Endoscopic Ultrasound Using Color Doppler MT Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Pancreatic cancer.

POSTOPERATIVE DIAGNOSES:
1.  A 3.8 x 2.4 cm head of pancreas mass.
2.  Dilated pancreatic duct in the head and tail of pancreas.
3.  Gallbladder sludge.
4.  Common bile duct stent in place.
5.  No obvious celiac lymphadenopathy.

PROCEDURE PERFORMED:
Endoscopic ultrasound using color Doppler flow.

PHYSICIAN:  John Doe, MD

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old woman with a history of pancreatic cancer. Endoscopic ultrasound is being performed for staging purposes. The risks, benefits, and alternatives to the procedure were explained including but not limited to infection, bleeding, aspiration, perforation, adverse medication reaction, missed diagnosis, and missed lesions. The patient verbalized understanding and signed the informed consent form.

DESCRIPTION OF PROCEDURE:  The patient was placed in the left lateral decubitus position and given incremental doses of propofol, fentanyl and Versed. The procedure was performed using the Olympus GF-UE160 radial echoendoscope. The oropharynx was sprayed with topical anesthesia through a bite-block.

The echoendoscope was inserted through the oropharynx, esophagus intubated, then advanced to the transgastric level of 46 cm at which point the celiac artery take-off was identified. There was no adjacent lymphadenopathy. At the transgastric level at 44 cm, the body and tail of pancreas was identified. At the body of the pancreas, the pancreatic duct measured in maximal dimension 0.6 cm and tail of pancreas was also dilated at 0.2 cm. The pancreas at these sites was somewhat lobulated in appearance, consistent with inflammation. The visualized left kidney appeared normal. Spleen was visualized and also appeared normal. In the antrum of the stomach, the gallbladder was filled with sludge and was somewhat thickened in appearance. The common bile duct stent was identified and surrounding the stent was a mass in the head of the pancreas measuring a maximum dimension of 3.8 x 2.4 cm in size. It abutted the portal vein but did not appear to involve within it. There was also a plane between this lesion and the superior mesenteric vein. There was no adjacent paraduodenal lymphadenopathy. The uncinate process appeared normal as well as the ampullary region. The visualized portion of the liver appeared normal.

Air was then withdrawn and the echoendoscope was removed. The patient tolerated the procedure well. There were no immediate postoperative complications. The patient’s vital signs were monitored throughout the procedure and remained stable.

CONCLUSION:  The patient is a (XX)-year-old woman with pancreatic cancer. Endoscopic ultrasound today shows a 3.8 x 2.4 cm mass in the head of the pancreas that abuts the portal vein but does not appear to be invading it nor does it appear to involve the superior mesenteric vein. There is no celiac lymphadenopathy. Endoscopic ultrasound stages as a T2N0Mx lesion.

ORIF of Orbital Zygomatic Complex Fracture Operative Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left orbital zygomatic complex fracture with orbital floor blow-out fracture.

POSTOPERATIVE DIAGNOSIS:  Left orbital zygomatic complex fracture with orbital floor blow-out fracture.

OPERATION PERFORMED:  Open reduction and internal fixation of left orbital zygomatic complex fracture with exploration without reconstruction of left orbital floor blow-out fracture.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

FLUIDS:  Crystalloids.

ESTIMATED BLOOD LOSS:  About 25 mL.

DESCRIPTION OF OPERATION:  The patient was brought to the operating suite and given general endotracheal anesthesia. Marcaine 0.5% with epinephrine was infiltrated into the areas where incision was made, which included the left upper buccal sulcus and the left lower eyelid. The patient was then prepped and draped in the usual sterile manner. The left upper buccal incision was made with electrocautery. Dissection was carried through the mucosa down to the underlying periosteum of the maxilla. A Joseph periosteal elevator was then used to dissect up to the inferior orbital rim. Fractures were noted along the anterior maxillary sinus as well as the zygomaticomaxillary buttress. After getting exposure, we then went to make the subciliary incision. Incision was made just below the eyelashes on the lower lid, on the left side. Dissection was carried with scissors from the lateral to medial direction. The underlying muscle was identified and divided in the direction of its fibers. Dissection was then carried just superficial to the septum orbitale. We went down to the inferior orbital rim and incised the periosteum. The Joseph periosteal elevator was then used to expose the fracture. The fracture was one of protrusion of the inferior orbital rim. This exposure was obtained. We went ahead and reduced the fracture by elevating the zygomatic prominence through the oral incision with an elevator. The inferior orbital rim protrusion was nice and flat and anatomically correct. Due to the comminution along the zygomaticomaxillary buttress, we placed the plate along the inferior orbital rim first. The Lorenz system was used for the fixation. Along the inferior orbital rim, an 8-hole plate was placed. Multiple 3 mm screws were placed into the fracture and just medial and lateral to it. The plate was a 1.0 mm plate. We then went to the zygomaticomaxillary buttress and reduced the butterfly fragment along this fracture line and then placed a 1.5 plate; this was a 6-hole plate.  Multiple 5 mm screws were placed along the fracture line. A 1.0 plate was then placed right along the side of that as there were some fragments along the anterior maxillary area that we wanted to reduce and fix anatomically. This was a 1.0 plate, 6-hole, and 3 mm screws used for the fixation. The wounds were then irrigated. Hemostasis obtained. Wound closure was performed along the buccal sulcus with 3-0 chromic. The subciliary incision approximated with 6-0 fast-absorbing gut. The patient was then awakened, extubated, and taken to the recovery room in satisfactory condition having tolerated the procedure well.

Vein Stripping Transcription Operative Sample Report / Example

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Primary varicose veins, left lower extremity.

POSTOPERATIVE DIAGNOSIS:
Primary varicose veins, left lower extremity.

OPERATION PERFORMED:
Left lower extremity varicose vein stripping and excision.

SURGEON:  John Doe, MD

ANESTHESIA:  General with endotracheal intubation.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room after the multiple large varicosities in the left lower extremity had been marked. The bulk of the large varicosities were present in the left posterior calf. Consequently, the patient was initially placed in the prone position for access to the posterior calf varicosities and was later converted to the supine position for stripping of the greater saphenous vein. A Foley catheter was inserted. The patient was then positioned on the operating room table in prone position. Rolls were placed on both sides of the chest. The left lower extremity was then prepped in the usual circumferential fashion. Sterile drapes were applied. Multiple transverse and vertical incisions were then made in the left popliteal fossa and in the posteromedial calf. The very large, tortuous varicosities were individually dissected and removed. Perforating veins were ligated with 3-0 suture prior to division. The dissection was continued on the medial and lateral sides of the calf. As much of the marked varicosities were removed from this approach. Varicosities in the left lower posterior thigh were also individually dissected and removed. After completion of the dissection, the multiple incisions were closed with interrupted 5-0 nylon. The patient was then repositioned for the supine approach. The left lower extremity was again prepped with Betadine solution and draped in the usual sterile fashion. A transverse incision was made in the left groin. The large proximal greater saphenous vein was identified. This was dissected to its origin with the common femoral vein. Tears were ligated with 3-0 silk suture and divided. The greater saphenous vein was then ligated flush with the common femoral vein using a 2-0 silk suture. The proximal greater saphenous vein was then divided. Attention was then turned to the left medial ankle. A transverse incision was made anterior to the medial malleolus. The greater saphenous vein was identified at this level. The vein was separated from the adjacent nerve. The distal greater saphenous vein was then ligated with 3-0 silk suture. An incision was made in the vein and a plastic stripper was advanced to the medial knee. The stripper would not go beyond the knee, so a vertical incision was made at the tip of the stripper in the upper calf. The stripper in the vein was identified. This was secured in the vein with 2-0 silk suture. The greater saphenous vein was then stripped from the knee out the ankle incision. Pressure was held along the course of the vein for hemostasis. After division of the greater saphenous vein in the groin, the plastic stripper was advanced distally to the medial knee. The vein containing the stripper was identified. The greater saphenous vein was then stripped from the groin to the knee in the usual fashion. Pressure was held along the course of the saphenous vein for hemostasis. At the completion of the dissection, no significant bleeding was noted. There was no hematoma. The multiple incisions were closed with interrupted 5-0 nylon. The groin incision was closed with interrupted 3-0 plain catgut in the subcutaneous layer and subcuticular 5-0 Vicryl for the skin closure. The estimated blood loss was less than 100 mL. The sponge count was correct. No blood transfusions were administered. A bulky fluff gauze dressing was applied to the left lower extremity and secured in place with Kerlix rolls, 4 and 6 inch elastic Ace bandages. The patient tolerated the procedure without difficulty and was awakened from the anesthetic in the operating room and extubated. The Foley catheter was removed. The patient was then transferred to the surgical recovery area in stable and responsive condition.

