Upper Lobectomy Mediastinal Dissection Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Left upper lobe lung cancer.
2.  History of cigarette smoking.
3.  Cleared for surgery by primary care and Pulmonary Medicine.
4.  PET scan does not reveal evidence of metastatic mediastinal or distant disease.

POSTOPERATIVE DIAGNOSES:
1.  Left upper lobe lung cancer.
2.  History of cigarette smoking.
3.  Cleared for surgery by primary care and Pulmonary Medicine.
4.  PET scan does not reveal evidence of metastatic mediastinal or distant disease.

OPERATION PERFORMED:
1.  Left upper lobectomy.
2.  Mediastinal dissection, lymph node dissection.
3.  Accufuser bupivacaine pump insertion.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ANESTHESIOLOGIST:  Jane Doe, MD

INDICATIONS FOR OPERATION:  This (XX)-year-old gentleman has a biopsy-proven non-small-cell lung cancer. He was brought to the operating room today for elective resection. Informed consent was obtained. Risks and benefits were explained. A preprocedure time-out was accomplished.

DESCRIPTION OF OPERATION:  The patient was placed on the operating room table in the supine position. Double-lumen endotracheal anesthesia was administered. Central venous catheter and arterial line were in place as well as a urinary catheter. The patient was placed into the right lateral decubitus position for a left thoracotomy and the left chest was prepped and draped in the usual sterile fashion. A standard posterolateral thoracotomy incision was created. The latissimus dorsi muscle was transected with electrocautery. The serratus anterior muscle was spared. The thorax was entered above the fifth rib in the fourth intercostal space. The left upper lobe, near the border of the anterior segment and the lingular subdivision, is the site of the malignancy, very close to the major fissure. The neoplasm did not cross the major fissure. The neoplasm corresponds quite nicely to the CT scan findings. The fissure was essentially complete, facilitating the anatomic and arterial dissection. The left lower lobe was carefully palpated and found to be without any dominant or suspicious masses. There is no pleural effusion, no pleural studding.

Attention was turned to the left hilum where the arterial supply to the left upper lobe was individually identified and ligated with 2-0 silk ties, 3-0 silk suture ligatures and then it was transected. The arterial anatomy was then traced into the major fissure where the lingular subdivision arteries were identified and ligated with 2-0 silk ties and 3-0 silk suture ligatures. There is a very large and presumed to be malignant lymph node in the N1 distribution of the hilum of the left lung that was mobilized off of the bifurcation between the lingular artery and the left lower lobe pulmonary artery, and this lymph node was removed in its entirety with clear margins and sent for permanent pathologic analysis. The lingular artery was identified and ligated accordingly. The left superior pulmonary vein was taken with individual branches, as a vascular stapler could not be put around the circumference of the left superior pulmonary vein. Therefore, each branch was individually ligated with 2-0 silk ties and 3-0 silk suture ligatures and then it was transected.

Attention was turned to the bronchus where a fibro-lymphatic tissue was mobilized off of the edge of the bronchus and the left upper lobe bronchus was occluded with a TA-30 stapling device. The left lung was inflated to prove that the left lower lobe inflates normally and the left upper lobe does not. The double lumen and tube including the blue balloon were easily mobilized and were not incorporated within the staple line. The specimen was oriented. The stapler was fired. The specimen was transected and the specimen was sent for pathologic analysis, confirming a clear bronchus margin. Aortopulmonary window lymph nodes were harvested at the beginning of the operation during the arterial phase of this procedure. These lymph nodes were removed without any trauma and the recurrent laryngeal nerve remained undisturbed. Hemostasis achieved with surgical clips.

The left inferior pulmonary ligament was mobilized and the left inferior pulmonary ligament lymph node was harvested accordingly. The subcarinal lymph nodes were not removed as it was a difficult dissection trying to get into the subcarinal space following the left upper lobe lobectomy and in light of the normal PET scan and the additional morbidity that may be accomplished, we have chosen not to harvest that subcarinal lymph node. It was normal on CT scan and normal on PET scan.

The left upper lobe inflates quite nicely and is reoriented in anatomical location within the left chest. The chest was drained with 36 French chest tubes anteriorly and posteriorly, each secured with nylon sutures. Intercostal nerve block performed with 0.25% Marcaine with epinephrine two interspaces above the incision, two interspaces below the incision, as well as at the level of the incision itself. There was no intravascular administration and hemostasis remains complete. The chest has been irrigated with normal saline. There is no active bleeding and there is no air leak at 25 cm of inspiratory pressure from the parenchyma, nor from the bronchus. The chest was drained with 36 French tubes placed anteriorly and posteriorly, each secured with nylon sutures. The ribs were closed with #3 Vicryl pericostal sutures and a rib punch.

The first Accufuser bupivacaine pump was a 10 inch long catheter from an anterior approach running underneath the inferior aspect of the sixth rib from anterior to posterior. It was curved and incorporated into the previously mobilized posterior paraspinal musculature. It was secured to the soft tissues with 3-0 chromic, secured to the skin with 3-0 Prolene. The serratus anterior muscle was closed with 0 Vicryl. The next Accufuser bupivacaine pump was a 5 inch long catheter, also from an anterior approach running underneath the latissimus dorsi muscle but anterior to the serratus anterior muscle. It also was secured to the soft tissues with 3-0 chromic and also secured to the skin with 3-0 Prolene.

The latissimus dorsi muscle was closed with 0 Vicryl. Rhomboid muscle closed with the remaining #2 Vicryl suture. The subcutaneous tissues were irrigated and closed with 2-0 Vicryl. Skin was closed with a running bidirectional 3-0 Monocryl subcuticular closure. Sterile dressings were applied. The sponge, needle and instrument counts were correct. The estimated blood loss was 150 mL. The patient tolerated the procedure well. He remained hemodynamically stable and will be transferred to the intensive care unit for postoperative monitoring.


Video Thoracoscopy Pleural Effusion Drainage Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left malignant pleural effusion.

POSTOPERATIVE DIAGNOSIS:  Left malignant pleural effusion.

OPERATION PERFORMED:  Left video thoracoscopy, drainage of pleural effusion and talc poudrage.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  Double-lumen general endotracheal.

ANESTHESIOLOGIST:  Jane Doe, MD

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

PATHOLOGIC SPECIMEN:  None.

DRAINS:  A 32 French chest tube to the apex.

INDICATION FOR OPERATION:  The patient is a (XX)-year-old female with a recently diagnosed left-sided malignant pleural effusion secondary to a left lung adenocarcinoma. The patient has had a transbronchial biopsy of the left lung consistent with an adenocarcinoma and adenocarcinoma was found in the pleural effusion. The patient has rapid reaccumulation of the left-sided pleural effusion with symptoms, and after discussion of options, the patient elected to proceed with video thoracoscopy and talc pleurodesis.
OPERATIVE FINDINGS:  Of 1700 mL of thin serosanguineous left-sided pleural effusion, the last 500 mL of which was much more sanguineous, incomplete re-expansion of the left lower lobe with apparent entrapment by a malignant process. There was also fairly diffuse pleural-based malignant disease. Five grams of aerosolized talc instilled under direct visualization.

DESCRIPTION OF OPERATION:  After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. After uneventful induction of double-lumen general endotracheal anesthesia and placement of a right radial arterial catheter, the patient was placed in the right lateral decubitus position. All pressure points were appropriately padded and protected. The patient's left chest was then prepped and draped in the usual sterile fashion utilizing ChloraPrep.

Beginning over the underlying seventh rib, the skin was infiltrated with 0.5% Marcaine with epinephrine and then an oblique skin incision was made with a #15 blade. This was carried down through the subcutaneous tissues utilizing electrocautery. The pleural space overlying the seventh rib was then meticulously dissected and serially expanded utilizing a curved hemostat. Upon entry into the pleural space, a thin serosanguineous effusion was encountered. The thoracostomy was then dilated using a curved Kelly hemostat and a Yankauer suction tip was introduced and 1700 mL of mostly thin serosanguineous to sanguineous effusion was drained.

Following near complete evacuation of the pleural space, a 12 mm thoracoscopic trocar was then inserted. A survey of the pleural space was performed utilizing a 0 degree thoracoscope. Upon entry into the pleural cavity, there was obvious malignant disease involving the left lower lobe. There was no visualizable normal lung parenchyma. The left upper lobe had a single adhesion from the apex of the lung to the cupola over the left hemithorax. The left costophrenic recess had a more sanguineous effusion that was drained utilizing a Yankauer suction tip. The diaphragmatic surface as well as the pericardial surface and the pericardial fat pad were chronically thickened and coated with a pearlescent material consistent with metastatic disease.

