axillary metastasis.

OPERATION PERFORMED:
1.  Right axillary sentinel node biopsy.
2.  Lumpectomy, right breast.
3.  Completion axillary node dissection.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

DESCRIPTION OF OPERATION:  The patient underwent radionucleotide injection in nuclear medicine and lymphoscintigraphy showed sentinel nodes visible by lymphoscintigram in the right axilla. There was faint uptake in a couple of internal mammary nodes as well, but very intense uptake in the axilla. The patient was placed in the supine position, and after satisfactory induction of general anesthesia, 500 mg of Levaquin was given intravenously. Isosulfan blue dye 4 mL was then injected into the breast in the subareolar fashion. The breast was then massaged briefly. The right breast, axilla, upper chest, neck and arm were prepped with Betadine and draped in the sterile fashion. A 5-minute massage of the right breast was then conducted on the clock to allow the blue dye to enter the lymphatics.

At the conclusion of that, a transverse incision was made in the lower end of the axilla after anesthetizing the skin with 0.5% Marcaine with epinephrine. The incision was carried deeper into the axillary tissue and a blue-stained lymphatic was identified and traced distally to a very firm and large node, which was partially blue stained and highly radioactive. This was dissected free from its surrounding tissue. It grossly was positive for metastatic disease. It was hard and lobulated. There was a second blue-stained node just posterior to that, which also was radioactive. Both of these were completely dissected free and labeled sentinel node #1 and sentinel node #2 respectively. Both were sent to pathology for immediate evaluation. Both were found to have metastatic carcinoma by touch imprint cytology. A completion axillary dissection was then performed, dividing axillary contents away from the breast tissue using cautery. It was then dissected away from the lateral chest wall and extended up towards the apex of the axilla. The axillary vein was visualized, but not stripped, and the axillary contents were dissected laterally away from the chest wall. There were additional firm nodes palpable within these axillary contents. Specimen was then dissected away from the anterior border of the latissimus muscle. It should be noted that an intercostobrachial nerve branch was identified and preserved during the dissection. The axillary contents were then sent to pathology for routine examination. There were no palpable suspicious nodes remaining after completion of the dissection. The wound was irrigated with sterile water and hemostasis was secured with cautery. A large Blake drain was inserted into the axilla and brought out through a separate stab incision inferiorly and secured to the skin with 2-0 silk stitch. The subcutaneous tissue was then closed with interrupted 3-0 Vicryl. The skin was closed with running subcuticular suture of 4-0 Vicryl. Drain was connected to a bulb suction.

At that point, attention was then turned to the right breast, and the skin was marked for an elliptical incision overlying the palpable mass. The palpable mass was in the lower inner quadrant at the edge of the breast tissue. Marcaine 0.5% with epinephrine was injected in the proposed skin incision. An incision was then made with a #15 scalpel blade and carried through the skin and subcutaneous fat and straight down to the chest wall. The specimen was completely dissected from the chest wall taking pectoralis fascia. The specimen was oriented for the pathologist with sutures and sent for routine examination. The wound was irrigated with sterile water. Hemostasis was secured with cautery. Breast parenchyma was mobilized and then closed with interrupted 3-0 Vicryl. The subcutaneous tissue was closed with interrupted 4-0 Vicryl. The skin was closed with running subcuticular suture of 5-0 Vicryl. Benzoin and Steri-Strips were applied followed by 4 x 4 and Tegaderm dressing. Benzoin, Steri-Strips, 4 x 4 and Tegaderm were applied to the axillary incision as well. Gauze was placed around the drain and taped in place. Estimated blood loss was 25 mL. Counts were correct. The patient tolerated the procedure well and was taken to the recovery room in good condition.

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Left Medialization Laryngoplasty Medical Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY
 
PREOPERATIVE DIAGNOSIS:  Left vocal fold paralysis secondary to lung carcinoma.
 
POSTOPERATIVE DIAGNOSIS:  Left vocal fold paralysis secondary to lung carcinoma.
 
OPERATION PERFORMED:  Left medialization laryngoplasty.
 
SURGEON:  John Doe, MD
 
ESTIMATED BLOOD LOSS:  25 mL.
 
ANESTHESIA:  Local sedation.
 
COMPLICATIONS:  None.
 
DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed in the supine position.  He was placed on a shoulder roll.  He had received IV Versed as well as fentanyl and was receiving oxygen via nasal cannula.  With the neck in extension, the laryngeal landmarks were palpated.  Approximately 6 mL of 1% Xylocaine with 1:100,000 epinephrine was infiltrated into the skin and subcutaneous tissues from the midline of the laryngeal cartilage laterally approximately 4 cm.  Next, the neck was prepped and draped in the usual fashion.  A pledget with Afrin and Pontocaine was placed into the right nasal cavity for vasoconstriction.  He received preoperative clindamycin and 10 mg of Decadron.  The thyroid notch, cricoid cartilage and midline of the cricoid cartilage were identified.  An incision just below the midpoint of the thyroid cartilage was made through skin and subcutaneous tissue.  The incision was approximately 5 cm through skin and subcutaneous tissue.  Superior and inferior skin flaps were elevated with the Bovie.  The flaps were retracted superiorly and inferiorly.  The strap muscles were identified in the midline and divided along the midline raphe and dissected off of the thyroid cartilage.  The perichondrium of the thyroid lamina was divided with the Bovie and elevated to the posterior aspect of the thyroid lamina with the Freer elevator.  Hemostasis was achieved with bipolar cautery.  There was some transient significant bleeding from the edge of the strap muscle, which was controlled with bipolar cautery.
 
The template for the implant, which measured approximately 0.5 cm x 1 cm, was obtained.  The dimensions of the larynx were measured.  The vertical height of the thyroid cartilage measured 20 mm.  The midline of the thyroid cartilage was marked with the Bovie at 10 cm from the inferior aspect of the thyroid cartilage.  The template was brought posterior to the midline approximately 9 mm.  The template was then used to demarcate the area of the thyroid cartilage, where our thyroplasty window would be created.  This was marked with a #11 blade and then a Bovie.  A 3 mm cutting bur was then used to create a window into the thyroid lamina.  After this had been egg-shelled, the remaining thyroid cartilage over the window was then removed with a Freer elevator, keeping the inner perichondrium intact.  The inner perichondrium was then elevated with a perichondrial elevator circumferentially around the medial aspect of our thyroplasty window.  A 5 mm implant was placed through the thyroplasty window; however, this appeared too big, as the patient had developed some stridor after the sizing implant was placed.  A 4 mm implant device was then placed and the patient asked to phonate.  His voice remained hoarse when the implant was in the anterior portion of the window.  The implant was positioned in the most posterior aspect of the thyroplasty window and this afforded him an excellent voice without stridor.  So, the sizing device was then removed.  The actual hydroxyapatite implant was placed through the thyroplasty window and rotated into its vertical position and slid posteriorly.  The patient was asked again to phonate, which revealed a very satisfactory voice.  A 0 mm hydroxyapatite shim was then placed in the anterior aspect of the thyroplasty window and snapped into place to secure the implant.
 
A flexible fiberoptic laryngoscopy was then performed, which showed excellent medialization of the left cord.  The wound was then copiously irrigated.  A Penrose drain was placed between the inner perichondrium and the implant to allow for drainage.  The strap muscles were approximated in the midline with 3-0 Vicryl and the skin closed with 4-0 Vicryl and 5-0 nylon sutures.  A fluff and Kling dressing were placed on the neck.  The patient was awakened from the sedation and transferred to the recovery room, having tolerated the procedure well.

Stereotactic Mammotome Biopsy Medical Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREPROCEDURE DIAGNOSIS: Microcalcifications, right breast, x2. 

POSTPROCEDURE DIAGNOSIS: Microcalcifications, right breast, x2.

PROCEDURE PERFORMED:  Stereotactic Mammotome biopsy, right breast, with clip localization x2.

SURGEON:  John Doe, MD 

ANESTHESIA:  Local.

DESCRIPTION OF PROCEDURE:  The patient was brought to the stereotactic room and placed prone on the table with the right breast compressed in the lateral to medial fashion. The clusters of calcifications in the upper outer quadrant were identified on scout images. Stereotactic views were obtained. The lesion was targeted. Mammographic coordinates were calculated. The breast was prepped with ChloraPrep and anesthetized with 1% lidocaine. A 3 mm puncture incision was made through the skin and an 11 gauge Mammotome probe was inserted and directed to the calcifications using the mammographic coordinates. Prefire images were obtained revealing good position of the probe. Corrections made on the X-axis and the device was fired. Postfire images revealed accurate position of the probe. Following that, the mechanical cutter was activated. Tissue was cut, excised and transported through the probe. Multiple samples of tissue were obtained, rotating the thumbwheel two full turns through the hands of the clock. Samples were sent for specimen radiography, which revealed multiple samples of calcifications within the specimens. Specimens were then sent to pathology for routine examination labeled site A. The probe was backed out of the breast 5 mm and the biopsy cavity was vacuumed free of blood. A Gel Mark Ultra clip was inserted via the probe and deployed in the biopsy cavity in the usual fashion. The probe was rotated 180 degrees and removed from the breast. The breast was then released from compression and pressure held over the biopsy site till bleeding subsided. It was then dressed with Steri-Strips.