Common Carotid to Subclavian Artery Bypass Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Right subclavian artery steal syndrome.

POSTOPERATIVE DIAGNOSIS:  Right subclavian artery steal syndrome.

OPERATION PERFORMED:  Right common carotid artery to subclavian artery bypass. 

SURGEON:  John Doe, MD 

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  Negligible.

COMPLICATIONS:  None.

INDICATION FOR SURGERY:  The patient is an (XX)-year-old female with a history of right subclavian artery stenosis, who has had progressive vertebral basilar insufficiency symptoms with dizziness, coordination problems, poor balance and difficulties walking. Head CT scan was negative for stroke. Duplex scan showed reversal flow on right vertebral artery and a severe stenosis on the right subclavian artery, greater than 90%. The patient was recommended the above operation, which the patient was agreeable to.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and given general endotracheal anesthesia, which the patient tolerated well. The right neck, shoulder and upper chest were prepped and draped in the usual fashion. A transverse incision was made in the right lower neck, about a fingerbreadth above the clavicle. The platysma muscle was incised. Crossing veins were ligated and divided between silk ties. We first exposed the right common carotid artery. The sternocleidomastoid muscle was mobilized off the common carotid artery and identified the right jugular vein and dissected it free and mobilized it off the common carotid artery as well. The common carotid was dissected free. The artery was soft with a good strong pulse and suitable for inflow. The preoperative carotid angiogram showed no significant disease. It was dissected free and encircled with vessel loops. During course of dissection, the ansa cervicalis nerve was identified, mobilized off the common carotid artery and preserved intact. The right subclavian artery was then exposed. The right sternocleidomastoid muscle was first divided near its attachment to the clavicle. The right scalene lymph nodes and fat pad was then mobilized off the right anterior scalene muscle. We then identified the right phrenic nerve and dissected it free; it branched. Both branches were preserved intact. We then were able to divide the right anterior scalene muscles. This allowed exposure of the right subclavian artery. The site of the cervical arterial trunk was identified and dissected free and the arterial trunk preserved intact but we did divide the vein. The subclavian artery had a very poor pulse. We dissected it free and encircled it with vessel loops. Enough of the artery was exposed to facilitate the anastomosis for the graft.

The patient was given 5000 units IV heparin. Vascular clamps were applied to the right common carotid artery. A longitudinal arteriotomy incision was made. Dacron 8 mm graft was used for the bypass. One end was spatulated and beveled to appropriate length and anastomosed in an end-to-side fashion with a running 5-0 Prolene suture. Prior to the completion of the suture line, flushing was performed. On release of the vascular clamps, there was excellent pulsatile flow through the graft. Of note, the patient's systolic blood pressure had increased, about 155-165 mmHg, when vascular clamps were applied to the common carotid. We subsequently let the blood pressure become normalized. The graft was tunneled deep to jugular vein to the right subclavian artery. Appropriate orientation was maintained. Vascular clamps were applied proximally and distally on the right subclavian artery and a longitudinal arteriotomy incision was made. The artery was soft without significant atherosclerotic disease. The end of the graft was spatulated and beveled to appropriate length and anastomosed in an end-to-side fashion, using running 5-0 Prolene suture. Prior to the completion of suture line, flushing was performed. On release of the vascular clamps, there was excellent pulsatile flow through the Dacron graft. There was noted to be some redundancy in the graft. To eliminate this, we re-clamped the graft, excised the redundant section, then reanastomosed the graft in an end-to-end fashion with a running 5-0 Prolene suture. This eliminated the redundancy and made a much smoother lie of the graft.

At this point, the wounds were irrigated and hemostasis secured. Topical hemostatic agents were applied. Heparin was reversed with protamine. Topical Tisseel was then applied to the wound bed. The sternocleidomastoid muscle was then reapproximated with 2-0 Vicryl horizontal mattress sutures. The deeper soft tissue layer was then closed with running 3-0 Vicryl suture over the graft. The platysma muscle was also closed with a running 3-0 Vicryl suture and the skin incision closed with a running 4-0 Monocryl subcuticular stitch. Topical Dermabond and sterile dressing was applied. The patient tolerated the procedure well. No complications occurred.


Laser Stapedectomy Medical Transcription Operative Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Left otosclerosis.
2.  Left conductive hearing loss.

POSTOPERATIVE DIAGNOSES:
1.  Left otosclerosis.
2.  Left conductive hearing loss.

OPERATION PERFORMED: 
Left laser stapedectomy, intraoperative facial nerve monitoring x1 hour, fascia graft, microsurgery.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

ANESTHESIOLOGIST:  Jane Doe, MD

DESCRIPTION OF OPERATION:  After informed 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 head was turned to the right, exposing the left ear. The left 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. The operating microscope was next brought in. Throughout the case, the operating microscope and microsurgical technique was used. The microscope was used for improved illumination and magnification. The left ear was examined. The tympanic membrane was normal. The ear canal was somewhat stenotic. An appropriately-sized speculum was placed. The ear canal was injected with 1% lidocaine with epinephrine. A tympanomeatal flap was created using a sickle knife and 7200 Beaver blade.

Next, a small postauricular incision was made. A piece of fascia was harvested, pressed and set aside under a heating lamp for later use. Hemostasis was achieved with bipolar cautery. The wound was closed using 5-0 fast-absorbing gut. The fascia, once dry, was trimmed into small pieces to seal the piston in place. The ear was examined again with the microscope. The speculum was held in place with a speculum holder attached to the bed. The tympanomeatal flap was elevated and the middle ear was entered. The chorda tympani nerve was identified and preserved. The ossicular chain was palpated and found to be rigidly fixed. The scutum was taken down using the Skeeter drill. This was done until the stapes superstructure was easily seen. The incudostapedial joint was separated. Using the OmniGuide CO2 laser at a setting of 4 watts, the stapedius tendon was sectioned. The posterior crus was removed with the laser. The anterior crus was down-fractured and removed. The distance from the footplate to the incus was measured and found to be 4.30 mm. The footplate itself appeared quite thick. Using the CO2 laser, a rosette was created in the footplate. The char was removed. There was additional bone present. Again, the laser was used to create another rosette. The char was again removed. Repeating this procedure many times, laser drill out of footplate was performed. Eventually, the vestibule was opened. An oval window rasp was used to remove the char at the edges. A Medtronic Big Easy 4.30 x 0.5 titanium and platinum MRI-compatible piston was next brought onto the field. This was placed from the incus to the fenestra. It was crimped in placed using a crimper. The ossicular chair was palpated and found to move normally. The piston was sealed in place using the previously harvested fascia. The tympanic membrane and tympanomeatal flap were returned to their normal position. The tympanic membrane was intact.

