Endoscopic Sphenoidotomies Partial Ethmoidectomy Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Bilateral sphenoid and posterior ethmoid sinusitis, acute.
2.  Meningitis.

POSTOPERATIVE DIAGNOSES:
1.  Bilateral sphenoid and posterior ethmoid sinusitis, acute.
2.  Meningitis.

OPERATION PERFORMED:
Image-guided bilateral endoscopic sphenoidotomies with right partial posterior ethmoidectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  Less than 25 mL.

DESCRIPTION OF PROCEDURE:  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. The nose was prepped with 3 Afrin-soaked pledgets bilaterally. Two mL of 1% lidocaine with 1:100,000 epinephrine was infiltrated in both the right and left greater palatine foramen to assist with hemostasis. Next, the patient was prepped and draped sterilely. Registration and calibration processes were performed followed by verification of the Stealth image-guided system. This was utilized for preoperative planning and intraoperative navigation. We began on the left side. The middle turbinate was placed in the lateral position using Freer. The posterior wall was then infiltrated locally with 0.5 mL of 1% lidocaine with 1:100,000 epinephrine. This was then repeated on the right. The superior turbinate was lateralized. Natural ostium in the left sphenoid sinuses was instrumented with the Freer and widened with 1 and 2 mm Kerrison rongeurs. The sphenoethmoid recess was fairly tight prior to this exploration. Mucoid material was evacuated from the left sphenoid sinus. There was polypoid edema of the walls. Kerrison was used to widely open the sinus to allow observation of the superior, medial and lateral walls. No obvious bony dehiscence was evident. Next, attention was turned to the right side. A portion of the superior turbinate was removed and opening was made into the posterior ethmoid area. Evacuation of thick yellow mucoid material was performed as well as culture with a swab. Lukens trap was placed on suction, which was attached in the image-guided system as the sphenoethmoidal recess was explored. The natural ostium was then opened. A 2 mm Kerrison rongeur was then utilized to open the ostia further inferiorly and medially. Careful opening was performed laterally into a posterior ethmoid air cell. All the purulent material was evacuated. There was some thick particulate yellow material, which was sent separately to cytology, obtained from the right sphenoid sinus. Again, the sphenoid walls were without obvious bony defect. Both right and left side was sequentially observed during Valsalva procedure per Anesthesia. No evidence of spinal fluid leak was identified. The sphenoid sinuses were then copiously irrigated. Liquid MeroGel was then inserted into the right and left sphenoid bony recess to assist with healing. The patient was turned over to the care of the anesthesia team for extubation and returned to the recovery room, having tolerated the procedure well.

Bilateral Open Orchiopexy Operative Sample Report / Example

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Right testicular torsion.

POSTOPERATIVE DIAGNOSIS:  Right testicular torsion.

PROCEDURE PERFORMED:  Bilateral open orchiopexy.

SURGEON:  John Doe, MD

ANESTHESIA:  General anesthesia via LMA.

COMPLICATIONS:  None.

DRAINS:  None.

ESTIMATED BLOOD LOSS: Minimal.

INDICATIONS FOR PROCEDURE:  This is a patient with a history of intermittent right-sided testicular torsion. Bilateral orchiopexy has been recommended and informed consent has been obtained.

DESCRIPTION OF PROCEDURE:  The patient was placed on the operating table in the supine position. General anesthesia was administered via LMA. The genitalia were sterilely prepped and draped in the usual fashion. A midline scrotal incision was carried down through the dartos layer. The tunica of the right testicle was opened and the testicle was examined. The right testicle was somewhat congested and inflamed. There were adhesions to the tunica. There was very scant hydrocele fluid present. The testicle had a normal position within the scrotum. A small appendix testis was removed and sent to pathology but appeared to be unremarkable and probably not a source of pain or torsion. The patient does demonstrate a bell clapper deformity consistent with possible torsion. The right testicle was pexed to the scrotal wall using three 2-0 chromic sutures in a triangle shape. The tunica was then closed with a running 3-0 chromic. The tunica of the left testicle was then opened. The left testicle appeared quite normal. There is a very small appendix testis, which was also removed. The left testicle was pexed to the scrotum using three 2-0 chromic sutures in a triangle fashion. The tunica of the left testicle was then closed with 3-0 chromic suture. Hemostasis was obtained when needed throughout the surgery with electrocautery. The dartos layer was reapproximated with a running 3-0 chromic. The skin was closed with a 2-0 chromic interrupted vertical mattress sutures. Polysporin ointment was applied followed by sterile dressings and a supporter. The patient tolerated the procedure well and was transported to the recovery room in satisfactory condition. Sponge and needle counts were correct x2.

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Foot Incision and Drainage Transcribed Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Right foot abscess.

POSTOPERATIVE DIAGNOSIS:
Right foot abscess.

OPERATION PERFORMED:  Right foot incision and drainage.

SURGEON:  John Doe, MD

ANESTHESIA:  Combination of MAC with local, 1:1 mixture of 0.5% Marcaine plain and 2% lidocaine plain infiltrated into the right foot.

ESTIMATED BLOOD LOSS:  75 mL.