The patient was then recompressed in the cranial to caudal position and scout image was again obtained to identify the clustered calcifications in the retroareolar region. Stereotactic views were obtained and the lesion was targeted and mammographic coordinates were calculated. The breast was again prepped with ChloraPrep and anesthetized with 1% lidocaine. A 3 mm puncture incision was made through which a new 11 gauge Mammotome probe was inserted and directed to the calcifications using the mammographic coordinates. Correction was made on the X-axis and the device was fired. It was noted that there was still a fairly significant X correction and X error. However, sampling was done through the 6 to 12 o'clock position, going through 9 o'clock in an effort to get the calcifications. Sampling was done through the hands of the clock twice, and these samples were sent for specimen radiography. No calcifications were noted within those samples and the probe was removed from the breast and a stereotactic view was obtained. The calcifications were noted to still be within the breast and approximately 2 cm away from the biopsy cavity. The calcifications were again retargeted and new set of mammographic coordinates were calculated. At this point, the new mammographic coordinates were not within the confines of the breast and it was not felt possible to obtain these calcifications through the craniocaudal approach. Therefore, the needle was removed from the breast and the breast was released from compression. That puncture site was dressed with Steri-Strips and patient was repositioned compressing the breast in a lateral to medial fashion. The cluster of retroareolar calcifications was again identified in the lateral to medial compression on a scout image and stereotactic views were obtained. The lesion was targeted and a new set of mammographic coordinates were calculated. These calculations were well within the breast parenchyma.

A third puncture incision was made after anesthetizing skin again with 1% lidocaine. The probe was then inserted following mammographic coordinates. Prefire images were obtained revealing reasonably good position of the probe. However, a slight correction was made on the Y-axis and the device was fired. Postfire images revealed good position of the probe. The mechanical cutter was then activated. Tissue was cut, excised and transported through the probe. Multiple samplings of tissue were obtained, rotating the thumbwheel two full turns through the hands of the clock. Samples were then sent for specimen radiography, which revealed multiple calcifications within the samples. Probe was backed out of the breast 5 mm and a MicroMark clip was inserted using the probe and deployed in the biopsy cavity in the usual fashion. The probe was rotated 180 degrees and removed from the breast. The second set of samples was sent to pathology for routine examination labeled site B. The breast was then released from compression and pressure held over the biopsy site until bleeding subsided. The third puncture site was then dressed with Steri-Strips as well. The patient was then removed from the table and taken for routine 2-view mammography. The patient tolerated the procedure well and had no immediate complications.

Distal Radius Fracture ORIF Medical Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left distal radius fracture.

POSTOPERATIVE DIAGNOSIS:  Left distal radius fracture.

OPERATION PERFORMED:  Open reduction and internal fixation of left distal radius fracture.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  Minimal.

SPECIMENS:  None.

DRAINS:  None.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  Risks and benefits of the operation were explained to the patient. Alternatives were also discussed with the patient. The patient elected to proceed. Consent for surgery was obtained. The patient was brought to the operating room and placed on the operating table in the supine position. After administration of general anesthesia, the left upper extremity was prepped and draped in the usual sterile fashion. The extremity was exsanguinated with an Esmarch and tourniquet on the upper arm was inflated.

An incision was made on the volar aspect of the wrist over the distal flexor carpi radialis tendon. Dissection was taken through the subcutaneous tissues to the tendon sheath. The tendon sheath was incised longitudinally and the tendon was retracted. The floor of the sheath was then incised longitudinally. Distal fascia was also incised. The pronator was exposed. The fracture was seen disrupting a portion of the pronator. The pronator was detached radially and distally and reflected off of the volar surface of the distal radius. The fracture was then reduced. Manipulation of all fragments produced excellent reduction of the fracture. A 0.062 K-wire was then passed percutaneously to the radial styloid. This pin was then passed across the fracture and engaged the more proximal ulnar cortex of the radius, maintaining reduction of the fracture. A volar distal radial plate was then applied to the bone and positioned under the image intensifier. A proximal screw was then placed to secure the plate. Distally, locking screws were placed through the plate into the distal fragment. Each of these was placed under fluoroscopic guidance. The radial-most screw was placed at the styloid. The ulnar-most screw captured dorsal ulnar corner of the distal radius. The K-wire was then removed. Two additional proximal screws were placed through the plate. Reduction of the fracture was near anatomic. Position of the plate and all screws were visualized in multiple projections with the image intensifier. The fracture was stable with fixation.