The lateral surface was packed with antibiotic ointment. The ear was dressed with antibiotic ointment and a cotton ball. 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. The facial nerve was covered in bone. In the recovery room, the patient's facial nerve function was normal. Estimated blood loss was minimal. Sponge and needle counts were correct.

Psychiatric Consult Medical Transcription Sample Report / Example

DATE OF CONSULTATION:  MM/DD/YYYY

REASON FOR CONSULTATION:  Mood disorder.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male with a history of AIDS who was admitted for treatment of aplastic anemia, pancreatitis, CMV retinitis, and CMV colitis. Consultation was requested for assessment of behavioral issues and the possibility of AIDS dementia. On interview, the patient reported feeling depressed. The patient denied having any suicide plans or intention. He is aware of the severity of his illness and he is not interested in treatment for depression. He does appear to have decisional capacity at this time. Collateral information was obtained from Dr. Doe, and according to him, this is the patient's baseline behavior. The patient was unwilling to participate with cognitive testing to help with assessment for AIDS dementia and he was unwilling to complete the psychiatric interview. He did admit to feeling somewhat depressed. He cited psychosocial stressors, poor finances, and difficulties with his family recently. Further questioning regarding symptoms of depression was unable to be performed due to the patient being unwilling to complete the interview. The patient did deny any homicidal ideations and did not report any auditory or visual hallucinations. The patient does not have much hope for any kind of meaningful recovery.

CURRENT MEDICATIONS:  Acetaminophen, fentanyl citrate, Zithromax, bisacodyl, danazol, Truvada, fentanyl patch, fentanyl PCA, folic acid, foscarnet, Lidoderm patch, lopinavir/ritonavir, normal saline at 100 mL per hour, Zofran, oxycodone immediate release tablet, OxyContin, Neutra-Phos, Klor-Con, Phenergan.

PAST PSYCHIATRIC HISTORY:  The patient denies any history of psychiatric illnesses or having seen a psychiatrist in the past. He does admit that he had tried to commit suicide multiple times.

PAST MEDICAL HISTORY:  AIDS, questionable leukemia, history of CMV colitis with GI bleeding, gastritis, pancytopenia, cardiomyopathy with ejection fraction of 50%, peripheral neuropathy, right eye blindness, AIDS. The patient has been poorly adherent with his AIDS medications.

ALLERGIES:  No known drug allergies.

FAMILY HISTORY:  Unable to obtain psychiatric family history.

SOCIAL HISTORY:  The patient reports that he was living with his father, unemployed.

SUBSTANCE ABUSE HISTORY:  The patient denied alcohol use but does smoke 2 packs per day of cigarettes. He denied any recent illegal drug use; however, he has a history of drug abuse in the past.

MENTAL STATUS EXAMINATION:  This is a (XX)-year-old male who appears his stated age. He appears somewhat thin but is in no acute distress, although he does appear to be in pain at times. He is lying in bed on his side throughout most of the interview. He is somewhat uncooperative with the interview. The patient displayed poor grooming. The patient made poor eye contact throughout the interview. The patient spoke with somewhat irritable tone, but he spoke in a normal rate and volume. The patient was not describing any tremors or tics. He did not have any psychomotor agitation or retardation. The patient did report feeling depressed. The patient appeared dysphoric and irritable. His affect was constricted and mood congruent and it was appropriate. Thought process linear and concrete. The patient is not expressing any paranoia or delusions. He denies any active suicidal or homicidal ideations but does seem to have passive death wish. The patient did not voice any auditory or visual hallucinations. The patient would not cooperate with testing of orientation, concentration, knowledge, or memory. The patient seems to have a fair amount of insight into his illness and its severity. The patient was expressing somewhat poor judgment at this time.

LABORATORY AND DIAGNOSTIC DATA:  Hematology panel significant for low white blood count and anemia with nucleated RBCs and a low platelet count of 34,000. HIV testing showed HIV-1 RNA by PCR copies of 98,400 and HIV-1 RNA by PCR log copies of 5. CMV DNA quantitative was less than 200. UA significant for trace protein and trace blood. CT scan of the abdomen was normal.

FORMULATION:  This is a (XX)-year-old male with AIDS with multiple infections and complications, who was admitted for treatment of his medical condition. He was assessed by his primary team to be having behavioral issues and there was question of possibility of AIDS dementia; therefore, psychiatric consult was obtained. With further history gathering and collateral from Dr. Doe, it was determined that the behavioral issues are consistent with the patient's baseline behavior. He would not allow for cognitive testing; therefore, possibility of AIDS dementia could not be ruled out completely. At this time, he likely does meet criteria for depression secondary to general medical condition and nicotine dependence; however, he is refusing treatment for either. The patient does appear to have decisional capacity at this time.

DIAGNOSES:
AXIS I:  Mood disorder secondary to general medical condition and nicotine dependence.
AXIS II:  Deferred.
AXIS III:  Acquired immune deficiency syndrome.
AXIS IV:  Problems with housing, finances, social and family support, and occupation.  Problems with chronic medical illness.
AXIS V:  Global assessment of functioning 45.

TREATMENT AND RECOMMENDATIONS:
1.  We would suggest ordering an MRI to evaluate for any brain pathology or changes that might be consistent with AIDS dementia.
2.  We would recommend involving Social Work to help with coordinating the patient's social service benefits and to assist with discharge planning, if the patient is having problems with housing.
3.  We informed the patient that if he changes his mind and would be interested in treatment for his depression and nicotine dependence, that we are happy to provide treatment.

Thank you, Dr. Doe, for this interesting consultation.



Brain MRI With and Without Contrast Transcription Sample Report

BRAIN MRI WITH AND WITHOUT CONTRAST

MRI is performed both with and without contrast using thin sections to the pituitary and sellar regions.  Postcontrast whole-head images were also performed.  We see on the noncontrast images, through the pituitary, a slightly irregular and/or more prominent posterior pituitary area of high signal.  Because of the substance difference present in the anterior pituitary versus the posterior pituitary, it is common to see a change in intensity on MRI between these two areas of the pituitary gland.  The posterior pituitary region of high signal is usually slightly more concave whereupon it appears somewhat dumbbell shaped on today's exam.  The amount of high signal is not significant enough to suggest a focal hemorrhage or definite other mass.  However, when contrast was given, in the immediate post-sagittal images, we did see on one image only a small area of inhomogeneous enhancement directly at the more anterior component of this area of high signal, presumed to be part of the posterior pituitary gland.  This is midline and directly beneath the pituitary stalk.  Although it is felt that this may be related to a slightly more prominent pituitary gland than normal, the possibility of a slightly unusual presenting pituitary adenoma must be considered.  This did show homogeneous enhancement on the coronal images, which were taken after the immediate bolus images in the sagittal plane.  The pituitary gland is normal in size overall.  The pituitary stalk is midline.  The optic chiasm is not compressed or affected in any manner.  The parasellar regions including the carotid artery areas are unremarkable.  I see no parasellar meningioma or other mass.  Images of the whole head both using T2 weighted imaging and contrast-enhanced T1 weighted imaging show no areas of other abnormality in the cerebral or cerebellar hemisphere regions.  We do see that the posterior and inferior component of the sphenoid sinus slightly left of midline does contain a small focus of probable mucus retention cyst or mucosal redundancy.