At this point, 5 grams of aerosolized talc was instilled under direct visualization utilizing the 0 degree thoracoscope. After complete coverage of the left lung and the pleural surfaces, a 32 French chest tube was placed to the apex through the existing single port site and secured with 2-0 silk sutures x2. This was connected to the Thora-Seal drain and attempts were made on expanding the left lung utilizing left lung isolation with the ventilator circuit. However, at the high airway pressures, only 150 to 185 mL of tidal volume was able to be delivered. The patient was then placed on standard two-lung ventilation, allowed to awaken from anesthesia, extubated and transported in a hemodynamically stable condition to the postanesthesia recovery room. Sponge, lap and needle counts were correct x2 at the end of the case.


Robotic Prostatectomy Operative Medical Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Prostate cancer.

POSTOPERATIVE DIAGNOSIS:  Prostate cancer.

OPERATION PERFORMED:  Robotic prostatectomy with bilateral nerve sparing and bilateral lymph node dissection.

SURGEON:  John Doe, MD

ANESTHESIA:  General with local.

INDICATIONS FOR OPERATION:  This (XX)-year-old patient was identified with rising PSA, and at time of presentation to Urology, this was 10 and a biopsy revealed 5 cores of prostate cancer, Gleason grade 6. We discussed options and the patient settled on robotic removal with nerve sparing.

DESCRIPTION OF OPERATION:  With the patient under general anesthetic in lithotomy position, after suitable preparation and draping, a Foley catheter was inserted. A supraumbilical midline incision was made and peritoneum entered under direct vision. The balloon trocar was introduced, pneumoperitoneum established and 0 degree laparoscopy confirmed suitable anatomy for continued laparoscopy. The patient was placed in Trendelenburg and robotic ports were inserted; two 8 mm on the left, one 8 mm, one 5 x 12 mm, and one 5 mm on the right, all under direct vision with no vascular incident. The robot was then docked and the remainder of the procedure was performed on the console. The instruments were used to take down peritoneum from left internal ring to right internal ring transecting urachus and obliterated umbilical bilaterally. Fourth arm was used for cephalad traction of the urachus. Preprostatic fat was cleared.

Endopelvic fascia was incised bilaterally and puboprostatic sharply divided. Dorsal venous complex was well exposed and was secured with a 3.5 vascular load with good effect. The transition between bladder neck and base of the prostate was identified and opened transversely. Catheter was identified, deflated and withdrawn into the prostate. The inspection of the anterior of the bladder revealed a modest median lobe. This was carefully circumscribed without entering the prostate tissue and posterior bladder neck separated from the base of the prostate. Ureteral orifices were well away from the resected margin. The fourth arm was then used for anterior traction of the median lobe, allowing development of posterior prostate. Lateral pedicles at this point were still bladder based and were controlled with bipolar cautery. After identifying seminal vesicles and mobilizing these to the apex bilaterally and securing apical vessels with bipolar, the seminal vesicles and ampulla of vas were used for anterior traction.

At this point, the lateral pedicles were no longer controlled with cautery, and after thinning them out appropriately alongside the prostate capsule, these were clipped with robotic arm Weck clips. No thermal energy was used at this point. Lateral prostatic fascia was opened prior to this maneuver and neurovascular bundles swapped laterally and posteriorly. Denonvilliers fascia was opened transversely behind the seminal vesicles and this was swept laterally to facilitate lateral neurovascular bundle release. Some venous oozing was tolerated at this point to avoid any cautery. The lateral pedicles with neurovascular bundle sparing continued satisfactory towards the apex. The lateral fascia was opened up to the urethra avoiding any transaction of the neurovascular bundle. There did not appear to be any obvious involvement beyond the capsule. At this point, all that remained was the urethra. This was sharply incised without cautery anteriorly and catheter retrieved into the penile urethra and posterior urethra divided. The prostate was liberated. The area was inspected and venous oozing had stopped at this point. The same instruments were then used for node dissection.

The prostate was placed in the left lower quadrant for later retrieval. First, the left pelvic dissection was performed and then the right. Limits of dissection were noted of Cloquet caudad, bifurcation cephalad, inguinal ligament anterior and internal iliac posteriorly. Obturator nerve was identified and spared at all times. Lymphatic and vessels were sealed with cautery. The specimens were retrieved through the 5 x 12 port. Instruments were then exchanged for the needle drivers and a double-armed 3-0 Monocryl was used for a continuous bladder neck to urethra anastomosis starting outside-in at 6 o'clock at bladder neck and continuing sequentially through the urethra and bladder neck. A fresh Foley catheter was placed under direct vision before closure. The sutures were tensioned up and tied to themselves at 12 o'clock across the anastomosis. The bladder was irrigated and was free of any leak and free of any bleeding. The robot was then removed and the specimen was retrieved through the midline port with an endosac and a #19 Blake drain brought out through the left lower quadrant 8 mm port. Fascia was enlarged with cautery and specimen delivered. Fascia was closed with interrupted figure-of-eight Vicryl and skin edges approximated with Monocryl and dressings applied. The patient tolerated the procedure well and no complications were encountered during the case. The patient was transferred to the recovery room in satisfactory condition. Sponge, needle and instrument counts were correct. Estimated blood loss was approximately 100 mL.

Laparoscopic Cholecystectomy Medical Report Example

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Symptomatic cholelithiasis.

POSTOPERATIVE DIAGNOSIS:
Symptomatic cholelithiasis.

OPERATION PERFORMED:
Laparoscopic cholecystectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

SPECIMEN:  Gallbladder with stone.

DESCRIPTION OF OPERATION:  The patient was placed in the preoperative holding area. Risks, benefits, indications and alternatives were discussed. All of the patient’s questions were answered and the patient voiced verbal understanding and elected to proceed. The patient was taken to the operating room and was placed on the operating room table in the supine position. The patient had just voided prior to surgery, so a Foley catheter was not placed. General endotracheal anesthesia was then induced. The patient was then prepped and draped in the normal sterile fashion. At that time, a final time-out was performed, which indicated the patient, medical record number and date of birth were verified and all equipment for a laparoscopic cholecystectomy was present in the room. All parties present acknowledged and agreed.

The operation was begun by injecting a local anesthetic solution of 0.5% Marcaine with epinephrine in an infraumbilical position. The skin was then grasped on both sides of the midline with Adson forceps. A skin incision was made in a vertical manner. Blunt dissection down to the anterior abdominal wall was done. Kocher clamp was then used to grasp the base of the umbilicus. The muscles were split in the midline raphe into the wound. A transverse incision was then made with a #11 blade knife. This gained access into the peritoneal cavity. Two stay sutures were placed with 3-0 Vicryl on the UR-6 needle. A Hasson trocar was then inserted through the fascial defect and secured with the stay sutures. Pneumoperitoneum was done, which was 15 mmHg and initial inspection of the abdomen was done with a 0 degree 10 mm scope. There was no evidence of visceral or vascular injury.

Upon entering the abdomen, routine diagnostic laparoscopy had findings mentioned above. Focus was then placed on placing three more ports; one was a subxiphoid 11 mm port and then two 5 mm ports, one at the midclavicular line and one at the anterior axillary line. These were all placed in the same manner as follows. Local anesthetic was used to identify the location within the peritoneal cavity with direct visualization. Local anesthetic was then injected into the peritoneum and then into the subcutaneous tissues and subcutaneously. A skin nick was then made with a #11 blade knife. This was explored using a hemostatic clamp. Appropriate size trocars were placed as mentioned previously. These were watched under direct visualization. There was no evidence of injury or problems entering the abdomen. Two graspers were used through the right lateral ports and used to hold the fundus of the gallbladder cephalad and the infundibulum of the gallbladder caudal and laterally to the patient's right. This exposed Calot triangle and peritoneum was opened around the infundibulum of the gallbladder, eventually exposing the cystic duct. The cystic duct was circumferentially dissected bluntly. Two clips were placed proximally and then one clip distally. There were some lateral structures that appeared to be a cystic artery. It was circumferentially dissected and then two clips were placed proximally and one clip was placed distally. It was then transected with Endoshears. Further dissection was then done with hook electrocautery.

As we approached the posterior area of the infundibulum, there was another structure identified that appeared to be a blood vessel. It was circumferentially dissected and a clip was placed proximally and distally. It was then transected with Endoshears. It did have a lumen that was consistent with likely a posterior branch of the cystic artery. This artery was clearly seen traversing only to the gallbladder from its current location. Once it was identified as an artery, a clip was placed proximally, to make two clips on the proximal end of this artery. Hook electrocautery was then used and the gallbladder was taken off the liver bed. There were some small areas of oozing, but these were controlled easily with electrocautery. Final visualization before the gallbladder came off was made of the liver bed. Hemostasis was ensured. The gallbladder was then taken off and an EndoCatch bag was placed through the subxiphoid port. It was then grasped through the infraumbilical port and then pulled though the Hasson trocar and then the Hasson trocar was removed and the gallbladder was removed. The fascial defect had to be enlarged, as well as the subcutaneous tissue, to accommodate this single large stone. The gallbladder was then removed and passed off the table as a specimen.