The wound was irrigated with copious amounts of sterile solution. Pronator was repaired to the radial side with 3-0 PDS suture. The floor of the FCR sheath was also repaired with PDS suture. The subcutaneous tissues and skin were then closed with Monocryl suture. A dressing was applied. The tourniquet was deflated. Splint was applied. The patient was awoken from anesthesia and taken to the recovery room in stable condition.


Canal Wall Up Tympanomastoidectomy Medical Transcription Operative Sample Report / Example

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Right-sided recalcitrant chronic otitis media.

POSTOPERATIVE DIAGNOSIS:  Right-sided recalcitrant chronic otitis media.

OPERATIONS PERFORMED:
1.  Right canal wall up tympanomastoidectomy.
2.  Microdissection.
3.  Right-sided facial nerve neural monitoring.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  Less than 50 mL.

COMPLICATIONS:  None.

SPECIMENS:  Middle ear tympanic membrane for pathology. Middle ear and mastoid contents were sent for culture and sensitivity including aerobic, anaerobic, fungal and TB.

IMPLANTS:  None.

DRAINS:  None.

OPERATIVE FINDINGS:  Inflamed and mucosalized tympanic membrane with perforation along with mucopus coming through the perforation. In addition, the middle ear mucosa was noted to be inflamed.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and placed supine on the operating table. After adequate general anesthesia had been obtained by endotracheal intubation, the patient was appropriately positioned and padded on the table. Attention was then turned to the right ear and right face. Facial nerve monitoring electrodes were placed into the orbicularis oculi and orbicularis oris muscles on the right side. The facial nerve monitoring and EMG system was then used throughout the procedure. There were never any abnormal or traumatic EMG potentials. Stimulating dissecting instruments were used when dissecting on the facial nerve. There were never any traumatic potentials. Lidocaine 1% with 1:100,000 epinephrine was injected into the postauricular region. The patient's right ear was then prepped and draped in standard surgical fashion. The operative microscope was used throughout the vast majority of the procedure except for the skin incision and skin closure. The patient's ear canal was cleaned. There was noted to be mucopus coming out through a tympanic membrane perforation in the inferior quadrant. In addition, the tympanic membrane was noted to be mucosalized and inflamed. Lidocaine 1% with 1:100,000 epinephrine was injected into the four quadrants of the ear canal.

A postauricular incision was then made 1 cm outside the postauricular crease. This was carried down to the level of the mastoid periosteum. Superiorly, temporalis fascia was identified and harvested for later grafting. A T-shaped mastoid periosteal incision was made and the entire mastoid cortex exposed. Elevation was carried into the ear canal. Canal incisions were then made 8 mm lateral to the annular rim. The ear canal was exposed. A tympanomeatal flap was elevated and the middle ear space was entered. Mucopus was then cultured and sent for culture and sensitivity. The chorda tympani nerve was preserved throughout the procedure. There was noted to be granulation tissue around the incus and the stapes, which was dissected free. Palpation of the malleus revealed the malleus and incus were noted to be mobile and it appeared the stapes was mobile, though view was limited secondary to granulation tissue around the base of it. The mucosalized portion of the tympanic membrane was resected, which left a large perforation on the drum. The periosteum of the malleus was incised and the tympanic membrane elevated off the malleus. The CO2 laser at 5 watt single pulse was used to help with dissection along with the release of some middle ear adhesions.

With a drill, a canal wall up mastoidectomy was performed. The tegmen was noted to be intact; sigmoid covered. Lateral semicircular canal intact. Mastoid air cells had mucus along with mucopus and thin granulation tissue and adhesions were present. Adhesions within the epitympanum were lysed. At this point, there was noted to be free flow of fluid within the mastoid and the middle ear space. Specimens were sent from mastoid for culture and sensitivity. The wound was copiously irrigated with bacitracin solution. There was noted to be good hemostasis. At this point, Gelfoam soaked in Ciprodex was packed in the middle ear cleft. A fascia graft was then trimmed.  It was placed in an over-under fashion over the handle of the malleus but underneath the tympanic membrane. There was noted to be good coverage of the large perforation. The grafted tympanomeatal flap was then redraped along the posterior ear canal. Further Gelfoam soaked in Ciprodex was packed lateral to this flap. The lateral meatal flap was realigned along the ear canal, followed by further Gelfoam and Ciprodex packing. Laterally, an ear pack was used.