IMPRESSION:  
1.  The posterior pituitary gland is somewhat more prominent than often seen.  It is apparent because of its slightly higher intensity signal than the anterior pituitary gland, which is normal.  However, on the immediate postcontrast images, the most anterior component of this area of high signal, which resides directly below the pituitary stalk midline and posterior, do not show uniform enhancement.  This could be a normal variant.  It could, however, represent a very small adenoma presenting with a slump, somewhat unusual noncontrast high signal equal to the pituitary gland.  This area measures only about 3-4 mm.  The rest of the gland enhances homogeneously both on the immediate and delayed images.
2.  The pituitary gland is of normal size and shape overall and the pituitary stalk and optic chiasm are all felt to be unremarkable, as are the remaining parasellar structures.
3.  Small focus of probable mucosal disease in the posterior left sphenoid sinus.

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MRA OF THE BRAIN

We do not see evidence, on this routine time-of-flight MRA, of any aneurysmal dilatation of the basilar artery or basilar tip aneurysm.  Basilar artery is intact.  There is one dominant feeding vertebral artery, which is not an unusual presentation.  Each of the internal carotid arteries show a very small amount of plaque disease.  The middle cerebral arteries are symmetrical and show some small tapering of the distal ends, which may indicate some mild atherosclerotic disease as well.  There is no aneurysmal dilatation or berry aneurysms in the normal location of the anterior communicating artery or the MCA/ICA bifurcation points.  Today's examination does not show definite posterior communicating artery.  There is a slim chance on today's examination that there may be a very small flow within a possible remnant posterior communicating artery on the left.

IMPRESSION:  Mild atherosclerotic disease.  No evidence of an aneurysm of the basilar artery or elsewhere is seen on the examination.

MRI OF THE BRAIN WITH CONTRAST:

This is a followup for the noncontrast MRI recently performed.  Today's examination does not show the small density seen anterior to the medulla, at the medulla-pons junction, to enhance.  When comparing it to the FLAIR images taken prior, we again see a very subtle presence in the area on the T1 weighted images today, with contrast, of some vague density in the same area, which brightly intensified on FLAIR imaging on the prior examination.  It also was well seen on the fast spin echo T2 on the prior examination.  As this area does not enhance, one might include a colloid cyst.  On further examination of the prior study, there is a small oval-shaped area of high signal also noted in the third ventricle.  This is sometimes a location for colloid cyst obstruction.  The ventricular system does not appear hydrocephalic at this time nor is there evidence of definite transependymal flow secondary to increased CSF pressure.  Neither of the very small change in the third ventricle nor that anterior to the brainstem enhances nor has it changed on today's examination when compared to prior study.  The remaining portion of the head also showed no abnormal enhancement with gadolinium.

IMPRESSION:  
1.  No abnormal enhancement of the mass of concern or elsewhere in this examination with gadolinium.
2.  The small focus anterior to the brainstem seen on the prior examination does again appear present on the sagittal images today suggesting that it is less likely an artifact.
3.  The small approximately 7 mm density presents as high signal on FLAIR and T2 weighted images on prior study, and in retrospect, there is a second small oval-shaped density in the third ventricle.  This is less than 1 cm.  These two densities may represent colloid cyst or an unusual artifact from draining veins.  I see no evidence of hydrocephalus to suggest that this is a definite obstructing cyst in the third ventricle.  In light of the negative MRA and no gadolinium uptake, one course of action would be to follow these carefully and see if there is any change in the ventricular size to indicate an obstructing process and any change in the brainstem to suggest a compressive process to the initially seen 7 mm density on the prior study.  If these are two colloid cysts, close followup is advised.  The alternative of abnormal enhancement due to an artifact of vascular flow, perhaps draining veins, is a possibility but felt less likely.  Should symptoms remain stable, one may want to repeat this examination in 6 months to make certain these two densities also remain stable.

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Sphenoidotomy, Ethmoidectomy, Polypectomy ENT Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Chronic sinusitis.
2.  Bilateral nasal polyposis.

POSTOPERATIVE DIAGNOSES:
1.  Bilateral nasal polyposis.
2.  Chronic sinusitis.
3.  Sphenoid sinus mucocele.

OPERATIONS PERFORMED:
1.  Bilateral sphenoidotomy with removal of tissue.
2.  Bilateral frontal sinus exploration.
3.  Bilateral total ethmoidectomies.
4.  Polypectomy.
5.  Bilateral maxillary antrostomy with removal of tissue.
6.  Stereotactic computer-assisted surgery.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA: General endotracheal anesthesia.

ESTIMATED BLOOD LOSS: 200 mL.

COMPLICATIONS:  None.

INDICATIONS:  The patient is a (XX)-year-old male who woke up 4 weeks ago with headache and double vision. CT scan revealed pansinusitis with expansion of the sphenoid sinus and erosion of the lateral wall of the sphenoid sinus. The patient also had severe nasal polyposis bilaterally.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and was placed in the supine position on the operating room table. General facemask anesthesia was given until adequate anesthesia was achieved. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty. The table was then turned 180 degrees. Approximately, 8 mL of 1% lidocaine with 1:100,000 epinephrine was injected into the uncinates, middle turbinate, septum and sphenoid bilaterally. Cocaine-soaked nasal pledgets 5% were placed in the nares bilaterally. At that point, the patient's images were loaded onto the LandmarX image guidance system. The head device was then placed. Point-to-point registration was then obtained with an accuracy of 1.8 mm.

The patient was then prepped and draped in the routine fashion. Cocaine-soaked nasal pledgets were removed. Surgery began on the right nasal cavity using a 0-degree nasal endoscope. The 0-degree Straightshot microdebrider was then used to remove polyps between the middle turbinate and septum. This was taken all the way back to the anterior face of the sphenoid. Superiorly, the dissection was carried up to the cribriform plate. After removal of these polyps, attention was turned towards the middle meatus. The middle turbinate was then partially resected and medialized. Polyps were removed from the anterior ethmoid cells including the ethmoid bulla. The uncinate was identified and outfractured with backbiting forceps. Straightshot microdebrider was used to remove the rest of the uncinate. A large maxillary antrostomy was then performed with a curved microdebrider. A large antrostomy was performed to remover the polypoid tissue from the maxillary sinus. Purulent material was also seen draining from the maxillary sinus. Straightshot microdebrider was then used to create a window through the basal lamella of the middle turbinate into the posterior ethmoids. Polypoid tissue again was removed from the posterior ethmoids.

Attention was then turned towards the sphenoid sinus on the right. Natural ostium was identified and enlarged in medial and inferior direction with Straightshot microdebrider. Concretions and purulent drainage were seen from the right sphenoid sinus. The sphenoidotomy was then enlarged laterally and superiorly with Straightshot microdebrider. Inflamed mucosa and mucocele was identified and ruptured, removed with Takahashi forceps. Attention was then turned towards the left nasal cavity. A 0 endoscope was used to identify structures in the left nasal cavity. The Straightshot microdebrider was then used to remove polyps between the middle turbinate and septum. This was carried posteriorly back to the anterior face of the sphenoid and superiorly to the cribriform plate. Attention was then turned towards the middle meatus. Again, a large amount of nasal polyps were in the anterior ethmoids and removed with Straightshot microdebrider.