The trocars were then replaced and irrigation of the liver bed began. There was again good hemostasis and irrigation of the abdomen quickly cleared. This was suctioned dry. The three trocars were then removed under direct visualization without any bleeding. The Hasson trocar was then removed and the two stay sutures were removed. The 2-0 Vicryl on a UR-6 was used to make two figure-of-eight stitches at the umbilicus to close the transverse incision. The wounds were then irrigated and dried. The skin was closed with interrupted 5-0 Monocryl. Skin was then washed and dried. Mastisol and Steri-Strips were placed on the top as an outer dressing for all but the infraumbilical port. This concluded the operation. The patient was extubated in the operating room without difficulty and was taken to the postanesthesia care unit in stable condition. There were no known apparent complications during the procedure or immediately after. All laparoscopic instruments, needles and sponges were counted and correct at the end of the procedure.

Graham Patch Repair and G and J Tube Placement Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Acute abdomen and sepsis.

POSTOPERATIVE DIAGNOSIS:  Perforated duodenal ulcer and peritonitis.

OPERATIONS PERFORMED:  Exploratory laparotomy, Graham patch repair of perforated duodenal ulcer, gastrojejunostomy and feeding jejunostomy placement, Witzel type.

SURGEON:  John Doe, MD

ANESTHESIA:  General with endotracheal intubation.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old male who was admitted to the intensive care unit with complaints of abdominal pain as well as physical examination and clinical findings consistent with cardiovascular shock, presumably secondary to sepsis. The patient was monitored in the intensive care unit and over the course of the previous 24 hours has had increasing requirements for critical care support including intubation with mechanical ventilation as well as increased abdominal distention. A diagnostic peritoneal lavage was performed at the bedside, which was positive for gastric contents. Rationale, risks and benefits of surgery were discussed with the patient's brother and an informed consent was obtained. Given the critical nature of the patient's illness, emergent exploratory laparotomy was scheduled and the patient was taken down for surgery.

DESCRIPTION OF OPERATION:  The patient was brought down from the intensive care unit and placed on the operating room table. The patient was sedated with fentanyl as well as Versed IV drip, induced with anesthesia, and mechanical ventilation was continued through a previously placed endotracheal tube. Bilateral lower extremity Venodyne was placed. The patient received approximately 6 units of fresh frozen plasma, given coagulopathic state with INR of 1.9 prior to surgery. In addition, the patient received a dose of DDAVP given his acute renal failure and possible uremic source of bleeding. At this time, the patient's abdomen was cleaned, prepped and draped in a surgical fashion. An opening incision was made in the midline running from the subxiphoid process, beyond the umbilicus. We incorporated the previous DPL incision site and took down the nylon sutures, which were previously placed. The incision was carried down with electrocautery dissection down to the level of the peritoneum, which was entered under direct visualization utilizing a scalpel and further continued with electrocautery dissection. Upon entering into the abdomen, there were gastric contents. The ascitic fluid was significant for turbidity as well as what appeared to be food particles. This fluid was all suctioned out and we began exploration of the abdomen.  We began in the right upper quadrant and immediately were able to visualize a large perforated duodenal viscus. The duodenal perforation appeared to be approximately 1 cm in size. The wall of the surrounding tissues appeared to be significantly inflamed with firm thickening and woody inflammation of the surrounding tissues. Mucosa was also very inflamed; however, it appeared to be intact. It was not friable and it was separated well, given the inflammatory changes, away from the muscular layer. The gallbladder appeared to be within normal limits.  Although there was some minor erythema within the wall of the gallbladder, it appeared to be viable. It did not appear to be acutely affected by biliary disease. Thus, the gallbladder was left intact. We were concerned that the perforation of the duodenum was in an area in close approximation to the common bile duct and thus, given this, we attempted to repair the defect carefully without affecting the biliary tree. We began with dissection of the gastrocolic ligament, taking down the mesenteric attachments between the two organs and we were able to, with some minor manipulation, get into a plane allowing us access to the posterior wall of the stomach. We continued our blunt dissection and manipulation of the stomach to encircle the stomach in its entirety and we then placed a Penrose drain from the lesser curvature and encircling the entire distal stomach. We identified the pylorus again and we fired a TA stapler across the distal portion of the stomach to exclude the stomach from the perforated duodenum. Following this, we then closed the mucosal defect at the perforation utilizing interrupted 3-0 Vicryl sutures x3. Following mucosal closure, we then placed a patch of viable omentum over the entire defect and we placed four interrupted 2-0 silk sutures to approximate the entire duodenal defect and we then tied these sutures down over the patch of omentum, effectively closing off the entire defect in a Graham patch fashion. Following this, we irrigated the entire abdomen with diluted Betadine with normal saline solution. We utilized copious amounts of this solution to irrigate out the entire abdomen until the effluent was noted to be completely clear. Following thorough irrigation, we continued thorough exploration of the abdomen. The stomach as well as the left upper quadrant appeared to be without any signs of pathology. The left lower quadrant appeared to be also without any obvious signs of pathology. The small bowel was run from the ligament of Treitz down towards the terminal ileum, and as we approached within 2 feet of the terminal ileum, we identified Meckel diverticulum; however, the diverticulum appeared to be completely healthy in appearance; it did not appear to be inflamed. There was no pathology, and given the patient's critical status, we elected to forego any surgical intervention at this time. We continued the exploration down towards the right lower quadrant and identified the appendix, and at this point, we identified a collection of some fluid which appeared to be turbid, which was tracking from the deep pelvis.  Thus, we irrigated the entire pelvis again with some further amounts of diluted Betadine with normal saline solution, and after several cycles of irrigation, we noted the effluent was clear. There did not appear to be any perforations or other sources of the fluid and it was presumably a collection that had tracked down to the most dependent portion of the abdomen. After thoroughly exploring the abdomen and irrigating out the abdominal contents, we then paid attention back to the stomach. We brought up a loop of jejunum approximately 40 to 50 cm from the ligament of Treitz proximally towards the stomach in an antecolic fashion and we then placed 2 stay sutures of 3-0 silk suture to approximate the stomach to the jejunum, in preparation for gastric jejunostomy. At this point, we laid down a series of 3-0 silk sutures in an interrupted fashion to serve as a back row of the gastrojejunostomy and we then opened a gastrotomy as well as jejunotomy openings utilizing electrocautery dissection. Following this, we then sutured the mucosa of the jejunum to the mucosa of the stomach utilizing 2 running 3-0 Vicryl sutures, and upon completion of the gastric jejunostomy, we then placed another series of 3-0 silk sutures to serve as the anterior wall of the gastrojejunostomy. Following completion of the gastrojejunostomy, we palpated the opening and noted it to be widely patent without any obvious signs of puckering or stricture. At this time, we identified an appropriate place distal from the gastric jejunostomy upon the jejunal approximately an additional 40 to 50 cm distal to the gastrojejunostomy. We then placed a pursestring 3-0 silk suture, and at the mid point of the pursestring, we opened another jejunotomy utilizing electrocautery dissection. Through this, we placed a 12 French feeding tube and tied the pursestring suture to fasten the feeding tube in place. We placed some additional interrupted 3-0 silk sutures in a Witzel technique to further fasten the feeding tube in place and to minimize the chance of leak. We carried out the Witzel sutures approximately 3 to 4 cm in length from the point of opening. Following this, we then delivered the distal end of the feeding tube through the anterior abdominal wall on the left side of the abdomen, utilizing a small skin incision and the tonsil clamps. We then sutured the portion of small bowel to the anterior abdominal wall utilizing the interrupted 3-0 silk sutures that had been placed prior, in order to bury the feeding tube within the jejunum. Following this, we sutured the distal end of the feeding tube at the level of the skin utilizing a 3-0 nylon suture. At this time, we placed a large Jackson-Pratt drain at the dissection bed and delivered the distal end through the skin on the right side of the abdomen utilizing the scalpel and tonsil clamp. We then sutured this drain at the level of the skin utilizing a 2-0 nylon suture. At this time, we then carried out some additional irrigation of the skin and subdermal tissues and we then began closure of the abdomen. We closed the fascia utilizing 2 running 0 loop Maxon sutures. At the conclusion of the fascia closure, we irrigated out the subdermal tissues and skin utilizing additional dilute Betadine and normal saline solution. We then placed one 2-0 nylon suture at the level of the skin just at the mid point of the incision to approximate the incision in a vertical mattress suture technique. The skin was then left open and the wound was packed with normal saline-soaked gauze and dressed with ABD pads. The drain and feeding tube were also dressed with drain sponges, and the patient was then brought out of anesthesia and taken back to the intensive care unit for ongoing recovery following the surgery. The patient tolerated the procedure well. There were no significant complications. All sponge and needle counts were correct at the conclusion of the case. The patient had approximately 200 mL of estimated blood loss.  The patient received 8 units of FFP total at the conclusion of the case.

Colonoscopy and ERBE Argon Laser Cautery Sample   Laparotomy Small Bowel Resection Sample

Colonoscopy and EGD Sample Reports               Colonoscopy Sample Report

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Gynecology Transcribed Medical Transcription Samples

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Menorrhagia.
2.  Dysfunctional uterine bleeding.
3.  Small leiomyomata uteri.