The postauricular incision was then closed in three layers. Dermabond was used for the superficial skin closure. A sterile mastoid dressing applied. Facial nerve monitoring electrodes were removed. The patient was then awakened by the anesthesia service, extubated and taken to the recovery room in stable condition. There were no intraoperative complications and the patient tolerated the procedure well.


Urgent Double Bypass Surgery Medical Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Unstable angina.
2.  Severe calcific triple-vessel coronary artery disease with critical left main coronary artery stenosis with total occlusion of the right coronary artery.

POSTOPERATIVE DIAGNOSES:
1.  Unstable angina.
2.  Severe calcific triple-vessel coronary artery disease with critical left main coronary artery stenosis with total occlusion of the right coronary artery.

OPERATIONS PERFORMED:
1.  Urgent double bypass surgery.
2.  Surgical myocardial revascularization using a reverse autologous greater saphenous vein as the aortocoronary conduit bypassing the ramus intermedius coronary artery and using a left internal mammary artery as a conduit to bypass the left internal descending coronary artery with endoscopic vein harvest techniques.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

DESCRIPTION OF OPERATION:  The patient was brought to the operating suite and placed in the supine position. After satisfactory induction of general endotracheal anesthesia, the patient was prepped and draped in the usual sterile fashion and the greater saphenous vein was harvested from the left leg using endoscopic vein harvest technique. The tributaries of the vein were divided and ligated and the wounds were closed in layers using Vicryl sutures. A median sternotomy incision was made. The sternum was opened carefully using the electric saw. The pericardium was opened and suspended. The left internal mammary artery was harvested as a pedicle up to the level of subclavian vein and placed in a papaverine-soaked sponge, at which time we heparinized the patient using 4 mg/kg of heparin. This was allowed to circulate. The aorta and right atrium were cannulated in routine fashion. The patient was placed on extracorporeal circulation and systemically cooled. The aorta was gently cross-clamped. Cold blood cardioplegia was used to arrest the heart. This was repeated every 15 minutes and as needed to maintain hypothermic diastolic arrest. Topical coolant was also maintained using iced saline solution to the pericardial well.

Reverse autologous greater saphenous vein was used for the aortocoronary conduit bypassing the ramus intermedius coronary artery. The distal anastomoses were fashioned using running 7-0 Prolene suture. Proximal anastomosis to the aorta using running 6-0 Prolene suture. The left internal mammary artery was then anastomosed in an end-to-side fashion to the left anterior descending coronary artery using a running 8-0 Prolene suture. The pedicle then tacked to the epicardium using a 6-0 Prolene suture. The procedure was performed under one cross-clamp.

The patient was then systemically rewarmed. The heart started to spontaneously beat. Once everything was satisfactory, the patient was easily weaned from cardiopulmonary bypass without difficulty. Protamine sulfate was given to reverse the heparin and the patient was decannulated. Cannulation sites were next reinforced. Warm antibiotic saline solution was used for irrigation. Attention was then directed at closing. Mediastinal and pleural tubes were placed. The sternum was closed using sternal wire. The fascia, skin and subcutaneous tissues were approximated using Vicryl sutures. Dressings were applied and 0.25% Marcaine was used as a parasternal block. The patient tolerated the procedure well and was sent to the cardiovascular intensive care unit in stable condition.


Second Stage Hypospadias Repair Medical Transcription Operative Sample / Example Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Hypospadias, status post multiple repairs.

POSTOPERATIVE DIAGNOSES:
1.  Hypospadias complications, status post multiple repairs.
2.  Recurrent chordee.

OPERATIONS PERFORMED:
1.  Redo second stage hypospadias repair following multiple prior operations.
2.  Nesbit dorsal plication.
3.  Artificial erection.

ANESTHESIA:  General and caudal.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room, general anesthesia administered and a caudal block placed. He was then positioned supine and prepped and draped in the usual sterile manner. Tourniquet was placed around the base of the penis and sterile injection with saline injected through a butterfly needle into the corporeal bodies. This revealed that there was still residual ventral chordee, most notably distally, over the ventral tilt of the glans. In light of this, we decided to perform plication to further straighten it. Incision was made transverse along the circumcising line dorsally, for less than 1 cm, and dissection proceeded to expose the corporeal bodies. Transverse parallel incisions were made into the corpora, in the proximal aspect and brought to the distal with interrupted 5-0 Vicryl sutures comparing the intervening bridge. The overlying Buck fascia was closed with a running 6-0 Vicryl. The skin on the surface was closed with several interrupted 5-0 chromic sutures. Artificial erection test was repeated which showed the penis was now completely straight with no residual ventral chordee.