PATHOLOGY:  Bone, sent for Gram bone culture.  Drainage sent for culture and sensitivity, aerobic and anaerobic, Gram stain, as well as AFB and fungal.

MATERIALS:  Graftjacket as well as Graftjacket Xpress and PDS suture.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old female who presents today with a right foot chronic abscess as well as ulcer for approximately 4 months. Currently healed over, but there is underlying abscess, reason the patient is being brought into surgery. Informed consent has been obtained. The patient has been medically cleared and n.p.o. for the appropriate time. There are no contraindications for surgery and all questions regarding surgery have been answered prior to the procedure. There were no postop injectables and no complication during the perioperative period.

DESCRIPTION OF OPERATION:  The patient was brought into the operating room lightly sedated and placed in the supine position on the operating room table under monitored anesthesia care. Then, 1:1 mixture of 0.5% Marcaine plain and 2% lidocaine plain was infiltrated into the right foot. A total of 12 mL was used. A pneumatic ankle tourniquet was placed on the right ankle.

The right leg was prepped and draped in the normal sterile fashion, elevated and exsanguinated using Esmarch bandage, at which time pneumatic ankle tourniquet was inflated to 250 mmHg.  Attention was directed to the right first metatarsal area, where a small ulcer was present on the skin. Hemostat was used to puncture through this area, and in doing so, fluid leaked out. This was then sent for culture and sensitivity. The wound opening was then further opened using 2 semi-elliptical incisions around original wound site where the skin was removed. The rest of the drainage that was present in this area was removed. There was also noted packing from prior, approximately 5 days ago, that was also removed. The wound was then investigated for any devitalized or necrotic tissue, which was then removed at this time. There was also a small piece of bone taken from the first metatarsal; this was sent for Gram bone culture. The plantar aspect of the right first metatarsal was also smoothed away. A small stab incision was made underlying this abscess area on the plantar aspect to allow for drainage. The incision site was then copiously irrigated with 3 liters of normal saline that had bacitracin in it. Next, one suture was then placed on the plantar opening so some drainage would be able to seep out. Next, Graftjacket Xpress was then used to fill the abscess void. Graftjacket dermal tissue was then placed on the dorsal aspect and sutured into place using PDS suture.

Vaseline gauze, sterile 4 x 4's, Kling, Ace wrap and Betadine-soaked 4 x 4's were then introduced as a dressing. Kling, Kerlix and Ace wrap were then further used as dressing. At this time, pneumatic ankle tourniquet was deflated and removed. The patient tolerated the procedure with vital signs stable and neurovascular status intact to digits 1-5 of the right foot.  The patient is to keep the dressing clean, dry and intact.

Ambulatory 24 and 48 Hour pH Study Transcription Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Rule out gastroesophageal reflux disease. 

POSTOPERATIVE DIAGNOSIS:  Normal study on Prevacid. 

PROCEDURE PERFORMED:  Ambulatory 24 hour pH study. 

PROCEDURE AND FINDINGS:  The patient was brought in to the ambulatory endoscopy center and had the pH catheter passed transnasally into the esophagus. It was then attached to the ambulatory computer and the patient was discharged and returned the following day. The catheter was withdrawn. The patient tolerated the procedure uneventfully. Reading the patient’s printout, the distal channel, composite score was 15.6, normal is less than 22. The patient had a total of 136 episodes of reflux, normal should be less than 50. Total time refluxing was 3.2% which is within range. The longest episode was 2.3 minutes, which is within range. In the proximal channel, the patient had a composite score of 5.5, within normal range, with 48 episodes of reflux, normal should be less than 50. Total time refluxing in the proximal channel was 0.8%. 

IMPRESSION:  Essentially normal study with the proviso that there is an increased number of reflux episodes in the distal channel, but the patient’s DeMeester score remains normal. 

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

DATE OF PROCEDURE:  MM/DD/YYYY

PROCEDURE PERFORMED:  A 48-hour Bravo pH study. 

PROCEDURE FINDINGS:  Normal DeMeester scores are less than 14.6. On day 1, he had a DeMeester score of 37.4, and on day 2, he did a little bit better with 26.2, but the patient’s total DeMeester score was still abnormal at 33. This reflects significant reflux. Although the patient’s main indicator for the pH study was cough, he really did not complain of any cough during the course of the procedure. The patient had episodes of chest pain which may have been secondary to the Bravo. He had episodes of regurgitation and episodes of heartburn. The regurgitation symptoms sometimes correlated with acid and sometimes did not, raising the question of possibly alkaline reflux; although, there is certainly no way that this can be measured. Indeed, most of the episodes of regurgitation did not appear to be associated with a pH of less than 4.

The patient did have significant heartburn and even chest pain, and the chest pain did seem to correlate with pH of less than 4. There were 4 discrete episodes at about 6:00, the probe was positioned, and these episodes did appear to correlate with a pH down to about 2. No other chest pain was recorded during the course of the procedure. The heartburn symptomatology on occasion was associated with a pH of greater than 4, but would estimate that probably at least two-thirds of the time, the heartburn symptoms did appear to be correlating with a pH of less than 4. As mentioned, no cough was recorded.