POSTOPERATIVE DIAGNOSES:
1.  Small endometrial polyp.
2.  Dysfunctional uterine bleeding.

OPERATION PERFORMED:
1.  Diagnostic hysteroscopy.
2.  Diagnostic dilation and curettage of uterus.
3.  Excision of endometrial polyp.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old gravida 3, para 1, AB 2 female, who has a long history of menorrhagia and dysfunctional uterine bleeding. The patient has had several ultrasound reports, the most recent one revealed a small fundal myoma. Other ultrasound reports have suggested a possible small submucous myoma. Because of continued menorrhagia and dysfunctional uterine bleeding episodes, the patient is being admitted for diagnostic surgery.

DESCRIPTION OF PROCEDURE:  Under excellent general anesthesia, the patient was prepped and draped in the modified dorsal lithotomy position. Pelvic exam revealed the uterus to be in the mid position and slightly enlarged and symmetric. Examination of both adnexa revealed no masses. A weighted speculum was introduced into the vaginal vault. The anterior lip of the cervix was grasped with a single tooth tenaculum. The cervical os was progressively dilated. The diagnostic hysteroscope was then placed through the cervical canal. After extensive irrigation, the endometrial cavity was clearly visualized. Both tubal ostia were visualized and appeared to be normal. At the top of the endometrial cavity, in the fundal region, was a small endometrial polyp, about 3 x 3 mm in dimension. Otherwise, there were no myomas visualized. At this time, the uterine cavity was then thoroughly curetted. Reinspection of the entire cavity revealed the polyp to be still in place at the dome of the fundus. At this time, small grasping forceps was placed through the hysteroscopic channel and the polyp was grasped and twisted off its base and sent as a separate specimen. The patient tolerated the procedure well. Total blood loss from the surgery was less than 10 mL. She returned to the recovery room in excellent condition with sponge and instrument counts correct.

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Menometrorrhagia secondary to submucosal fibroid.

POSTOPERATIVE DIAGNOSIS:  Menometrorrhagia secondary to submucosal fibroid.

OPERATION PERFORMED:  Hysteroscopic myomectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  Less than 25 mL.

ANTIBIOTICS:  Prophylactic antibiotic with cefoxitin 2 g given intravenously within 1 hour of the surgery.

DESCRIPTION OF PROCEDURE:  After general anesthesia was given, the patient was prepped and draped in the usual manner in a dorsal lithotomy position. Pelvic examination was done and found the uterus to be slightly irregular and enlarged. There were no gross adnexal masses that were palpated. At the time of prep, one laminaria and gauze was removed. A weighted speculum was then placed into the vagina. The anterior cervix was then grasped with a single tooth tenaculum. The resectoscope was easily inserted into the endometrial cavity. Both ostia were visualized and found to be normal. Noted was submucosal fibroid that was protruding slightly into the endometrial cavity. Then, using resectoscope, the fibroid was then gradually resected. Tissue was everted within the endometrial cavity. The procedure was completed after several passes and most of the fibroid had been removed. Specimen was sent to pathology. After this was done, the Overstreet polyp forceps was used to remove the remainder of the submucosal fibroid. After this was completed, the area was then inspected and bleeding was found to be of minimal amount. The resectoscope as well as single tooth tenaculum were removed. The patient was repositioned in supine position and taken to the recovery room in satisfactory condition.

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Pelvic mass.

POSTOPERATIVE DIAGNOSIS:  Left ovarian cyst.

OPERATION PERFORMED:  Left salpingo-oophorectomy via laparoscopy.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  10 mL.

 DESCRIPTION OF PROCEDURE:  Under adequate general anesthesia, the patient was prepped and draped in dorsal lithotomy position. A single blade weighted speculum was placed into the vagina. The anterior lip of the cervix was grasped with the single tooth tenaculum. Cohen cannula placed. There was some difficulty in catheterizing her bladder. Urethra was somewhat stenotic and would not accept the 14 French catheter; therefore, a 10 French catheter was placed. Attention was then turned to the abdomen. A small umbilical incision was made and immediately the abdomen was entered. The second trocar sites were placed at a 5 mm site on the left and a 10 mm site on the right in the area of the previous incision. The uterus was normal. The right ovary was normal, although somewhat adherent to the posterior left side of the uterus. There was a large multiloculated ovarian mass in the cul-de-sac consistent with ultrasound report. This was somewhat large, approximately 8 cm in diameter. This was somewhat adherent to the sidewall. The infundibulopelvic ligament was cauterized for a distance of about 1.5 cm and then cut. Fallopian tube was cauterized and cut near the cornual region and the utero-ovarian ligament was cauterized and cut. At that point, there was noted the adhesions of the ovary to the posterior cul-de-sac and these filmy adhesions were carefully cauterized and cut taking care to stay on the ovary side of the adhesions, close to the ovary, and not into the sidewall. Good hemostasis noted throughout. The ovary was freed from its adhesion, placed into the Endopouch bag. The ovary needed to be taken in piecemeal, as it was quite enlarged and would not easily fit through the 1 cm incision. This was taken out in piecemeal with Allis clamps and there was noted to be a large amount of old chocolate-type cyst material within this cyst. Taking the ovary out piecemeal, we were able to take the ovary out in several pieces and sent to the lab. The abdomen was carefully irrigated. Good hemostasis noted throughout. Second puncture sites were taken out under direct visualization.  The umbilical and right lower quadrant port fascia was closed with interrupted suture of 2-0 Vicryl. Skin closed with 4-0 Vicryl, subcuticular stitch, at all port sites. Good hemostasis noted. Steri-Strips placed. The patient was taken to the recovery room in stable condition.

Ob/Gyn Transcription Samples 1         Ob/Gyn Transcription Samples 2

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Psychiatric History and Physical Transcription Sample Report

IDENTIFYING INFORMATION:  The patient is a (XX)-year-old Hispanic male who had dropped out of high school and pursuing a GED.

SOURCE:  History obtained from the patient, who had fair to good reliability on review of chart.

CHIEF COMPLAINT:  "I was drunk and did something stupid."

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male without prior psychiatric history but a history of alcohol, cocaine and cannabis abuse, who was brought to the emergency room. The patient was intoxicated on alcohol, cocaine and marijuana when he got into an argument with his father over the cell phone, at which time, he put a wire cord around his neck. The police were called and they brought him into the ER. His UDS in the ER was positive for alcohol at 0.19, cocaine and marijuana. The patient stated he was quite drunk at that time and was not thinking about what he was doing. He had no suicidal ideations and denied it in our interview. In the recent past, he has been doing his normal daily activities. His appetite and sleep have been normal. He has not been depressed. He usually likes to wind down after a day of working out by using alcohol and marijuana. In the ER, he became quite upset when he found out that he would not be able to leave the emergency room, but he was able to calm down by himself.

PAST PSYCHIATRIC HISTORY:  No prior hospitalization or suicide attempts. He identified that he did have anger issues. He has gotten into fights at school in the past but that has been decreasing. He is happy on most days and denied any history of major depression, manic or hypomanic episodes.

PAST SUBSTANCE ABUSE HISTORY:  The patient has been drinking increasing amounts of alcohol. He uses that mainly to relax from a day's work. He denied any withdrawal symptoms when he stops drinking. He uses cocaine very rarely. He uses marijuana almost daily and it is also helping to calm him down. He has not been into any substance treatment program.

PAST MEDICAL HISTORY:  The patient denied any history of head trauma or seizures. He has no medical illnesses.

ALLERGIES:  No known drug allergies.

CURRENT MEDICATIONS:  None.

FAMILY HISTORY:  The patient’s mother was dependent on methamphetamine. He does not know of any other psychiatric illnesses in the family.

SOCIAL HISTORY:  The patient denied any history of physical or sexual abuse. His parents have been separated for a few years. He currently lives with his father and 2 brothers at home. He is the oldest and he tries to serve as a role model. He does not get along with his father and he thinks this is mainly because of his mouth. He used to attend high school but dropped out in the 11th grade and has been pursuing a GED. He does have a girlfriend.

MENTAL STATUS EXAMINATION:
The patient is well-groomed, cooperative. Psychomotor activity is normal. Eye contact good and appropriate. Speech is clear and spontaneous with normal rate, volume and quantity. Mood is euthymic. Affect is happy, full and congruent to mood. In regards to thought content, he denies any auditory or visual hallucinations and did not appear to be responding to internal stimuli. His thought was linear without paranoia, delusions, suicidal or homicidal ideations. In regards to memory, he was alert, oriented to person, place, time and situation. Memory is fair. Attention good. Language grossly intact. Abstraction concrete. Insight is fair. Judgment is fair. Impulse control is good.