Attention was then turned towards urethroplasty. Initially, a 10 French Foley catheter was placed into the bladder and some urine drained. The balloon was not inflated to allow the catheter to be changed later. With tourniquet in place, we then incised the dorsal midline of the urethra, where it was tight and narrowed. This allowed slight relaxation of the distal segment. Thus, we widened the markings in a couple of areas which included the narrowest. We made the transverse parallel incisions, then came around proximal to the meatus. The glans wings and penile shaft skin were then elevated to mobilize them. This was done just superficial to the corporal bodies. A flap of dartos tissue was then developed along the left lateral aspect to mobilize, to allow later coverage over the urethra. This was done by dissecting proximally, particularly on the left ventral aspect. Once that was completed and adequate glans wings had been developed, we then turned our attention towards the second-stage redo urethroplasty.

The graft was quite adherent and stuck down and thus we had to perform extensive sharp dissection to mobilize the lateral aspects of the medial urethra to allow to roll into a new urethra. This was pretty dense scar tissue, which required to be divided to mobilize these edges. Once that was accomplished, then the new urethra was formed using interrupted 7-0 Vicryl sutures, first with interrupted layer to approximate the edges and then a running inverting layer. The dartos flap was then brought overlying the urethra and tacked in place with interrupted 7-0 Vicryl sutures to avoid overlapping suture lines. Glansplasty was then performed by bringing the glans together with interrupted 6-0 Vicryl horizontal mattress sutures. The meatus was matured to the entrance of the glans with interrupted 7-0 Vicryl and redundant dog ears trimmed on either side. Once that was accomplished, then the ventral glans skin was closed with a running locking 7-0 Vicryl stitch. The skin was then reconfigured in the ventral area, incorporating it. We trimmed a couple of dog ears from the transverse closure along the proximal glans to bring the skin together and then the ventral midline skin of the remainder of the shaft. The dog ear was trimmed proximally along the penile shaft skin.

The tourniquet was then released and attention turned towards the dressing. The catheter had been changed to an 8 French Firlit-Kluge stent and this was secured to the glans with interrupted 7-0 Vicryl sutures. Next, a dressing was placed which consisted of Owens gauze soaked in benzoin, wrapped with Coban and taped to lower abdominal wall. This allowed drainage freely into double diapers. The patient was then awakened and brought to the recovery room. He tolerated the procedure without complications. All counts were correct.

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Cervical Epidural Steroid Injection Medical Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD 

PREPROCEDURE DIAGNOSIS:  Cervical radiculopathy.

POSTPROCEDURE DIAGNOSIS:  Cervical radiculopathy.

PROCEDURE PERFORMED:  Cervical epidural steroid injection with fluoroscopy.

ANESTHESIA:  Local with IV sedation.

DESCRIPTION OF PROCEDURE:  The patient was brought into the operating room and laid in a prone position. The patient's neck was prepped and draped in the usual sterile fashion. The skin and underlying subcutaneous tissues overlying the C7-T1 cervical epidural space was identified and infiltrated with 5 mL of 1% plain lidocaine. At this juncture, a 17 gauge Tuohy needle was advanced through the anesthetized area into the cervical epidural space. Loss of resistance was confirmed with air and saline. A nonstyletted epidural catheter was passed up to the level of C5-C6 on the left side and 2 mL of Isovue dye confirmed spread of the medication along the C6 nerve root. Four mL of preservative-free normal saline with 120 mg of Kenalog was administered and the needle was removed. A bandage was placed over the injection site and the patient was returned to the supine position and to the recovery room in stable condition. There were no complications as a result of the procedure.

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DATE OF PROCEDURE:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD 

PREPROCEDURE DIAGNOSES:
1.  Cervical radiculopathy.
2.  Lumbar radiculopathy.

POSTPROCEDURE DIAGNOSES:
1.  Cervical radiculopathy.
2.  Lumbar radiculopathy.

PROCEDURE PERFORMED:  Cervical epidural steroid injection under fluoroscopic guidance.

ANESTHESIA:  Local anesthetic with IV sedation.