During the course of the night, there was no significant acid reflux, even though the patient did have some symptoms. Indeed, the patient complained of heartburn on the second night at about 7:00 to 8:00 in the morning, and on that occasion, the pH was 5. This would suggest that his heartburn symptomatology may not be completely on the basis of acid, but he clearly does have significant acid and does have regurgitation-type symptoms, both when acid is present and when it is not. 

IMPRESSION:  Significant acid reflux with DeMeester scores being higher than normal. Correlation of heartburn and some chest pain symptomatology with acid reflux.


Laryngoscopy Bronchoscopy Tracheotomy Operative Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Tracheal mass with airway obstruction.

POSTOPERATIVE DIAGNOSIS:  Tracheal mass with airway obstruction.

PROCEDURE PERFORMED:
1.  Direct laryngoscopy.
2.  Flexible bronchoscopy.
3.  Tracheotomy.
4.  Rigid bronchoscopy.
5.  Transtracheal removal of tracheal mass.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  Less than 50 mL.

FLUIDS:  Crystalloid.

COMPLICATIONS:  None.

PROCEDURE FINDINGS:  A 1.5 cm tracheal mass at the prior tracheotomy site.  It became a foreign body upon being freed up from its pedicle, and the remaining portion of the procedure was involved with removal of the floating free body.  This was successfully accomplished.  The patient also was incidentally noted to have small left arytenoid nodules, clinically insignificant, followed subsequently as an outpatient.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and placed in the supine position.  She was intubated intraorally and given general anesthesia.  Care was taken to use a small tube and cuff just below the cords so as not to disturb the tracheal mass, which was at the old tracheotomy site, approximately 3 cm subglottically.  The anterior neck was prepped and draped in the usual sterile fashion.  The old tracheotomy scar at the skin was excised; this was at the level of the cricoid ring.  The anterior tracheal subcutaneous scar tissue was excised.  The strap muscles were separated in the midline.  There was some remnant of thyroid isthmus, which was electrocauterized to expose the anterior tracheal wall.  An inferiorly-based tracheotomy flap was created using the second and third tracheal rings, and this was sewn to the inferior dermis margin using 3-0 chromic stitch.

Upon elevating the inferiorly-based tracheotomy flap, the mass was visible in the trachea.  It was a smooth covered black mass with a very narrow pedunculation on the anterior tracheal wall, which was just above the entry into the tracheotomy site at this time.  Attempts at mobilization of the mass freed up the mass and then the mass then proceeded down the trachea into the right mainstem bronchus.  At this point, a reinforced anode tube was passed into the left mainstem and the patient ventilated.  At this point, multiple attempts at removal of this tracheal mass, which was now a foreign body, was attempted.  Flexible bronchoscopy with a Fogarty catheter placed distal to the mass, attempts at withdrawal on multiple occasions were unsuccessful.  Multiple attempts then with rigid bronchoscope were unsuccessful as well.  An oral intubation tube was placed subglottically and a foreign body bronchoscope with a foreign body forceps attached was then passed and was able to grasp the foreign body.  The foreign body was then brought back up into the area of the newly created tracheotomy site.  At this point, it was grasped with a Blakesley-Wilde forceps off the sinoscopy set and retrieved.  Upon completion of removal of mass, flexible bronchoscopy was repeated down to both mainstem bronchi and found to be free of tumor.

At this point, the anode tube was removed and a fresh #8 Shiley low-pressure cuffed tube passed into the newly created tracheotomy site and sewn into place with four 2-0 silk ligatures.  Further ventilation occurred to the newly placed tracheotomy tube.  The patient was then allowed to awaken from anesthesia and taken to the recovery room in stable condition.

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Carotid Endarterectomy with Dacron Patch Angioplasty Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Moderately severe extracranial carotid artery disease.
2.  Right subclavian artery occlusion.
3.  Hypertension.
4.  Coronary artery disease.
5.  History of total hip replacements.

POSTOPERATIVE DIAGNOSES:
1.  Moderately severe extracranial carotid artery disease.
2.  Right subclavian artery occlusion.
3.  Hypertension.
4.  Coronary artery disease.
5.  History of total hip replacements.

OPERATION PERFORMED:  Left carotid endarterectomy with Finesse Dacron patch angioplasty.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and sterilely prepped and draped in the supine position. Preoperative prophylactic antibiotics were administered and multiple monitoring lines were placed.  An incision was made along the anterior border of the sternomastoid muscle in the left neck. The skin and subcutaneous tissue were sharply incised. The dissection was carried down to the platysma with the use of electrocautery. Gelpi retractors were placed for adequate exposure. The omohyoid muscle was divided between ties of 2-0 silk to give exposure to the common carotid artery. The vagus nerve was seen, identified and preserved. The dissection was then carried out distally to where the superior thyroid, external carotid and internal carotid were exposed and in turn encircled with vessel loops. The patient was systemically heparinized with 6000 units of heparin and adequate time for circulation was allowed for. The internal, external and common carotid arteries were in turn cross-clamped.