REVIEW OF SYSTEMS:  Other than back pain, it was unremarkable.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 140/82, pulse 50, temperature 98.6 and respirations 18.
GENERAL APPEARANCE:  The patient was not in acute distress, well-nourished male.
HEENT:  Extraocular movements are intact. Pupils are equally round and reactive to light.
NECK:  No abnormal masses.
HEART:  Regular rate and rhythm. No murmurs.
LUNGS:  Clear to auscultation bilaterally. No crackles, wheezes or rhonchi.
ABDOMEN:  Normoactive bowel sounds, nontender, nondistended.
EXTREMITIES:  Full range of motion in all extremities.
NEUROLOGIC:  Cranial nerves II through XII grossly intact. Gait normal.

DIAGNOSTIC STUDIES:  LFTs within normal limits. TSH 2.42 which was within normal limits. CBC was within normal limits. The electrolytes are within normal limits other then a carbon dioxide elevated at 31. UDS was positive for alcohol of 0.19, cocaine and THC.

FORMULATION:  The patient is an (XX)-year-old male with a genetic predisposition for substance dependence. He has already been abusing substances as a way of coping with daily stress. His use of substances may also be affecting his mood and behavior. He appears to have a history of using aggression to get his needs met. He has a non-intact family and has not been able to come to a compromise with his father.

DIAGNOSES:
AXIS I:
1.  Mood disorder, not otherwise specified.
2.  Substance-induced mood disorder, provisional.
3.  Alcohol abuse.
4.  Cannabis abuse.
5.  Rule out cocaine abuse.
AXIS II:  Deferred.
AXIS III:  Back pain.
AXIS IV:  Support, educational.
AXIS V:  Global Assessment of Functioning is 51 to 55.

PLAN:  No medications indicated at this time. Social work to arrange a family meeting to have the patient and parents come to more amicable terms before his discharge. We will recommend substance treatments. Social work to assist with case management, disposition and planning. The patient is likely dischargeable after the family meeting.


Mental Status Examples                                Psychiatric Discharge Summary Sample

Aortic and Mitral Valve Replacement CABG Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Moderate to severe aortic stenosis.
2.  Moderate to severe mitral regurgitation.
3.  Severe 3-vessel coronary artery disease.
4.  Ejection fraction 30%.

POSTOPERATIVE DIAGNOSES:
1.  Moderate to severe aortic stenosis.
2.  Moderate to severe mitral regurgitation.
3.  Severe 3-vessel coronary artery disease
4.  Ejection fraction 30%.

OPERATION PERFORMED:
1.  Aortic valve replacement.
2.  Mitral valve replacement.
3.  Coronary artery bypass grafting x3 using the internal mammary artery and segments of the saphenous vein.
4.  Endoscopic saphenous vein harvesting.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old gentleman with a several month history of exertional shortness of breath. He has multiple risk factors including diabetes, hypertension and elevated cholesterol. The patient has a history of heart failure and also a previous pacemaker implantation. His cardiac catheterization showed severe 3-vessel coronary artery disease. The anterior descending had at least a 70% proximal to mid area stenosis. The circumflex had a 70% area of narrowing before giving rise to the obtuse marginal branch. The right coronary artery was a dominant vessel with at least 80-90% stenosis beyond the origin of the posterior descending branch and before terminating into 2 large posterolateral branches. Also identified was moderate to severe aortic stenosis with a valve area of 1 sq cm. Ejection fraction was about 30%.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room where he was placed supine and then induced under suitable general anesthesia. He was then prepped and draped in the usual sterile fashion. Intraoperative transesophageal echocardiography was carried out and moderate to severe mitral regurgitation was identified. There was a central jet with no structural problems involving the valve or chordae tendineae.  Because of the moderate to severe regurgitation, it was felt that a mitral valve replacement was also indicated.

The sternotomy incision was made and the sternum divided with the use of the sternal saw. Using a self-retaining retractor, the left internal mammary artery was mobilized in a pedicle, which included the slip of the endothoracic fascia as well as accompanying vein. A length of the left greater saphenous vein was harvested endoscopically. Systemic heparin was administered. The pericardium was opened in the midline and the distal ascending thoracic aorta cannulated. The superior vena cava was cannulated directly with right angle venous cannula and a second cannula placed in the lateral body of the right atrium and directed down toward the inferior vena cava. The patient was then placed on cardiopulmonary bypass. Successful cardioplegic arrest of the heart was achieved by cross-clamping the aorta and by infusing cold blood cardioplegia into the aortic root at approximately 5 degrees centigrade. Initially, 700 mL of blood cardioplegia was administered. Thereafter, every 15-20 minutes throughout the operation, additional cardioplegia was infused through the retrograde coronary sinus catheter. Using the saphenous vein graft, the first distal anastomosis was completed to the distal posterolateral branch of the right coronary artery. A 4 mm arteriotomy was made and the distal end-to-side anastomosis was completed with a running suture of 7-0 Prolene. A second sequential side-to-side anastomosis was completed to the distal circumflex branch. Again, a 4 mm arteriotomy was made, a corresponding venotomy was made on the vein graft and the second sequential side-to-side anastomosis completed with a running suture of 7-0 Prolene. As mentioned above, every 15-20 minutes throughout the operation, additional cardioplegia was infused into the retrograde coronary sinus catheter. Next, the internal mammary artery was transected distally. The proximal end was appropriately beveled. The left anterior descending was identified in the mid portion where a 4 mm arteriotomy was made. The internal mammary artery to LAD anastomosis was completed with a running suture of 7-0 Prolene.

Next, the mitral valve replacement was carried out. A left atrial incision was made starting at the right superior pulmonary vein and extending the incision down towards the inferior vena cava. A self-retaining retractor was used to provide exposure for the mitral valve. The caudal attachments to the anterior leaflet were preserved. However, the large surface area in the mid portion of the valve was removed as an elliptical patch. Only the caudal attachments to the leading edge of the leaflet were preserved along the anterior leaflet and this was incorporated as part of the suture line. The posterior leaflet was left in place. A series of interrupted pledgeted mattress sutures were then placed circumferentially around the annulus with the pledgets on the atrial or inflow side of the annulus. As mentioned, the sutures along the anterior part of the annulus incorporated the leading edge of the leaflet with the caudal attachments. A 29 Medtronic Mosaic valve was selected as the appropriate size. The sutures were placed through the sewing ring of the valve. The valve was then lowered in place and the suture line secured and tied. The atrial incision was closed in 2 layers with a running suture of 4-0 Prolene.

Next, the aortic valve replacement was carried out. A transverse aortotomy was made about 2 cm above the aortic commissure. Incision was carried down on the left in the sulcus between the pulmonary artery and aorta and on the right toward the noncoronary cusp. The aortic valve had 3 leaflets, which were moderately calcified. The leaflets were excised and the annulus debrided of all calcium. A series of interrupted pledgeted mattress sutures were then placed around the annulus with the pledgets on the inflow or ventricular side of the annulus. A 23 Edwards pericardial tissue valve was selected as the appropriate size. The sutures were then placed through the sewing ring of the valve. The valve was lowered in place and the suture line secured and tied.

Warming was then initiated and the aortotomy closed in a single layer with running suture of 4-0 Prolene. The single proximal anastomosis was completed with the use of a partial occluding aortic clamp. A 5 mm aortic punch was used to remove a single button of the aortic wall. The single proximal anastomosis was then completed with a running suture of 6-0 Prolene. A vent was then placed in the anterior portion of the aorta to remove any air present within the heart. The presence of air within the heart was also monitored with the use of the transesophageal echocardiogram. Warming was continued until a venous temperature of 37 degrees centigrade, at which time, the patient was weaned from cardiopulmonary bypass. All of the cannulas were removed and protamine sulfate administered. The pericardium was left opened. Two #32 Blake drains were used to drain the pericardial space. The sternum was reapproximated with monofilament #5 wire along the sternum in the appropriate end spaces. In addition, sternal plates and screws were used to reinforce the sternal closure. The deep fascia was closed with a running suture of 0 Vicryl and the skin with a running subcuticular stitch of 4-0 Monocryl. The patient tolerated the procedure well and was returned to the ICU in satisfactory condition. The cross-clamp time was 3 hours and 50 minutes. Pump time was 4 hours and 52 minutes.

Cardiology Operative Samples #1         Cardiology Operative Samples #2

Laparoscopic Roux-en-Y Gastric Bypass Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Morbid obesity.

POSTOPERATIVE DIAGNOSIS:  Morbid obesity.

OPERATION PERFORMED:
1.  Laparoscopic Roux-en-Y gastric bypass.
2.  Intraoperative upper endoscopy.

SURGEON:  John Doe, MD

ANESTHESIA:  General with endotracheal intubation.

INDICATION FOR OPERATION:  The patient is a (XX)-year-old female who has a BMI of 40 and with comorbid features of obesity including obstructive sleep apnea, hypertension, polycystic ovarian syndrome, dyslipidemia, as well as significant dyspnea on exertion. Thus, the patient underwent education and training with the comprehensive weight management program and has elected to undergo surgical weight loss intervention.