DESCRIPTION OF PROCEDURE:  The patient was brought to the procedure suite and positioned on the bed in the prone position. The area overlying the cervical and upper thoracic spine was prepped and draped in the usual sterile fashion. Using a 25 gauge needle, 1% lidocaine, roughly 5 mL was used to anesthetize the skin overlying C7-T1 epidural space. A 20 gauge epidural needle was used to find the epidural space using loss of resistance to both air and saline. Approximately 3 mL of Isovue-M 300 dye was injected showing bilateral spread to the level of bilateral C5 nerve root through T1. Negative for intravascular or intrathecal spread. Approximately 4 mL of 120 mg of Kenalog plus 2 mL of preservative-free normal saline was injected without complication. The needle was then removed. Sterile dressing was then placed. The patient was returned to supine position and brought to recovery room in stable condition.

*********************************************************************************

DATE OF PROCEDURE:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD 

PREPROCEDURE DIAGNOSES:
1.  Cervical radiculopathy.
2.  Herniated disk at C5-C6.

POSTPROCEDURE DIAGNOSES:
1.  Cervical radiculopathy.
2.  Herniated disk at C5-C6.

PROCEDURE PERFORMED:  Cervical epidural steroid injection under fluoroscopy, injection #2.

ANESTHESIA:  Local with IV sedation.

DESCRIPTION OF PROCEDURE:  The patient was brought to the fluoroscopy imaging suite and positioned prone on the imaging table. The patient was sedated with Versed and fentanyl intravascularly. The neck area was prepped with Betadine and draped in a sterile fashion. With the C-arm in AP projection, cervical vertebral bodies were identified and C6-C7 interspace was selected for epidural injection. Lidocaine 1% was injected locally with a 25 gauge needle. With 18 gauge Tuohy, loss of resistance to air technique, epidural space was identified under fluoroscopic guidance. After reaching the epidural space, after negative aspiration for blood and CSF, 2 mL of Isovue-M 300 was injected and good epidural spread of the dye was confirmed with AP and lateral view on the C-arm. Again, after negative aspiration for blood and CSF, 120 mg of Kenalog with 2 mL of 0.25% Marcaine and 2 mL of preservative-free 0.9 normal saline was injected into the epidural space and the needle was removed. Sterile dressing was applied. The patient tolerated the procedure well without any complications. The patient was monitored in the clinic for an hour and discharged home in stable condition.


Submental Liposuction / Abdominoplasty Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Submental lipodystrophy.
2.  Abdominal laxity.

POSTOPERATIVE DIAGNOSES:
1.  Submental lipodystrophy.
2.  Abdominal laxity.

OPERATION PERFORMED:
1.  Ultrasonic liposuction, submental.
2.  Abdominoplasty with diastasis repair and translocation of umbilicus.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  100 mL.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room in the sitting upright position. The submental area was marked for liposuction and the abdomen was marked for abdominoplasty, marking a long, low transverse incision from hip to hip, crossing the pubic hairline and moving onto the opposite side in the identical fashion. The incision was then marked from the edge of that, marking up and around the umbilicus and around to the opposite side. The patient was then placed supine on the operating room table. General anesthesia was administered and the procedure was begun by tumescence of the submental area with 60 mL of normal saline, incorporating 10 mL of 1% lidocaine with epinephrine. After skin blanch was noted, a 3 mm incision was made in the submental area and the ultrasonic catheter was inserted and approximately 2 minutes of ultrasonic energy used in the submental and neck area, emulsifying fat, and then using a 3 mm cannula, the submental area was liposuctioned until the contour desired was achieved and the thickness of the flap was achieved. A single 6-0 nylon was used to close the incision.

Then, attention was directed to the abdomen which was prepped and draped in a routine fashion. A Foley catheter had been inserted preoperatively. SCD boots had been applied preoperatively and 1 gram of Ancef had been given preoperatively. The procedure was then begun, making a low transverse incision as marked below the top of the pubic hairline, extending from hip to hip and actually beyond the inferior iliac crest on each side. The incision was continued through the subcutaneous tissues using electrocautery down to the fascia. The flap was then elevated, releasing the scar adhesions up to the level of the umbilicus. An incision was made around the umbilicus, which was quite retracted and scarred in, releasing the umbilicus. Then, the umbilical stalk was dissected down to the fascia. The flap was then divided from the umbilical opening to the free edge and then the flap was elevated above the umbilicus at the fascial plane, separating the subcutaneous tissue from the fascia up to the xiphoid and extending across the costal margins lateral to the xiphoid. Meticulous hemostasis was achieved. The midline was plicated using #1 Nurolon from xiphoid to pubis and then a second layer was used from pubis to umbilicus using a running locking suture of #1 Nurolon. After this was completed, the wounds were reinspected for hemostasis. Drains were inserted. A drain on the right, lateral to the incision, was brought up and around the upper flap and from the left side across beneath the umbilicus. The bed was then placed into semi-Fowler's position. The flap was retracted inferiorly. The incision was then made as marked, extending from hip to hip above the old umbilical opening and the subcutaneous tissue divided with electrocautery and the lateral corners were defatted. Meticulous hemostasis was achieved and the wound was closed in layers, approximating the midline and restoring the midline, which was deviated from previous scarring.