An arteriotomy was created with a #11 blade and extended with Potts scissors from the common carotid artery out the internal carotid artery.  Findings at this time are coral reef plaque in the carotid bulb that extended into the internal carotid artery producing an 85% stenosis of the left internal carotid artery. A 3.5 mm shunt was introduced into the internal carotid artery and allowed to back bleed. It was secured in the common carotid artery as well. No EEG abnormalities were noted during this or any subsequent maneuvers. An endarterectomy was then commenced on the carotid bulb and brought back proximally. The plaque was divided with the use of the Strully scissors. An eversion endarterectomy was done of the external carotid artery. The plaque was then found to feather off quite nicely in the internal carotid artery. No distal or interval packing sutures were required. A portion of Finesse Dacron was then sewn as an onlay patch angioplasty with running continuous suture of 6-0 Prolene. The shunt was then cross-clamped and removed. The remainder arteriotomy was completed. All air and debris were allowed to flush out the external carotid artery. The internal carotid artery was opened after approximately 6 cardiac cycles. Sterile Doppler was used to ascertain that there was excellent flow present in the internal carotid artery. The patient's heparin was then reversed with 50 mg protamine IV.

All wounds were then copiously irrigated with normal saline and Kantrex. The neck was then closed in layers with 2-0 and 3-0 Vicryl. The skin was reapproximated with running subcuticular 4-0 undyed Vicryl. Benzoin and Steri-Strips were applied to the wound. Needle and sponge counts were correct x2. The patient was then awakened and transported to the recovery room in stable condition.

Radius Osteotomy and Tendon Transfer Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Malunion, distal radial fracture, left wrist.
2.  Rupture of the extensor pollicis longus, left.

POSTOPERATIVE DIAGNOSES:
1.  Malunion, distal radial fracture, left wrist.
2.  Rupture of the extensor pollicis longus, left.

OPERATION PERFORMED:
1.  Osteotomy of left distal radius.
2.  Reduced malunion with internal fixation and bone graft, left distal radius.
3.  Tendon transfer, left extensor indicis proprius to the extensor pollicis longus.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room, placed in the supine position and induced under general anesthesia. The left upper extremity was prepped with Betadine and draped in the usual sterile fashion. The areas to be incised were outlined with a marking pen with a zig-zag type border incision dorsally over the area of the fracture. In addition, a transverse incision was designed over the ulnar side of the MP joint and the left index finger and a transverse incision designed over the path of the extensor pollicis longus between the wrist and the MP joint of the left thumb. The arm was exsanguinated and the tourniquet was inflated to 250 mmHg.

A #15 blade was used to make an incision at the back of the wrist, down through the skin, through the subcutaneous tissue. The retinaculum was found by sharp and blunt dissection and it was opened and the fourth dorsal compartment was retracted. Using a Freer elevator, the volar surface of the compartment was carefully separated from the distal radius. The area that was injured was exposed and subsequent evaluation revealed that the dorsal tilt, which was opened from the fracture, was limited only to an area where the fracture had occurred. The fracture site was inspected and confirmed with C-arm and using a Freer elevator was carefully separated and rongeur was used to clean at the fracture site. Proximally, osteotomy was made in order to advance this large fragment. The fragment was then rotated in to a normal anatomic position, which was confirmed visually and also confirmed on x-ray. This appeared to give adequate alignment and it appeared to be near anatomic visually. The 2-hole 16 mm pin plate was then put in place by standard technique and secured. It was advanced approximately 2.5 mm dorsally. The hole was driven to secure the pin plate and it was approximately 18 mm in length and the pin plate was then held in place by standard technique in the TriMed System. X-rays were then taken and confirmed the normal tilt to the distal radius as well as the adequate alignment of the fragments.

The retinaculum was then repaired with 4-0 Vicryl suture material, allowing the volar portion of it to cover the area of plate fixation. The transverse incision was then made over the MP joint of the index finger down through the skin, down through the subcutaneous tissue, exposing the insertions of the extensor digitorum communis as well as the extensor indicis proprius. The tendon was then severed just on the ulnar side proximal to its insertion and was retracted into the wound. A tunnel was then made from the distal portion of extensor retinaculum to the wound using a tendon passer. This was in the same plane as the tendon which had ruptured. It was then passed distally and kept distally. The wound was irrigated over the dorsal aspect of the wrist and closed with 5-0 Vicryl to the derm layer and subcuticular 4-0 Prolene to the skin. Attention was then turned to the thumb, where tendon weaver was used to weave the extensor indicis proprius and the extensor pollicis longus. The extensor pollicis longus was cut proximally as the proximal portion of the tendon had scarred in. Tenolysis was performed in that area. Adequate tension was set and adequate weave was sewn in place with 4-0 Mersilene suture material.

The two distal wounds were then closed with 4-0 Prolene in a subcuticular fashion. Sensorcaine 0.5% plain was then injected in to all operative areas. A dry dressing was applied using Xeroform, fluffy gauze, hand wrap, and a thumb spica-type splint to keep the thumb in extension. The tourniquet had been released after 130 minutes of tourniquet time, after closing of the dorsal skin wound. It was then reinflated 15 minutes later and that is when the weave and wound closure was completed. The patient then had tourniquet released for the second time, that is approximately 50 minutes of tourniquet time and was taken from the operating room to the recovery room in satisfactory condition, having tolerated the procedure well.