DESCRIPTION OF OPERATION:  The patient was brought back to the operating room and placed on the table in the supine position. Bilateral lower extremity venodynes were placed. The patient received a dose of IV antibiotics as well as a dose of preoperative venous thromboembolism prophylaxis with heparin. The patient was then subsequently induced via general anesthesia and intubated. The patient's abdomen was then cleaned, prepped and draped in a surgical fashion. Opening incision was made 3-4 cm from the umbilicus approximately at the 2 o'clock position. This incision was carried down with light Bovie electrocautery dissection down to the level of the subdermis. Through this incision, we initially placed a Veress needle, and upon verifying placement of the needle with a saline drop and air bubble test, we then began CO2 insufflation to achieve pneumoperitoneal pressure of approximately 15 mmHg.

We then utilized the Optiview trocar to insert a 0 degree laparoscope through the layers of the anterior abdominal wall. Upon gaining entry into the peritoneum, we then visualized the intra-abdominal organs. There appeared to be no obvious signs of hemorrhage, no obvious signs of injury. There was also no significant pathology noted within the abdomen. Thus, at this time, we then placed all of our working trocars. Two small 5 mm trocars were placed in the bilateral subcostal margins. We then also placed two additional 12 mm working trocars bilaterally at the mid points between the 5 mm trocar and the umbilicus. We then utilized blunt dissection to identify the greater omentum and divided it at the midline. We continued our dissection towards the transverse mesocolon until we were able to gain appropriate visualization of the proximal small bowel. We then utilized blunt dissection to identify the ligament of Treitz. The small bowel was run distally to a length of approximately 40 cm, and at this point, we then divided the jejenum utilizing an Endostapler. At this time, we further dissected the mesentery of the jejenum an additional 1-2 cm. We continued our progression along the small bowel distally, this time to a length of approximately 150 cm. This was the area of the proposed jejuno-jejunal anastomosis. Thus, we reapproximated the cut end of the proximal jejenum to the distal jejenum in a side-to-side fashion and placed a stay suture utilizing a 4-0 Polysorb suture.

Following this, small enterotomies were made along the proximal distal limbs utilizing sharp and blunt dissection. We then created a side-to-side staple anastomosis utilizing an additional stapler load firing. We observed the staple line and noted it to be completely hemostatic. We then closed the enterotomy created by the stapler firing with 3 approximating sutures of additional 4-0 Polysorb to reapproximate the edges and then completely closed off the opening utilizing an additional stapler load. At this time, we paid our attention to the stomach. We placed a Nathanson retractor through an additional small 5 mm port site incision at the level of the subxiphoid space. Retracting the left lobe of the liver superiorly, we were able to visualize the gastroesophageal junction. Blunt dissection as well as some minimal sharp dissection was carried out to free up the proximal edges of the GE junction. The pars flaccida was exposed and its filmy attachments taken down sharply.

Following this, we then created a pouch utilizing series of Endostapler load firings. Thus, we were able to create a small 2-3 cm diameter size pouch of the proximal stomach. We carried out some additional sharp dissection of the fatty attachments and adhesions on the posterior aspect of the newly created pouch and then we identified the proximal aspect of the Roux limb and approximated it to the anterior surface of the pouch. We then anchored the pouch to the Roux limb utilizing an additional 4-0 Polysorb suture and a running 4-0 Polysorb suture was then utilized to create a posterior anastomosis line in an antecolic antegastric fashion.

Following this, enterotomies were made upon the pouch as well as the Roux limb and an additional stapler load was utilized to create a 1 cm anastomosis. The enterotomy was then closed utilizing interrupted 4-0 Polysorb suture. Following this, we clamped the proximal aspect of Roux limb and then performed an upper endoscopy to visualize the newly created Roux-en-Y gastric bypass anastomosis. Significant insufflation was utilized to inflate the gastric pouch as well as the proximal aspect of the Roux limb. However, there appeared to be no obvious leakage of air or intraluminal contents into the peritoneal space. Thus, we then evacuated all of the insufflation, carried out some normal saline irrigation within the peritoneum and then began removal of our retractor and working trocars.

There appeared to be complete hemostasis at the conclusion of this procedure. All of the skin incisions were then closed utilizing 4-0 Monocryl suture in a subcuticular technique. Incisions were all dressed with benzoin, Steri-Strips and Band-Aid dressings, and the patient was brought out of anesthesia and taken to the postanesthesia care unit for ongoing recovery following surgery. All sponge and needle counts were correct at the conclusion of the case. There is only very minimal bleeding.

Ophthalmology History and Physical Transcription Sample

CHIEF COMPLAINT:  Double vision after left eye socket fracture.

HISTORY OF PRESENT ILLNESS:  This (XX)-year-old male was noticed to have persistent nonimproving diplopia after suffering fractures of the left eye socket. The patient reports that a foot hit the left side of his eye socket wall while playing. The patient noted immediate swelling that has improved. There was diplopia that improved slightly; however, there has been no improvement over the last 4 days. The patient had nausea and dizziness from this problem, but this has improved as well. There is pain with down gaze and right gaze as well. The patient reports that the eye remains in a higher position, though there is no change in the position of the eye ball. There is numbness of the left side of the face that has not improved as well and associated drooping of the left upper eyelid. The patient was evaluated by the ophthalmologist, who noted orbital fractures on the left side. A CT scan of the orbit was obtained confirming medial and inferior orbital fractures of left eye.

PAST MEDICAL HISTORY:  Significant for asthma.

MEDICATIONS:
1.  Acetaminophen.
2.  A 5-day course of cephalexin.
3.  Afrin nasal spray used p.r.n.
4.  Albuterol inhaler used on a p.r.n. basis.

REVIEW OF SYSTEMS:  A 14-point comprehensive review of system is negative.

SOCIAL HISTORY:  The patient is employed. Smoked 4 cigarettes per day over the last 12 years. Does not use alcoholic beverages. The patient has previously lived outside of the country for a period of time.

FAMILY HISTORY:  Significant for diabetes mellitus, cancer and heart disease.

ALLERGIES:  The patient reported no known drug allergies.

PHYSICAL EXAMINATION:  Ophthalmic examination showed a corrected visual acuity measured at 20/30, both eyes. Extraocular muscle ductions were intact on the right side and decreased to 40% infraduction on the left side with 100% lateral and medial and superior ductions noted. Confrontation visual fields were intact to finger counting stimuli in both eyes. External exam showed 1 to 2+ edema and ecchymosis of the left periorbital region with 2+ dense hypesthesia in the area of the left infraorbital nerve with no step-off noted and no orbital emphysema palpated with orbital rim palpation. There were exophthalmometer measurements with a base of 97 utilizing the Hertel unit measuring 13 mm on both sides. Retropulsion was 1+ resistance on the left side and normal on the right side.

Slit-lamp examination was within normal limits on the right side. There was 2+ mechanical ptosis of the left upper eyelid present with 1+ lash ptosis. Normal lacrimal puncta, conjunctivae and sclerae, iris shape and morphology. Anterior chamber depth is 3+ with no cell or flare and the lens was clear on both sides.

Sensorimotor testing documented a 10 prism diopter left hypertrophia that was increasing on increasing down gaze.

A CT scan of the orbits performed was reviewed. This documented a left intraorbital wall fracture that was at the mid orbit level with entrapment of the perimuscular left inferior rectus, with a smaller fracture of the left medial orbital wall present.

Multiseries visual external ocular photography documented primary left hypertrophia with poor infraduction on the left side.

IMPRESSION:  Acute left orbital floor and medial orbital wall fractures, left eye. This is seen with nonimproving diplopia and inferior rectus perimuscular entrapment. There is dense hypesthesia in the distribution of the left infraorbital nerve with persistent pain.

PLAN:  Planned procedure is for left orbital floor and medial orbital wall repair utilizing nylon orbital implant, left side. Discussed the risks, benefits and alternatives to surgery including no surgical intervention. The patient is aware of the risk of bleeding, infection, loss of vision, scarring, asymmetry, eyelid hypesthesia, problems with anesthesia, dry eye formation after surgery, failure of the procedure, as well as a need for revision surgery. The procedure was diagramed on an anatomical chart in the presence of the patient and all questions were answered. The patient is aware that the dense hypesthesia in the distribution of the left infraorbital nerve will take up to a year for improvement and may result in no improvement. The patient is further aware that direct neuromuscular damage to the muscle and/or nerve would result in persistent diplopia even after orbital fracture repair that would require extraocular muscle surgery at a later time. The patient was advised to restrict blowing his nose for 2 weeks after surgery.

Shoulder Arthroscopy Subscapularis Labral Repair Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Right shoulder recurrent dislocations.

POSTOPERATIVE DIAGNOSES:
1.  Right shoulder recurrent dislocations.
2.  Subscapularis tear.
3.  Posterior labral tear.
4.  Multidirectional capsular instability.

OPERATION PERFORMED:
1.  Right shoulder diagnostic arthroscopy.
2.  Subscapularis repair.
3.  Posterior labral repair.
4.  Multidirectional anterior and posterior capsulorrhaphy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal tube and interscalene block.