A partial middle turbinectomy was then performed for access. A large antrostomy was then performed after removal of the uncinates with backbiting forceps. Antrostomy was widened with curved microdebrider. Polypoid tissue from the left maxillary sinus was then removed with the curved microdebrider. A small window was made in the basal lamella of the middle turbinate to gain access into the posterior ethmoids. Again, polypoid tissue was removed. A large sphenoidotomy was then performed on the left side, first in the medial and inferior direction. Polypoid tissue was removed from the sphenoid sinus with microdebrider and Takahashi forceps. The inner sinus septum and the posterior septum were then taken down with through-cutting instrumentation and rongeurs. This allowed communication between the right and left sphenoid sinuses. Curved suction was then used to remove concretions from the base of the sphenoid sinus.

The sphenoid sinus was then thoroughly irrigated. After entry into the sphenoid sinus, purulent drainage was seen. Access to the sphenoid sinus on both sides was confirmed with image guidance to avoid injury to the skull base. Image guidance was also used to identify the carotid artery and the optic nerves bilaterally. This aided in complete removal of the disease within the sphenoid sinus. Approximately 10 mL of Surgiflo was then placed in the sphenoid sinus, anterior-posterior ethmoids and maxillary sinuses for hemostatic control. After application of Surgiflo for 5 minutes, the nasopharynx was inspected and there was no further evidence of bleeding. At that point, the procedure was terminated. The patient was then awoken from general anesthesia, extubated and sent to the postanesthesia care unit in stable condition.

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Concha Bullosa Resection and Ethmoidectomy Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Pituitary tumor.
2.  Left concha bullosa of the middle turbinate.

POSTOPERATIVE DIAGNOSES:
1.  Pituitary tumor.
2.  Left concha bullosa of the middle turbinate.

OPERATIONS PERFORMED:
1.  Endoscopic resection of left concha bullosa.
2.  Endoscopic left anterior and posterior ethmoidectomies.
3.  Endoscopic transsphenoidal hypophysectomy with Stealth image guidance.

SURGEON:  John Doe, MD

NEUROSURGEON:  Jane Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

COMPLICATIONS:  None.

INDICATIONS FOR OPERATION:  The patient is a pleasant (XX)-year-old female who presented with visual loss. Despite the findings of glaucoma and cataract, suspect this may have been related to suprasellar extension of a pituitary tumor found on MRI imaging. Therefore, the patient elected to proceed with surgical intervention. The risks, benefits, alternatives, and indications were reviewed in detail with the patient and informed consent was obtained from the patient.

DESCRIPTION OF OPERATION:
The patient was brought into the operating room and placed on the OR table in the supine position. After demonstration of adequate endotracheal anesthesia, the table was turned 90 degrees. Next, the infrared camera and image-guidance wand were used to perform the registration of fiducial points. The system was utilized for intraoperative navigation and preoperative 3-dimensional planning of approach. CT scans were also reviewed in the room. There did appear to be a possible small area of dehiscence over the right carotid in the lateral aspect of the sphenoid sinus. The left carotid was well covered though the intersinus septum was obliquely oriented toward the left side. After Dr. Jane Doe and and I reviewed these films, the nose was prepped with Afrin-soaked pledgets bilaterally and 0.5 mL of 1% lidocaine with 1:100,000 epinephrine was infiltrated into both greater palatine foramina transorally. The patient was then prepped and draped sterilely.

A 0-degree endoscope with Endo-Scrub was placed in the left nasal cavity. It was clear that the left nasal turbinate was obstructive and would prevent adequate view and instrumentation in the sphenoid sinus. Local anesthetic was then applied to the superior attachment and the turbinate removed with curved endoscopic scissors, being one-third down from the anterior superior attachment. It was extended posteriorly and excised from the space with straight through-biting forceps. It appeared otherwise normal and it was not sent to Pathology.

Next, the superior turbinate was lateralized and sphenoid os identified. It was dilated with Freer and then further open medially and inferiorly with a 2 mm Kerrison rongeur. On the right, we observed the septal spur. I was able to medialize the middle turbinate and superior turbinate and visualize the sphenoid sinus. It was also opened in a similar fashion with Kerrison rongeur.

Next, the posterior septum was fractured with a Cottle and backbiter and straight through-bite used to perform a crescent-shaped posterior partial septectomy. This allowed visualization and instrumentation from both right and left nasal cavity. The sphenoid was widely opened. Dr. Jane Doe felt, for visualization, she needed to get further on the left. Therefore, a portion of the superior turbinate was removed with the straight through-bite forceps.

Next, the posterior ethmoid cells were entered and removed with straight through-bite forceps. The skull and basal lamina were identified and preserved in these areas. This allowed for further widening of the anterior wall of the sphenoid sinus laterally. The sphenoid sinus was notable for a septum, which extended obliquely to the left. Midline was marked using the image-guidance wand. The lateral and medial opticocarotid recesses were identified. The sphenoid was aerated underneath the sella, right of the septum.

Next, Dr. Jane Doe proceeded to meticulously remove mucosa from the sphenoid, taking care particularly around the region of the carotid arteries. The septum was removed with a straight through-bite and drill. The floor was removed and hypophysectomy performed. Please see Dr. Jane Doe's dictation for further details. Some spinal fluid was noted. We were able to identify this coming from the superior aspect behind the diaphragma. It was treated with a small amount of abdominal fat. Next, inlay and overlay DuraGen grafts were placed followed by obliteration of the anterior sphenoid sinus with fat. These layers were included with Tisseel placement.

Next, a Stammberger sinus dressing was applied to the cut edge of the middle turbinate. The posterior cut edge of the middle turbinate had been previously cauterized with suction Bovie and hemostasis well maintained. Some of the Stammberger dressing was then placed in the right middle meatus, after replacement of the middle turbinate to its native position. The patient was then turned over to the care of the anesthesia team for extubation and return to the ICU, having tolerated the procedure well without complications.

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ENT Consultation Medical Transcription Sample Report / Example

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who has been complaining of right ear pain. The patient relates that she had a similar episode approximately 4 weeks ago and saw a nurse practitioner, who diagnosed the patient with acute otitis media and treated her with antibiotics. The patient completed the course and had some improvement after 3-4 days. The patient denies any hearing loss, any problems with upper respiratory infection prior to the onset of the ear pain, and significantly, she does have allergy problems which have been exacerbated in the fall season. She has been taking Zyrtec prior to admission. She relates that she continues with nasal congestion and drippiness from her nose with associated postnasal drip, despite the fact that she is in the hospital currently. She has had difficulty with sinusitis. Importantly, she has also had problems with infected teeth and had root canals. However, denies any current or recent dental problems. She has had history of TMJ syndrome in the past. She relates that the pain is somewhat similar to this. The patient relates that she has had difficulty with cervical myalgia in the past as well as migraine headaches. She has undergone chiropractic treatment for her migraine headaches with improvement in her headache symptoms. Significantly, she has been involved in multiple accidents sustaining whiplash injuries on 4 separate occasions, according to the patient.