Implantable Cardioverter-Defibrillator Implantation Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Ischemic cardiomyopathy with ejection fraction of 35%.  
2.  Coronary artery disease, status post myocardial infarction and status post coronary artery bypass graft.  
3.  Congestive heart failure.
4.  Right bundle branch block with intraventricular conduction delay of 130 milliseconds.
5.  Dyslipidemia.  

POSTOPERATIVE DIAGNOSES:
1.  Ischemic cardiomyopathy with ejection fraction of 35%.  
2.  Coronary artery disease, status post myocardial infarction and status post coronary artery bypass graft.  
3.  Congestive heart failure.
4.  Right bundle branch block with intraventricular conduction delay of 130 milliseconds.
5.  Dyslipidemia.  

PROCEDURE PERFORMED:
1.  Implantation of biventricular implantable cardioverter-defibrillator.  
2.  Serial defibrillation threshold testing.  
3.  Fluoroscopic guidance.

SURGEON:  John Doe, MD 

ANESTHESIA:  Monitored anesthesia.

ESTIMATED BLOOD LOSS:  Minimal.  

BRIEF HISTORY:  This is a (XX)-year-old female with ischemic cardiomyopathy, depressed ejection fraction, intraventricular conduction delay, classification III congestive heart failure, referred for biventricular ICD implant.  Meeting criteria of MADIT II trial and COMPANION trial.  

DESCRIPTION OF PROCEDURE:  The patient was prepped and draped in the regular fashion.  After giving lidocaine locally in the left pectoral region, a 12 cm incision was made after a blunt dissection.  A subcutaneous pocket was created at the left pectoral region.  The subclavian vein was punctured three times.  Using the wire system, the coronary sinus extended hook with the help of coronary sinus straight decapolar catheter used to cannulate the coronary sinus.  A coronary sinus angiogram was done and the lateral vein was selected.  However, the lateral vein was too small and it was felt it might not be very good to stabilize the LV lead for a long period of time, concern of lead dislodgement later, so the anterior cardiac vein was then selected.  The LV lead was then placed to the anterior cardiac vein with good sensing and pacing parameters.  Then, RV active fixation lead was placed at the RV apex with good pacing and sensing parameters.  The right atrial lead was then also screwed in the anterior cardiac vein with good pacing and sensing parameters.  All leads were anchored to pectoralis major muscle with 0-silk.  The subcutaneous pocket was irrigated with antibiotic solution.  All leads were then attached to the generator and the generator was implanted in the subcutaneous pocket.  After interrogating the device, VF was induced with T-wave shock, which was correctly diagnosed by the device without any dropout, and the patient was cardioverted back to sinus rhythm with 11 joules.  The subcutaneous pocket was closed with 2-0 Vicryl and the skin was closed with staples.  The patient tolerated the procedure and there were no complications seen.  We will check chest x-ray postprocedure to rule out pneumothorax.  

TECHNICAL DATA:  Device implanted is Guidant Contak Renewal 3HE, model xxxx with serial #xxxxxx.  Leads implanted, right atrial lead is a Medtronic CapSureFix xxxx, 52 cm with serial #PJNxxxxxxV.  The right ventricular lead is Guidant model xxxx with a serial #xxxxxx.  The left ventricular lead is a Guidant Easytrak 2, model #xxxx, serial #xxxxxx.  

MEASURED DATA:  Atrial electrogram in the right atrium is 0.8 millivolts, in the RV 14.6 and in the LV 3.3 millivolts.  Atrial lead impedance 540 ohms.  RV lead impedance 528 ohms and the LV lead impedance 1372 ohms.  The atrial capture threshold is 0.6 volts at 0.5 milliseconds, RV is 0.6 volts at 0.5 milliseconds and the LV is 3.0 volts at 0.5 milliseconds.  

DEFIBRILLATION THRESHOLD TESTING:  High shock impedance of 38 ohms.  VF was induced with T-wave shock and was successfully cardioverted back to sinus rhythm with 11 joules and high shock impedance again at 33 ohms .  

SUMMARY:  Successful biventricular implantable cardioverter-defibrillator implant from left subclavian vein.  Good defibrillation threshold testing, equal to 11 joules.

Ethmoidectomy - Septoplasty - Sinus Surgery Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Chronic rhinosinusitis.
2.  Deviated nasal septum.
3.  Turbinate hypertrophy.
4.  Bilateral concha bullosa.

POSTOPERATIVE DIAGNOSES:
1.  Chronic rhinosinusitis.
2.  Deviated nasal septum.
3.  Turbinate hypertrophy.
4.  Bilateral concha bullosa.

OPERATION PERFORMED:  
1.  Bilateral anterior-posterior ethmoidectomy, complex, right side.
2.  Bilateral maxillary antrostomy.
3.  Bilateral endoscopic sinus surgery.
4.  Nasal septoplasty, complex.
5.  Columellar reconstruction.
6.  Submucosal resection, bilateral anterior turbinates.
7.  Fractured bilateral anterior turbinates.
8.  Partial bilateral middle turbinectomy and turbinopexy.

SURGEON:  John Doe, MD

SEDATION:  General and local, 8 mL 1% Xylocaine with 1:100,000 epinephrine.