OPERATIVE FINDINGS:  Exam under anesthesia revealed anterior, posterior and inferior subluxability.  Intraoperative findings revealed that there was a partial attachment tear of the subscapularis on the deep surface involving about 50% of the tendon attachment.  The anterior labrum did not have a Bankart or ALPSA lesion, but it was with significant capsular redundancy.

Superiorly, there was a Buford complex with a cord like middle glenohumeral ligament and an absent anterior superior labrum.  Posteriorly, there was a posterior labral tear with posterior capsular insufficiency.  The superior labrum was intact.  The biceps was intact.  The remainder of the rotator cuff was intact.  The humeral head and glenoid did not have significant traumatic changes.  There was no posterior capsular or anterior capsular defect at the insertion on the humerus.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room where general and regional anesthesia was administered without difficulty.  Intravenous antibiotics were given.  The patient was carefully positioned lateral decubitus on a beanbag with foam supports and padding maintaining her spinal alignment.  Venodyne stockings were applied.

The patient’s shoulder and arm were prepped and draped with chlorhexidine and alcohol and she was draped in a sterile fashion.  Her arm was placed into 10 pounds of balanced suspension.  Landmarks were noted.  Stab incisions were made and the joint was accessed with blunt-tipped obturators without difficultly.  Diagnostic arthroscopy was then symptomatically performed throughout the entire joint with the above-listed findings noted.

Based on these findings, the subscapularis tear and attachment site were debrided.  The subscapularis was then repaired by utilizing a Linvatec Bio-Anchor placed into the attachment site on the lesser tuberosity.  There was not good stability of the anchor as it pulled out, and therefore, we switched to an Arthrex titanium Corkscrew suture anchor loaded with a #2 FiberWire suture.  This obtained excellent purchase within the bone.  We then utilized the Spectrum suture passing device to place it through the subscapularis and tied it securely into place firmly reattaching the subscapularis to the footprint of the lesser tuberosity.

The posterior labrum was then repaired.  We utilized a shaver and an elevator to abrade the posterior inferior labrum and capsule to stimulate cicatrix formation and stimulate a healing reaction.  We placed a Linvatec Bio-Anchor at the posterior glenoid rim with excellent purchase within the bone.  A Hi-Fi suture was utilized.  This was passed underneath the labrum and into the capsule posteriorly and inferiorly approximately 7 to 10 mm, taking care to avoid the motor branch of the axillary nerve to the teres minor.  When tensioned and tied into place, this eliminated the capsular redundancy, recreating a very tense and robust posterior inferior glenohumeral ligament.   It also created a posterior labral bumper.  That resulted in a repair of the posterior labrum and a posterior capsulorrhaphy.

The anterior capsule was then addressed by placing two more Linvatec Bio-Anchors in the anterior glenoid rim inferiorly and mid sagittal.  Once again, the suture was passed beneath the labrum under the capsule going peripherally approximately 7 to 10 mm, taking care to avoid the axillary nerve.  This resulted in a reefing of the anterior inferior glenohumeral ligament as well as eliminating the anterior capsular redundancy.  We were careful not to over-tighten or to tack down the Buford complex.  The capsule was, however, elevated to the level of the glenoid rim, eliminating the capsular recess.  Once completed, the humeral head was noted to shift to a reduced position in the glenoid fossa.

We, therefore, irrigated out the surgical sites and carefully closed the incisions with buried subcuticular 3-0 Monocryl sutures.  Sterile dressings were applied.  A Donjoy UltraSling ER was applied.  Estimated blood loss was minimal.  Sponge and needle counts were correct.  The patient tolerated the procedure well and was transferred to the recovery room in stable condition.


Robotic Laparoscopic Hysterectomy BSO Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  High grade carcinoma of the endometrium.

POSTOPERATIVE DIAGNOSIS:  High grade carcinoma of the endometrium.

OPERATION PERFORMED:
1.  Robotic laparoscopic hysterectomy and bilateral salpingo-oophorectomy.
2.  Laparoscopic pelvic lymphadenectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  100 mL.

DESCRIPTION OF OPERATION:  Under adequate general anesthesia, the patient was placed in the dorsal supine position using the split-leg stirrups. She was prepped and draped in the standard manner. An incision was made 2 cm above the umbilicus. The incision was carried down through the fascia and into the peritoneal cavity. The US surgical trocar was inserted and the balloon was insufflated. The laparoscope was then introduced through this trocar. The 8 mm trocars were then inserted into the right and left lower quadrant and a 12 mm trocar inserted into the left upper quadrant. The abdomen and pelvis was inspected. There was no evidence of metastasis. The uterine corpus and adnexa were grossly unremarkable. Washings were taken from the pelvis. The camera was then removed and the da Vinci robot was docked to the patient.

Attention was then turned to the surgeon's console. The round ligaments on both sides were cauterized and transected and the retroperitoneal spaces were developed. No gross adenopathy was appreciated. The bladder was taken down using sharp dissection; however, there were some adhesions along the bladder flap due to the previous cesarean section. The infundibulopelvic ligaments on both sides were cauterized and transected. The adnexa were then mobilized. The uterine vessels on both sides were cauterized and transected. The cardinal ligaments were then cauterized and transected and dissection extended down to the vaginal cuff. The bladder was further mobilized. Following this, the vaginal probe was inserted into the vagina. The posterior cul-de-sac was incised and a posterior colpotomy was performed. This was similarly done anteriorly. Remaining attachments to the uterosacral ligaments and cardinal ligaments were then cauterized and transected. The remaining vaginal attachments were then cauterized and transected. The entire specimen was mobilized and grasped with a single-tooth tenaculum, which was inserted through the vagina. The specimen was easily extracted through the vagina. Frozen section revealed a superficial malignant tumor of the endometrium.

Following this, the retroperitoneal space on the right side was exposed. The peritoneal incision extended up to the distal common iliac area. The bifurcation of the common iliac artery was identified and the ureter was also identified and retracted medially and cephalad. First, a biopsy was taken from the distal common iliac lymph nodes. Next, an en bloc pelvic lymphadenectomy was performed. Lymph nodes were removed beginning over the external iliac artery and extending down towards the groin. The nodes along the external iliac vein were then mobilized. The dissection then extended down to the hypogastric artery and the obliterated umbilical artery. Next, the obturator space was exposed and the obturator nerve identified. The lymph nodes from the obturator fossa were then removed along with the specimen. All of these lymph nodes were then inserted into an EndoCatch bag and sent to pathology.

On the left side, the distal descending colon was mobilized and the sigmoid colon was reflected towards the right. The right ureter and bifurcation of the iliac artery was identified. A similar dissection was then performed. Lymph nodes were removed beginning along the anterior lateral surface of the external iliac artery. The lymph nodes were mobilized and pulled medially. These were then dissected off the external iliac artery beginning at the bifurcation of the common iliac artery and extending towards the groin. The lymph nodes were then removed from the external iliac vein. The dissection extended down along the hypogastric artery until the left obturator nerve was identified. The lymph nodes were then removed from the obturator fossa. These specimens were also inserted into an EndoCatch bag and brought out through the 12 mm trocar and sent to pathology.

Following this, the vaginal cuff was closed with 0 Vicryl suture using Lapra-Ty. The pelvis was irrigated with warm normal saline. Hemostasis appeared satisfactory at this time. The instruments and the camera were removed. The da Vinci was undocked. The camera was reinserted and the trocars removed under direct visualization. Following this, the fascia was closed with 2-0 Vicryl suture and the skin closed with subcuticular 4-0 Vicryl suture. Final sponge and needle counts correct. The patient tolerated the procedure well and was sent to the recovery room in satisfactory condition.

Tympanoplasty Canal Wall Mastoidectomy Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Right chronic otitis media.
2.  Right tympanic membrane perforation.
3.  Right conductive hearing loss.

POSTOPERATIVE DIAGNOSES:
1.  Right chronic otitis media.
2.  Right tympanic membrane perforation.
3.  Right conductive hearing loss.

OPERATION PERFORMED:
1.  Right tympanoplasty with intact canal wall mastoidectomy.
2.  Intraoperative facial nerve monitoring x1 hour.
3.  Microsurgery.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal.

OPERATIVE FINDINGS:  A right near total tympanic membrane perforation was present. This was repaired using an over-under tympanoplasty technique. The ossicular chain was intact and mobile. The chorda tympani nerve was identified and preserved. Intact canal wall mastoidectomy was performed. The mastoid was clean. Facial nerve was covered in bone.

DESCRIPTION OF PROCEDURE:  After proper consent was obtained, the patient was brought to the operating room and placed on the table in the supine position. General endotracheal anesthesia was administered. With the patient asleep, the bed was turned 180 degrees. The patient’s head was turned to the left, exposing the right ear. The right ear was then prepped in the usual manner. It was injected with 1% lidocaine with epinephrine. Intraoperative facial nerve monitoring electrodes were placed by the operating surgeon. These were placed in the orbicularis oris and orbicularis oculi. They were connected to the nerve integrity monitor. The monitor's proper functioning was confirmed by performing a tap test and by checking electrode impedances. The ear was then cleansed with Betadine paint and covered with sterile drapes.