She recently notes that she was given a diagnosis of a nasal septal deviation as well. She denies any throat pain. She has had tonsillectomy performed in the past. She describes the pain as throbbing, achy pain. She denies any hearing loss, vertigo or otorrhea. She relates that she has had longstanding tinnitus, which she describes as a high-pitched ringing sound, worse on the right than the left, and not associated with fullness of the ear or any facial weakness. She had been previously evaluated by an otorhinolaryngologist, who performed an audiometric evaluation and found her hearing to be fine. The patient denies any significant noise exposure history. The patient denies eustachian tube dysfunction symptoms including pressure, pain, throbbing or popping sensation of the ears. She denies any acute dental problems. She denies frank symptoms of prodromal aura or migraine headaches. She denies any type of temple headache to suggest temporal arteritis. She has not had any recent trauma to the ear area. The patient denies upper respiratory infection symptoms or symptoms related to sore throat. She has no numbness or tingling sensation of the face or the head. She has discomfort related to her abdominal procedure.

CURRENT MEDICATIONS:  Pepcid, Ancef, Lidoderm patch as well as a PCA, Lovenox. 

PAST MEDICAL HISTORY:  Morbid obesity, GERD, hypercholesterolemia, environmental allergies, peripheral edema, insomnia, chronic arthritis with associated chronic pain, history of hepatitis and TMJ syndrome. Suspect a recent history of acute otitis media. 

PAST SURGICAL HISTORY:  Significant for tonsillectomy, ocular procedures, appendectomy, cholecystectomy, gastric banding, bilateral podiatric procedures, tubal ligation, carpal tunnel, rotator cuff surgeries and left total knee arthroplasty. 

FAMILY HISTORY:  Significant for diabetes, hypertension, and coronary artery disease. 

SOCIAL HISTORY:  Nonsmoker. She uses alcohol on a social basis.

REVIEW OF SYSTEMS:  As noted in HPI.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.6, blood pressure 96/56, pulse 84 and respiratory rate 21. 
GENERAL:  The patient is resting in her hospital bed. She appears generally to be comfortable with occasional episodes of pain. She uses her PCA frequently. The patient is in no acute respiratory distress. She is alert and oriented x3. She is conversive. There is no gross cellulitis or facial swelling noted bilaterally. 
HEENT:  The patient is wearing corrective lenses. Examination of the ears reveals both tympanic membranes to be intact and clear bilaterally. There is no middle ear cleft process, including effusion or infection noted. Canals and pinnae do not reveal any masses or lesions. There are no inflammatory or edematous changes. Nasal examination reveals the septum essentially in the midline anteriorly. There is a mild deflection of the septum to the left. Posteriorly, turbinates are within normal range. Both nasal passages are widely patent anteriorly. There is minimal clear discharge present. There is no significant rhinitis appreciated. The outward appearance of the nose is not markedly deviated. There are no masses, lesions or polyps noted on anterior rhinoscopy bilaterally. In the periorbital regions, there is no significant cellulitis or erythema noted. In the temple region, there is no palpable tenderness. There are no masses or lesions noted in the right parietal temporal as well as the mastoid, superior neck as well as preauricular regions, including any cellulitic changes. There is tenderness to palpation that has been initially reproduced by the patient's tenderness on the right consistent with palpation over the temporomandibular joint. Additional palpation superiorly, anteriorly and posteriorly elicited pain as well. However, did not reproduce the initial pain that the patient is complaining of. Oral examination reveals multiple areas of ulceration, gentle rasping of the upper and lower molars on the right did not elicit any tenderness. There are no inflammatory changes noted. The parotid and submandibular glands did not reveal any masses or tenderness bilaterally. Oral mucosa did not reveal any masses or lesions to the lips, hard palate and soft palate, buccal mucosa, the mouth or the tongue. The oropharynx did not reveal any localized infection, severe pharyngitis or postnasal drip, and tonsils are absent bilaterally.
NECK:  Examination reveals the trachea essentially in the midline. There is no discrete thyroid mass appreciated. There is no significant cervical lymphadenopathy or masses noted. There is generalized tenderness of the paravertebral musculature as well as sternocleidomastoid notch to a much lesser degree.

LABORATORY DATA:  INR 0.98, pro time 9.8, PTT 22.4. Sodium 134, potassium 4.3, glucose elevated at 198, creatinine 0.6, BUN 14, calcium 8.4, albumin 3.7, total protein 7.3, hemoglobin 11.3, white blood cell count 21.2 and platelet count 262,000.

IMPRESSION:
Right otalgia, likely secondary to referred pain from temporomandibular joint syndrome; cervical myalgia; rhinitis and deviated septum, mild; environmental allergies; obesity, status post banding; status post gastric bypass and gastric resection; respiratory insufficiency; gastroesophageal reflux disease; leukocytosis.

RECOMMENDATIONS:
The addition of NSAIDs at this time will not be entertained due to the recent surgery. The patient is currently on PCA, which should suffice. With the patient's extensive history of previous workup and evaluation and diagnoses made, we would like to check old records including audiometric evaluation and TMJ studies including Panorex x-ray or bitewings. Additional evaluation by dentistry in TMJ workup and treatment can be performed on an outpatient basis. Currently, it appears that her abdominal discomfort supersedes that of her ear. Extensive discussion including history taking and examination was completed with the patient. Questions were answered to her satisfaction but no promises or guarantees were given. The patient understands that there are additional etiologies for her otalgia and that the workup is far from being completed. However, in light of her other issues, we will defer additional workup at this time, unless her symptoms begin to accelerate. At this time, the patient's TMJ syndrome appears to be the most likely cause of her otalgia.

Tonsillectomy Sample Reports

Child Psychiatric Evaluation Medical Transcription Sample Report

DATE OF SERVICE:  MM/DD/YYYY

TIME SEEN:
This psychiatric assessment started at 3:30 p.m. and ended at 4:30 p.m.

IDENTIFYING INFORMATION:
The patient is a (XX)-year-old boy.  He is in kindergarten and lives with his mother and his three other siblings.

SOURCE OF INFORMATION
Mother and child intake summary at this facility.

PRESENTING COMPLAINT:
The patient reported on time for this assessment.  He was accompanied by his mother and sister.  This is the patient’s first formal psychiatric evaluation.  He was diagnosed with pervasive developmental disorder at 3 years of age by a neurologist.  He is reported to be aggressive and violent, gets angry easily.  He bangs his head on the floor or the wall, tries to stab himself with various things, rocks in the chair, among other things.  He has difficulty staying seated.  He is distractible, disruptive and impatient.  He has been written up on the school bus at least thrice.  He has lots of disorderly conducts like spitting anywhere and everywhere all the time.  Because of his hyperactivity, he tends to be accident-prone.  He gets into time-out every day at school.  Consequences of his actions do not seem to modify his behavior.  The patient has never been on any psychotropics.  Mother reports that his behavior has been progressively worsening.  He is not reported to have any symptoms suggestive of hypothyroidism or hyperthyroidism.

PAST PSYCHIATRIC HISTORY:
The patient has used extensive psychiatric and other intervention services as follows.  He has received early intervention services.  He received BHRS and also received resource coordination.  As mentioned earlier, he was diagnosed with PDD and sensory integration problems when he was 3 years old.

PAST MEDICAL HISTORY:
The patient was born with a congenital heart defect.  He also had several seizures on multiple occasions and has received EEG and sleep study, both were found to be within normal limits.

ALLERGIES:
None.

DEVELOPMENTAL HISTORY:
Mother was (XX) years old at the time of pregnancy; it was unplanned.  Throughout the pregnancy, she was in and out of the hospital for multiple medical problems related to pregnancy, including dehydration, anemia and premature contractions.  The patient was born one month preterm.  Apparently, it was a prolonged labor and the patient had fetal distress and forceps was used during delivery.  The patient had developmental delays in the form of crawling at (XX) months, walking at (XX) months, and talking at 4 years of age.  The patient did not like to be held as a baby and was fed in the crib.  He had extreme stranger anxiety.  He never slept well, even as a newborn, and even now, is up until 2 a.m.  He has received occupational therapy, physical therapy and speech therapy because of various developmental delays and speech problems.