ESTIMATED BLOOD LOSS:  Approximately 150 mL.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  After the patient was identified, he was taken to the operating room and placed on the operating room table in flat, supine position. The patient received IV induction and gas inhalation maintenance via an oral endotracheal tube. The patient was placed in a semi-seated reverse Trendelenburg position in a Richards headrest and gently turned to the right. Neo-Synephrine-impregnated cottonoids were placed in the nasal cavity. A transoral sphenopalatine block was completed to the greater palatine foramen with instillation of 1.5 mL of local. Additionally, the septum was infiltrated using a hydraulic dissection technique bilaterally, as well as routine lateral nasal wall and sphenopalatine foramen infiltration on the lateral nasal wall bilaterally. Betadine prep was completed. VTI head apparatus was applied. The patient was sterilely prepped and draped in the routine fashion. The VTI CT-assistance equipment was calibrated and anatomically confirmed and used throughout the case on an as-needed basis, but particularly to address the posterior ethmoid cells and towards the recess of the frontal sinuses bilaterally. Then, 0-degree and 70-degree endoscopes with Xenon lighting was employed with a routine microdebrider/shaver as well as endoscopic sinus equipment, both upbiting and straight as well as backbiters and side-biting Stammberger instrumentation and through-cut instruments. Irrigator to the endoscopic equipment with camera head was also employed. We were able to access the left nasal passage beyond the deviated septum. The middle turbinate was medialized. Uncinectomy was performed using a sickle knife, backbiter and shaver after the natural ostia was identified in the lower one-third of the hiatus semilunaris. The maxillary antrostomy was widened until examination did not reveal any acute process or masses. Following this, an anteroposterior ethmoidectomy was completed, first with dissection through the bulla ethmoidalis and inferior aspect of the anterior ethmoid cells into the posterior ethmoid cells superiorly to the base of the skull and then anteriorly. We did not create a CSF leak or encroach the intracranial space. The medial orbital wall was identified. There was no dehiscence noted. The wall was left intact and there was no encroachment of the orbital space. Positive bulbar pressure was employed and no herniation was identified. A shaver was used to remove any additional debris. Dissection towards the frontal sinus recess was completed and the opening towards the frontal sinus recess was noted to be patent. The left middle turbinectomy was completed using a sinus shaver, as well as backbiting and through-cut instrumentation. In this fashion, the concha bullosa was taken down. This did leave the middle turbinate slightly more floppy but still had some integrity anteriorly. Neo-Synephrine-impregnated cottonoids were placed into the surgerized field as we addressed the right side. The septum on the right was deviated in the region of the middle turbinate, likely due to the larger concha bullosa on the left. We were able to flatten the middle turbinate on the right. Access to the lateral nasal wall ethmoid sinuses was difficult, but we persisted, despite the deflected septum. Uncinectomy was performed on the right as it was on the left. It was flattened and lateralized making it more difficult. Maxillary antrostomy was created more widely on the right than on the left due to presence of a Haller cell and lateral displacement of the lateral nasal wall due to the aforementioned deformity. Anterior-posterior ethmoidectomy was completed, but we were somewhat restrained towards the frontal sinus and the superior aspect of the posterior as well as anterior ethmoid cells. Our first attempt at completing the right endoscopic sinus surgery was foiled by the deviated septum, and therefore, we paused prior to completion to undertake the nasal septoplasty. Otherwise, the right endoscopic sinus surgery was essentially completed as it was on the left side with similar instrumentation. The septum was then addressed using a hemitransfixion incision. The mucoperichondrium and periosteum were carefully elevated bilaterally without any tears or rents. There was some difficulty in elevating the tissue due to the complexity of the deformity, septal crest dislocation, columellar dislocation and the curvature of the septum. We separated the caudal portion of the septum from the maxillary septal crest. The redundant cartilage was taken down sharply and then the bony component was taken down with the Takahashi as well. A caudal Freer elevator and Freer knife were used for the elevation of the mucoperichondrium and periosteum. The Freer knife and Freer elevator were used in addition to the Takahashi, Gorney scissors to take down the deviated portion of the nasal septum. Once the redundant portion of the septum was removed on the left, this did reduce the lateral nasal wall contact and allowed us to swing the septum more into the midline position within the columella. This did remove some of the support more posteriorly, but the anteriormost aspect remained on the septal crest once the septum was able to be repositioned and was fashioned in a way to avoid the redundancy. A Takahashi Freer knife and Freer elevator were used to take down additional portion of the nasal septal cartilage and bone, particularly in the region of the right middle turbinate and inferiorly on the left, leaving an adequate dorsal as well as caudal strut. The portion of the nasal septal cartilage and bone were removed and the mucoperichondrium and periosteum were allowed to redrape. There remained some deflection of the septum anteriorly. A 6-0 Prolene suture was used to fix the septum to the anterior septal spine. An additional suture was placed on the columella region to fix the caudal portion of the septum in a more midline position. The mucoperichondrium and periosteum were allowed to redrape then. This revealed a significant improvement in nasal passage bilaterally and particularly for the completion of right ethmoid sinus surgery and reduction of the deflection of the septum and nasal obstruction. The hemitransfixion incision was closed using chromic suture. A running horizontal mattress plain gut suture was used to reapproximate the mucoperichondrium and periosteum along the length of the dissection. Outfracture of the anterior turbinates was completed bilaterally. The right anterior-superior and posterior-superior ethmoidectomy was completed as it was on the left, once the middle turbinate was able to be lateralized sufficiently to allow for safe dissection. The middle turbinate on the right was particularly floppy in nature. There was concern of lateralization. The medial aspect of the middle turbinate on the right as well as on the left was abraded with the sinus shaver as well as the adjacent septal mucosa without any perforation. A transseptal stitch was applied and a middle turbinopexy was thereby completed bilaterally. This proved to be difficult, in order to pass a Keith needle through both turbinates and the septum under endoscopic methods. This was ultimately completed with protection of the lateral nasal wall bilaterally. Photodocumentation was taken. A splint impregnated with Bactroban was applied in the middle meatal region bilaterally and fixed the Neiman splints, also impregnated with Bactroban, and fixed using a transseptal nylon suture x1. Infiltration of the anterior aspect of the inferior turbinates was completed. Through-cut instrumentation was used to submucosally resect the turbinates bilaterally with gentle cauterization, avoiding the anterior turbinate bone bilaterally. Single stitch was placed on the right side. The degree of dissection on the left was not as cumbersome, and therefore, a stitch was not applied. NG tube was passed transorally. The oropharynx, hypopharynx and nasopharynx were suctioned. All blood clots and debris were removed. The table was flattened, the patient was awakened, extubated and then taken to the recovery room in stable condition. There were no complications including CSF leak, injury to the nasolacrimal duct or encroachment in the orbital space.