Next, the operating microscope was brought in. Throughout the case, the operating microscope and microsurgical technique was used. The right ear was examined. There was a near total tympanic membrane perforation. The ear was injected with 1% lidocaine with epinephrine. A tympanomeatal flap was created using a sickle knife and 7200 Beaver blade. The ear canal was packed with topical epinephrine.

Next, a postauricular incision was made. This was carried down to the temporalis fascia and mastoid periosteum. A piece of temporalis fascia was harvested, pressed and set aside under a heating lamp for later use. A T-shaped periosteal incision was made and the mastoid cortex was exposed. Self-retaining retractors were placed. An intact canal wall mastoidectomy was next performed. This was done using a high-speed otologic drill with continuous suction irrigation. Progressively, smaller cutting and diamond burs were used. Dissection was carried back to the sigmoid sinus, superior to the tegmen, inferiorly to the mastoid tip and anterior thinning the bony canal wall. The antrum was opened. The mastoid was clear of disease.

Next, ear canal was examined. The posterior skin was elevated forward. The edges of the tympanic membrane were freshened using a Rosen needle. The tympanomeatal flap was elevated with a weapon knife and the middle ear space was entered. Chorda tympani nerve was identified and preserved. The malleus periosteum was incised and the tympanic membrane was elevated forward off of the malleus. The middle ear was healthy. The eustachian tube orifice was palpated with a gimmick. It was mildly stenotic but with gentle pressure opened. The facial nerve was covered in bone. The ear was copiously irrigated with saline.

Next, the previously harvested temporalis fascia was trimmed. It was brought in place and put under the anterior annulus lateral to the malleus and up the posterior canal wall. The middle ear space was packed with Xeroform soaked with saline. The lateral graft and drum was packed with Gelfoam soaked with ciprofloxacin. The mastoid periosteum was closed using 3-0 interrupted Vicryl. The lateral ear canal was examined. It was packed with Gelfoam soaked with ciprofloxacin. The postauricular wound was then closed in layers using 3-0 interrupted Vicryl and 5-0 fast absorbing gut. The ear was dressed with antibiotic ointment and Glasscock ear dressing.

Throughout the case, intraoperative facial nerve monitoring was performed. The monitor was personally observed and controlled by the operating surgeon. At no point during the case was there spontaneous activity to suggest injury to the nerve. At the end of the case, the patient was awakened and extubated. The patient was transferred to the recovery room in stable condition. Estimated blood loss minimal. Sponge and needle counts correct. In the recovery room, the patient's facial nerve function was normal.

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History and Physical Medical Transcription Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

REASON FOR ADMISSION:  Respiratory failure with severe bronchospasm requiring a higher level of care.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male with a history of asthma who has never been intubated before. The patient is unable to provide history and history taking is thus limited. The patient, according to the daughter, had been short of breath for the past 3 to 4 days with audible wheezing. He had been using her nebulizer machine without significant relief. He had a dry cough as well. There is no known fever, chills or pain. There were no ill contacts at home. According to the daughter, the patient's chief complaint was tightness in the chest. The patient was admitted and required intubation later that day for severe bronchospasm and respiratory failure. He has required heavy sedation and is being transferred here for pulmonary consultation and further ventilator management.

PAST MEDICAL HISTORY:  According to the daughter, he has a history of asthma, hypertension. No history of diabetes mellitus or heart disease, according to the daughter.

SOCIAL HISTORY:  According to the patient's daughter, he had no known occupational exposures. He never smoked tobacco or drank a large amount of alcohol. He is widowed and lives with his daughter.

ALLERGIES:  No known drug allergies.

FAMILY HISTORY:  Positive for asthma. The patient's sisters had cancer of unknown type. There is no history of heart disease or diabetes mellitus in the family, according to the daughter.

MEDICATIONS ON TRANSFER:  Solu-Medrol 60 mg IV q. 6 h., albuterol nebulized frequently, Levaquin 500 mg IV q. 12 h., propofol drip for sedation which was switched to fentanyl and Versed during air ambulance transport, vecuronium 7 mg twice during his air transport to facilitate ventilation and Zantac 50 mg q. 12 h.

PHYSICAL EXAMINATION:
GENERAL APPEARANCE:  Intubated and currently not responsive. By report, he had received sedation.
VITAL SIGNS:  Temperature 35.2 degrees Celsius, blood pressure 104/68, heart rate 48, respiratory rate 14, oxygen saturation 100% on 100% FiO2, on the ventilator. Current ventilator settings:  PCV bilevel ventilation with airway pressures of 40/5 leading to a tidal volume of 1.1 liters and FiO2 of 100%.
HEENT:  Head is normocephalic and atraumatic. Pupils are 4 mm and poorly reactive to light bilaterally.
LUNGS:  Poor air movement. Tight expiratory wheezes throughout.
CARDIOVASCULAR:  Bradycardic, regular. Normal S1 and S2. No audible murmur, rub or gallop.
ABDOMEN:  Normoactive bowel sounds. Soft, mildly distended. No tenderness elicited as the patient has been sedated. There is a well-healed suprapubic midline scar.
EXTREMITIES:  No edema, clubbing or cyanosis.
NEUROLOGIC:  The patient appears to be sedated and paralyzed. He does not move any extremities.

LABORATORY DATA:  The lab data here is pending. At the outside hospital, the sodium was 138, potassium 3.8, chloride 104, CO2 of 26, BUN 33, creatinine 1.4. Glucose was 246. BNP was 36. CPK was 436. LDH was 484. Troponin 0.06. White blood cell count was 10.2, hemoglobin 11.8, hematocrit 36.2 and platelet count 204,000. The differential on the white blood cell count was 87% segs, 6% lymphocytes and 6% monocytes. Arterial blood gas done prior to transfer showed a pH of 7.38, PCO2 of 46, PO2 of 192, bicarbonate 28 and oxygen saturation 100% on 48% FiO2 via SIMV mode.

DIAGNOSTIC DATA:  Chest x-ray revealed hyperinflated lungs with tip of endotracheal tube near the aortic knob in the airway. There were no focal infiltrates. Electrocardiogram is pending.

IMPRESSION:  The patient is a (XX)-year-old male with a reported history of asthma, who appears to have status asthmaticus and respiratory failure. He has been transferred here. The patient has been difficult to ventilate at times due to severe bronchospasm. The patient is currently quite bronchospastic and had initially arrived with tidal volumes in the 300 range with bilevel PCV ventilation and airway pressures of 40/5. This subsequently improved dramatically following multiple serial albuterol and Atrovent treatments, and the patient currently has tidal volumes in the 1 liter range. Given the inability to obtain a history from the patient, the trigger for his asthma exacerbation is unclear, but may be related to an episode of bronchitis given the report of a nonproductive cough from the daughter.

PLAN:
1.  Status asthmaticus:  The patient will be treated with high-dose Solu-Medrol and frequent albuterol and Atrovent metered dose inhalers. The patient will be empirically placed on Avelox for possible bronchitis. There is no evidence of pneumonia on his chest x-ray.
2.  Respiratory failure:  This appears to be related to his asthma exacerbation. We will adjust his ventilator to prolong his expiratory time as much as possible. Currently, with his set I-time, his I:E ratio is 1:4. We will attempt to minimize auto PEEP and reduce his PCV pressures accordingly and lower his tidal volume to the 500 mL range. The patient had been sedated and paralyzed to facilitate air transport. We are holding any further paralysis at this time to neurologically assess the patient. We will attempt to sedate him with Diprivan to maintain compliance with the ventilator, but should he become agitated and difficult to ventilate, then he may require paralytic agents again.
3.  Possible small bowel obstruction:  The patient reportedly had a distended abdomen and the abdominal films at the outside hospital revealed distended loops of small bowel, which were suspicious for partial or early small bowel obstruction. CT scan was done immediately prior to transfer here and has not been reviewed yet. There does not appear to be marked distension of the small bowel and we will review this with radiology and obtain a surgical consult accordingly. In the meantime, we will place him on n.p.o. status with his orogastric tube to low intermittent wall suction. The patient's abdomen is currently soft and difficult to assess due to his recent paralysis, but he does not appear to require a surgical intervention at this time.
4.  Routine medical ICU care:  The patient will be placed on a proton pump inhibitor for stress ulcer prophylaxis and we will place him on subcutaneous heparin for DVT prophylaxis. The patient will have an arterial catheter inserted for frequent ABG analysis and monitoring of his blood pressure, which is currently borderline. Should the patient have worsening hypotension or need additional IV access, we will insert a central venous catheter temporarily in the femoral region until a PICC line can be inserted, given the high risk of pneumothorax and severe subsequent consequences of a potential pneumothorax. We will use Diprivan for sedation, but we will need to decrease the dose given the borderline blood pressure and his bradycardia.
5.  Code status:  I discussed this with the patient's daughter, who indicates that the patient would want full code and full care status for now.

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