SOCIAL HISTORY:
The patient is the fourth of four children born to his mother.  He has two sisters and one brother.  Parents recently separated because of frequent arguments between them.  Father maintains regular contact with all the children.  No physical or sexual abuse reported.

FAMILY PSYCHIATRIC HISTORY:
All his siblings have ADHD.  Mother states that the father probably has bipolar affective disorder.  Mother reports that multiple family members on the father’s side have psychiatric problems.  She states that there has been a successful suicide, attempted suicide and homicide on the paternal side.  Mother further adds that on the father’s side, multiple members have received inpatient treatment at psychiatric facilities.  She also states that a lot of members on the father’s side are drug and alcohol involved.

MENTAL STATUS EXAMINATION:
The patient is appropriately dressed and groomed.  He is cooperative and communicative.  He maintains eye contact when spoken to.  He is easily distracted.  Psychomotor activity is noticeably increased.  No involuntary movements.  His speech is spontaneous with normal volume and tone.  His affect is bright and full range.  He does not appear to be responding to any abnormal perceptions or delusions.  His judgment is age appropriate.

DIAGNOSES:
Axis I:    1.  Attention deficit hyperactivity disorder.
              2.  Pervasive developmental disorder by history.
Axis II:   Deferred.
Axis III:  Congenital heart defect.
Axis IV:  Deferred.
Axis V:  Global assessment of functioning between 50 to 60.

RECOMMENDATIONS:
The patient does not pose any imminent danger of harming himself or others; therefore, he can be followed as an outpatient.  The patient is not on any medications at the moment.  He should be started on Adderall 1.25 mg t.i.d.  If he is able to tolerate the medication, then it can be increased to 2.5 mg t.i.d.  Side effects were reviewed with the mother.  The patient should be provided with a RN.  The patient should continue to receive treatment.  The patient should return for reassessment on MM/DD/YYYY at 5:30 p.m.



MRI of the Cervical and Lumbar Spine Radiology Sample Report

DATE OF STUDY:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

INDICATIONS FOR STUDY:
1.  Spinal stenosis.
2.  Low back pain.
3.  Bilateral leg numbness.
4.  Weakness in hands.

CERVICAL AND LUMBAR SPINE MRI:

Due to the patient's body habitus and size, the patient could not be moved into the coil more and visualization of the upper lumbar spine is very limited.  The patient's head was also squeezed into the cervical spine coil and was very uncomfortable during the study.

MRI OF THE CERVICAL SPINE:

Sagittal and axial images were obtained.  The craniocervical junction is within normal limits.  Spinal cord is normal in location and signal intensity.  There is straightening of the normal curvature.  Marrow signal within the bony structures is unremarkable.

At C7-T1, there is no focal disk disease.

At C6-7, there is a disk bulge which causes mild flattening of the anterior CSF space and some neural foraminal narrowing, left greater than right.

At C5-6, there is a combination of disk bulge and posterior osteophytes, which narrows the neural foramina and flattens the anterior CSF space, more so than at the C6-7 level.

At C4-5, there is a disk bulge, which flattens the anterior CSF space and causes some bilateral neural foraminal narrowing, left greater than right.

At C3-4, there is a combination of bone and disk, which slightly flattens the anterior CSF space and narrows the neural foramina bilaterally.

IMPRESSION:
Some mild multilevel disk disease, as described above, with some disk bulges and posterior osteophytes.  There is no frank disk herniation.

MRI OF THE LUMBAR SPINE:

Sagittal and axial images were obtained.  The upper lumbar spine is not well visualized due to body habitus and positioning within the coil.  The conus appears grossly within normal limits, normal in location and signal intensity.  The marrow signal appears within normal limits.  There is marked narrowing at L5-S1 with some apparent fusion at this level to the left of midline.  There is some minimal scoliosis.  Marrow signal within the bony structures is unremarkable.

At L5-S1, the nerve roots exit normally.  There is some slight right neural foraminal narrowing on one image due to a combination of bone and disk; however, the neural foramina are patent on the next image.

At L4-5, there is a mild disk bulge and posterior facet degenerative changes.  Nerve roots are patent.

At L3-4, there are some mild posterior facet degenerative changes, thickening of the ligamentum flavum, and neural foraminal narrowing.  On the next image, the nerve roots exit normally.

IMPRESSION:
1.  There is some slight trilateral narrowing at L3-4.  The nerve roots exit more normally on the next image.
2.  At L4-5, there is a disk bulge and some posterior facet degenerative changes.
3.  At L5-S1, there is a bulging disk and narrowing on the right with slight right neural foraminal narrowing on one image.  On the next, the neural foramina are more patent.  There is no focal disk herniation.

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Triple Arthrodesis / Achilles Tendon Lengthening Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Right calcaneonavicular coalition.
2.  Equinus contracture.

POSTOPERATIVE DIAGNOSES:
1.  Right calcaneonavicular coalition.
2.  Equinus contracture.

OPERATIONS PERFORMED:
1.  Right triple arthrodesis.
2.  Right Achilles tendon lengthening.
3.  Excision of right calcaneonavicular tarsal coalition.
4.  Right distal tibial autograft.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and intravenous Ancef 1 gram was administered. After induction of general anesthetic, a tourniquet was placed over his right upper thigh. His right lower extremity was then prepped and draped in the usual sterile fashion. The foot was exsanguinated with Esmarch bandage and tourniquet was inflated to 275 mmHg. A longitudinal incision was made along the lateral aspect of the foot extending from the distal tip of the fibula towards the base of the fourth metatarsal. The skin was dissected sharply. Blunt dissection was carried down to the overlying extensor digitorum brevis muscle belly that was elevated and reflected distally. We exposed the dorsal aspect of the anterior calcaneus and then the calcaneocuboid joint. The joint was distracted using Caspar retractors and then the articular surface was debrided of cartilage.  A high-speed bur was used to remove overlying cortical bone and expose underlying cancellous bone. We used an osteotome to remove the portion of the prominent anterior process of the calcaneus. This was morcellized and used as bone graft later. We then carried our dissection deep into the wound and took down the calcaneonavicular coalition using a combination of rongeurs and osteotome as well as curette. When we had adequately mobilized the calcaneonavicular joint, we then evaluated the subtalar joint. It was fairly stiff and so I elected to proceed with exposure of the medial side of the joint.

We made a longitudinal incision just medial to the tibialis anterior tendon. Skin was dissected sharply. Blunt dissection was carried down to the talonavicular capsule and that was incised in line with skin incision. We exposed the articular surface, elevated the periosteum both medially and laterally to expose the dorsal half of the joint. Joint was distracted again using Caspar retractors and then articular surface was removed using combination of curettes and a periosteal elevator. We used rongeurs to remove remaining soft tissue. At this point, we were better able to mobilize the hindfoot and redirected our attention laterally. I placed a laminar spreader between the lateral process of the talus as well as the anterior process of the calcaneus and used it to distract the joint. We removed the articular cartilage from the subtalar joint using curettes and periosteal elevator. We used a high-speed bur to remove cortical bone. At this point, we were able to passively correct the position of the hindfoot. While correcting the valgus malalignment of the hindfoot, we provisionally fixed the subtalar joint using a screw that was placed through the dorsal neck of the talus and directed into the posterior tuberosity. We first placed the guidewire and checked its position under fluoroscopy and then secured it using a 6.5 mm cannulated screw.