Cleft Lip Repair Transcribed Operative Sample Report / Example

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Complete left cleft lip and palate.

POSTOPERATIVE DIAGNOSIS:  Complete left cleft lip and palate.

OPERATION PERFORMED:  Left cleft lip repair.

SURGEON:  John Doe, MD

ANESTHESIA:  General anesthesia with orotracheal intubation.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  5 mL.

DESCRIPTION OF OPERATION:  The patient was brought into the operating room and placed in a comfortable reclining position.  General anesthesia was uneventfully instituted, including with orotracheal intubation.  Ampicillin was given for prophylaxis.  The operative site was prepped in the usual manner and sterile drapes were applied in the usual fashion.  With excellent illumination and loupe magnification, the procedure was undertaken.  A mouth pack was put in place and the tube was protected with gauze; this was removed at the end of the case.  Measurements and marks were undertaken with 1.3 cm from the oral commissure to the base of the philtrum, 3 mm the width of the philtrum  and 4 mm the width of the nasal floor.  The vertical height of the philtrum was marked out with a wire and kept equal on the left side to that on the right.  There was fortunately just enough tissue to allow for good closure planning on a nasal floor Z-plasty using the vermilion to constitute the nasal floor and rotate the ala by completely releasing it into the inferior meatus.  Note that the alveolar cleft had widened, as we have waited for the baby to be healthy enough to do the cleft lip repair.  Hopefully, now with the lip pressure over it, we will get better direction of the bone and close this cleft somewhat.  We were not able to attempt any soft tissue plugging across this alveolar defect just because of the substantial distance involved.  Key points were then tattooed with methylene blue and 3 mL of 1:100,000 epinephrine was injected through a 30 gauge needle for hemostasis.  We had excellent hemostasis through the procedure and really did not need cautery.  Once white blanching was seen, with an 11 blade, the skin incisions were made pretty much along the edges of the cleft but designed to allow closure as equal as possible to the location of the philtrum on the right side.  A 15 blade was used to incise the vermilion and the vermilion flaps were then elevated on good blood supply basis to the ala laterally and the columella medially.  We did dissect along the lower lateral cartilage, nasal surface, from both medial and lateral sides to try to free up the cartilage and give a better curvature to the ala.  Similarly, we did elevate along the maxilla towards the infraorbital nerve on the left side.  The ala was indeed dissected into the inferior meatus to get a complete release, and at this point, it manipulated well including forming a good curvature and a good location.  With the flaps all being dissected and the muscle completely removed from the columella base and the ala, attention was directed to closure.  The Z-plasty was now closed on the nasal floor with the left coming medial and the right going posterior.  These were sutured into place with 5-0 Vicryl sutures and the flaps were sutured one to the other to help reconstitute the nasal floor.  The ala was now brought towards the midline and held in place with a well-placed buried 5-0 Vicryl suture tightening this down just to the point of a 5 mm distance allowing for expected contracture in comparison with the 4 mm on the right side.  Additional intranasal closure was done with more 5-0 Vicryl sutures and additional buried 5-0 Vicryl placed in the lip; although, we did place one 5-0 clear nylon suture in the orbicularis muscle to try to keep it in proper orientation.  The vermilion border was now meticulously realigned with a vertical mattress suture of 6-0 Novafil.  Additional 6-0 Novafil was placed in interrupted fashion for the dry vermilion and the lip.  One buried 5-0 Vicryl suture was placed in the substance of the deep vermilion and then the vermilion itself was closed with multiple interrupted sutures of 5-0 Vicryl.  In order to hold the nasal ala cartilage in the desired curvature, a portion of red rubber catheter was placed along it intranasally and then tied to a similar piece of red rubber along the dorsum using a horizontal mattress suture of 4-0 nylon.  Excellent closure was seen, good symmetry, good vitality.  All areas were cleansed and then dressed with a light coat of Polysporin ointment.  Mouth pack was removed.  Needle and sponge counts were correct.  Anesthesia was ended.  The patient was extubated uneventfully and escorted to the recovery area, having tolerated the procedure and anesthesia in satisfactory condition.