The Scarpa's fascia was closed with 2-0 Vicryl, the subdermal plane with 3-0 Vicryl and running intracuticular 3-0 Monocryl all the way across. The future position of the umbilicus was marked before wound closure was completed, and this ellipse was then incised and a core of fat was resected. Significant amount of defatting was required to facilitate bringing the umbilicus to the skin level and close the wound, suturing the umbilicus in position with 4-0 Vicryl and a running horizontal mattress of 5-0 nylon. Good contours were achieved. The patient tolerated the procedure well. A chin strap had been applied around the submental area at the conclusion of the liposuction, and at this time, the wounds of the abdomen were dressed with bacitracin ointment, Adaptic, ABD pads and a gently fitting elastic abdominal binder. The patient was moved to a bed in the semi-Fowler's position and returned to recovery in good condition after extubation.

Bronchoscopy Medical Transcription Sample / Example Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREPROCEDURE DIAGNOSIS:  Nodular infiltrates, rule out carcinoma, tuberculosis, fungal infection, allergic alveolitis or pneumonia.

POSTPROCEDURE DIAGNOSES:
1.  Nodular infiltrates, rule out carcinoma, tuberculosis, fungal infection, hypersensitivity pneumonitis or pneumonia.
2.  Leukoplakia of the vocal cords.

PROCEDURE:  Bronchoscopy.

PHYSICIAN:  John Doe, MD

PREMEDICATIONS:
1.  Demerol 50 mg.
2.  Phenergan 12.5 mg.
3.  Atropine 0.4 mg IM.
4.  Versed 0.5 mg IV.

ANESTHESIA:  Xylocaine 4% solution by updraft, cocaine 4% solution nasally, Xylocaine 2% solution through the bronchoscope.

SPECIMENS:  Bronchoalveolar lavage will be sent for Gram stain, culture and sensitivity, AFB smear, TB culture, direct and TB smear, fungal smears and culture, differential cell count and cytology.

PROCEDURE FINDINGS:
1.  Bilateral leukoplakia on the vocal cords.
2.  Diffuse tracheobronchitis.
3.  Patent segmental airways.
4.  Status post bronchoalveolar lavage, brushings and transbronchial biopsies from the right lower lobe with minimal bleeding.
5.  Touch preps of the specimens consistent with a necrotizing inflammatory process, but no malignancy or fungal element seen.

DESCRIPTION OF PROCEDURE:  The patient was premedicated with Demerol 50 mg, Phenergan 12.5 mg and atropine 0.4 mg IM. He received a treatment with Xylocaine 4% solution by updraft. His nasal mucosa was anesthetized with cocaine 4% solution applied by Q-tips. Additional 2% Xylocaine was given through the bronchoscope. The patient was breathing oxygen at 2 liters per minute by nasal prongs. He received additional Versed 0.5 mg IV for sedation. The Olympus fiberoptic bronchoscope was introduced transnasally into the posterior pharynx and vocal cords were visualized. There were bilateral whitish plaques on the cords consistent with leukoplakia. The cords otherwise moved well. The bronchoscope was then passed through the cords and the tracheobronchial tree was inspected. There was diffuse tracheobronchitis with slight viscous secretions noted. The segmental areas of the right upper lobe, right middle lobe, right lower lobe, left upper lobe, lingula and left lower lobe were patent with no fixed endobronchial obstructing lesions, active bleeding or mucous plugs.

The bronchoscope was then inserted into the right lower lobe and 20 mL aliquots of saline was lavaged into the right lower lobe with the return of nonpurulent and bloody solution. A brush was then passed though working channel of the bronchoscope and the brushings were taken from the periphery under fluoroscopic guidance. A biopsy forceps was then passed through the working channel of the bronchoscope, and under fluoroscopic guidance, transbronchial lung biopsies were taken from the various segments of the right lower lobe. There was minimal bleeding noted. Touch preps from the biopsies and also the brushings were consistent with a somewhat necrotizing inflammatory process, but no malignant cells or fungal elements were seen. After adequate clearing of secretions was accomplished, the bronchoscope was removed from the patient and the procedure was ended. The patient tolerated the procedure well and there were no complications. Post-bronchoscopy chest x-ray revealed good expansion without pneumothorax.


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