Next, we corrected the rotation of the supination of the forefoot. There was a fair amount of tightness in the Achilles tendon, so we proceeded with lengthening of the Achilles tendon using #11 blade scalpel and percutaneously lengthening the tendon using the Hoke method. We then corrected supination of the forefoot and provisionally fixed the talonavicular joint using two guidewires and the 4.5 mm cannulated screws. We checked position of the guidewires under fluoroscopy. We drilled and then inserted two 56 mm partially threaded cancellous 4.5 mm cannulated screws and obtained good purchase with both screws. We checked positioning under fluoroscopy again. Finally, we secured our calcaneocuboid joint using crossed 3.5 mm cancellous screws that were placed after measuring, drilling, and tapping in the usual fashion. We made a small incision in the distal tibia along the distal anteromedial border of the tibia. The skin was dissected sharply. We made a window in the periosteum, and then using our Acumed bone graft harvesting device, we harvested some bone graft from the distal tibia. Using this and the previous morcellized bone graft, we packed this within the remainder of the subtalar joint after preparing the articular surface again using a high-speed bur. We made a trough in the dorsal aspect of the talonavicular joint and packed this with bone graft as well. We had good bony apposition of our calcaneocuboid joint.

The wounds were irrigated prior to placing the bone graft. We then closed the periosteum over the talonavicular joint using 2-0 Vicryl sutures. Periosteum of distal tibia was closed using 2-0 Vicryl suture as well. Extensor digitorum brevis muscle belly was reapproximated using 2-0 Vicryl suture. Subcutaneous tissues were closed using inverted 2-0 Vicryl sutures and the skin was closed using surgical staples. Xeroform sterile dressings followed by well-padded short leg posterior splint with the foot in slight plantarflexion were applied. The patient tolerated the procedure well and was transferred to the PACU in stable condition.  There were no intraoperative complications. Estimated blood loss was 50 mL. Tourniquet was elevated for 140 minutes and down for 30 minutes and up again for 33 minutes.


Suboccipital and Frontal Craniotomy Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Right frontal tumor.

POSTOPERATIVE DIAGNOSIS:  Right frontal tumor.

OPERATION PERFORMED:  Right frontal craniotomy for resection of right frontal tumor with Stealth image guidance and stereotactic preoperative planning.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room, and after induction of anesthesia and administration of antibiotics, he was placed in the Mayfield headholder with his head turned to the left side.  Prior to coming to the operating room, a stereotactic protocol MRI was done and was downloaded into the intraoperative Stealth system.  The patient’s head was registered on the Stealth station.  Next, a curvilinear incision was marked out and the skin was prepped and draped in the usual sterile fashion.  The previously marked incision was infiltrated with local anesthetic.  A #10 blade was then used to incise the skin.  Raney clips were placed on the skin edges.  It was flapped over a rolled sponge and held in place with fishhooks.  Four bur holes were created.  Next, the dura was opened and flattened medially.  There were very many draining veins medially and one venous lake began bleeding. This was stemmed with Gelfoam and pressure.  Next, the tumor was identified and a corticectomy was made.  The tumor was found to be fleshy colored.  This was resected with CUSA ultrasonic aspirator.  Several pieces were taken and sent to pathology for histologic examination.  The frozen section report came back as high-grade glioma, most likely glioblastoma multiforme.  Next, thorough evacuation of all visible tumor was made.  Once the margins of the tumor had been identified and resected, the corticectomy and tumor bed were packed with cotton balls.  Once adequate hemostasis had been achieved, tumor bed was lined with Gelfoam and FloSeal.  The dura was flapped loosely back into place.  Several tenting sutures were placed around the outside of the skull flap.  Next, some DuraGen was placed over the open dura.  The bone flap was replaced and held in place for bur hole covers.  The skin was closed with inversion interrupted 2-0 Vicryl sutures and skin staples.  All sponge, needle and instrument counts were correct.  Estimated blood loss was 350 mL.  The patient was extubated and transferred to the PACU in stable condition.

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DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Suboccipital mass with secondary hydrocephalus.

POSTOPERATIVE DIAGNOSIS:  Suboccipital mass with secondary hydrocephalus.

OPERATION PERFORMED:
1.  Suboccipital craniotomy and gross total resection of tumor with microscopic guidance.
2.  Right frontal external ventricular drain placement.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

DESCRIPTION OF OPERATION:  The patient was brought to the operative suite and underwent general endotracheal anesthesia.  He was then prepped and draped in the usual sterile fashion.  A 1 to 2 cm incision was made in the right mid pupillary line just anterior to the coronal suture.  Blunt and sharp dissection was performed down to the skull.  A small twist-drill hole was created and the dura was sharply incised.  The external ventricular drain was then easily passed into the lateral ventricle with spontaneous flow of minimally blood-tinged moderate pressure CSF.  Greater than 25 mL of CSF was aspirated and sent for cytology prior to any further intervention.  The EVD was appropriately sewn in place and the exit site closed using 4-0 Vicryl Rapide .  The patient was then carefully placed in the Mayfield pins and positioned prone on the surgical table.  The patient was then prepped and draped in the usual sterile fashion and a 4 to 5 cm incision was made traveling down to C1.  Blunt and sharp dissection was performed down through the skull, where a cerebellar retractor was placed in the incision to reflect the paraspinal musculature laterally.  A Midas Rex was used to create a trough over the torcular and a curved Penfield #4 was used to free the dura.  Midas Rex with B1 bit and footplate was then used to turn the craniotomy flap down to the foramen magnum.  The dura itself was grossly normal in appearance.  Four circumferential holes, both on the skull and on the bone flap were created to allow reattachment of the bone flap at the completion of the operation.  The dura was incised using a 15 blade and Geralds with teeth.  A Budde halo retractor was placed in the incision.  The Budde halo was carefully attached to the Mayfield headholder and 1/2 inch blades were used to reflect the cerebellar hemispheres laterally.  A midline cerebellar vermis dissection proceeded.  Portions of the tumor coming out of the obex were identified and sampled.  Frozen pathology was consistent with medulloblastoma.  The microscope was brought in to allow careful circumferential dissection of the lesion.  The tumor itself was vascular, beefy and bloody.  It appeared to arise from the region of the right foramen of Luschka and was briskly adherent to the stria on the floor of the fourth ventricle just medial to the right foramen of Luschka.  Careful circumferential dissection was continued up to the aqueduct of Sylvius where spontaneous flow of CSF was appreciated.  Looking into the aqueduct, the tip of the external ventricular drain was identified in the third ventricle.  Careful circumferential dissection was continued such that it was felt that a gross total resection was obtained.  After resection, there was minimal bleeding.  Hemostasis was achieved using bipolar electrocautery and the dura was closed in a simple running fashion using 4-0 Vicryl.  Durepair was used to patch the dura in a watertight fashion.  Closure was watertight to a Valsalva to 35.  The bone flap was then reaffixed using the circumferential holes previously made and 2-0 Vicryl suture.  The incision was copiously irrigated with antibiotic irrigation, closed in anatomic layers using 2-0 and 3-0 Vicryl.  Final layer of skin was closed using 4-0 Vicryl Rapide.  The patient tolerated the procedure well and was sent to the PACU intubated postoperatively.

Suboccipital Craniotomy and Resection Sample Report

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