Palatoplasty and Bilateral Myringotomy Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Cleft palate.
2.  Chronic bilateral otitis media.

POSTOPERATIVE DIAGNOSES:
1.  Cleft palate.
2.  Chronic bilateral otitis media.

OPERATION PERFORMED:
1.  Palatoplasty.
2.  Bilateral myringotomy and placement of transtympanic ventilation tubes.

SURGEON:  John Doe, MD

ANESTHESIA:  General anesthesia with orotracheal intubation.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  50 mL.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and placed in the supine position on the operating table.  General anesthesia by mask was uneventfully instituted, IV was started, and then intubation was uneventfully accomplished.  The operating microscope was brought into the field with the right ear first approached. Cerumen was removed from the canal and eardrum was noted to be intact and rather unremarkable. A myringotomy was made halfway between the annulus and the anterior annulus, pretty much at the level of the umbo and parallel to the long process of the malleus. Minimal amount of fluid was suctioned away and the middle ear mucosa appeared to be unremarkable. The Donaldson tube was placed uneventfully. Vasocidin was instilled into the ear and cotton ball was applied near the canal.  The same process was applied on the left side, although there was less cerumen.  Myringotomy tubes being completed, attention was now directed to the palatoplasty.  The face area was prepped in the usual manner and sterile drapes were applied in the usual fashion. Ampicillin 200 mg had been given for prophylaxis. With excellent illumination by headlight and loupe magnification, the palatoplasty was undertaken.  Dingman mouthgag and a throat pack were put in place; it was removed at the end of the case.  The area was carefully examined and it was evident that we would need septal flap to complete the left nasal fistula closure. In addition, it was thought that a turn-down flap from the labiobuccal sulcus at the area of the anterior alveolar defect would be adequate to put a soft tissue plug in place without disturbing the periosteum of the alveolus itself.  Then, 6 mL of 1% lidocaine with 1:100,000 epinephrine was injected uneventfully into the palatal areas for hemostasis.  Firm pressure was applied, and once white blanching was confirmed, the procedure was undertaken.  A 12 blade was used to open up the free edge of the complete left cleft and deep resection was done with curved tenotomy scissors in soft palate and then a variety of palate resectors in the hard palate. A 15 blade was used to complete the hard palatal incision along the margin of the dentition and this was raised up with Cottle elevator. Hemostasis was obtained with topical epinephrine on neuro patties and also selected Bovie cauterization.  The muscle was taken down from the free edge of the bony palate and the nasal surface was separated along the inferior and particularly medial edges, so that the nasal fistula could be closed.  Attention was now directed to the right side, where we similarly dissected up the soft palate, including separating the muscle from both the nasal and oral surfaces so they could be redirected in the desired horizontal direction. A portion of the septum was kept attached to this particularly, extension posteriorly, so it could be placed into the junction between the hard and soft palates. On the left side, we raised up enough of the septum to allow closure to the nasal surface of the hard palate.  Additional hemostasis was obtained with the Bovie.  Good condition and vitality of all the tissue was seen.  From the alveolus, a running 4-0 Vicryl was used to close the septal flap to the nasal surface of the hard palate flap all the way back to the point of the choana.  The uvula was brought together with a buried 4-0 Vicryl suture and then the soft tissue was brought together with the running 4-0 Vicryl. The nasal surface of the soft palate was closed up to the point of the septal flap also with a running 4-0 Vicryl suture. The muscle was rather thick, but not particularly long, in the anterior to posterior dimension. The muscle was brought together with two well-placed 4-0 Vicryl mattress sutures.  The oral surface was now closed with multiple interrupted sutures of 4-0 Vicryl, including setting in the septal flaps so that the conjunction between the hard and soft palates was closed completely. The flap was sutured with the horizontal mattress suture through and through, holding it down to the nasal surface repair, and several tacking sutures were placed around the periphery. We did raise up a U-flap in the sulcus and sutured that to the end of the palate repair across the alveolar defect.  The throat pack was removed. All the neuro patties and sponges were removed.  Suction was done down the esophagus, into the stomach and then also in the pharynx and the nose. No active bleeding. Excellent repair. The mouthgag was then removed.  Needle and sponge counts were correct.  Anesthesia was ended.  The patient was extubated uneventfully and escorted to the recovery area, having tolerated the procedure and anesthesia in satisfactory condition. 

Excision of Corneal and Conjunctival Lesions Operative Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Limbal/corneal neoplasia concerning for conjunctival intraepithelial neoplasia versus squamous cell carcinoma of the ocular surface, left eye.

POSTOPERATIVE DIAGNOSIS:  Limbal/corneal neoplasia concerning for conjunctival intraepithelial neoplasia versus squamous cell carcinoma of the ocular surface, left eye.

OPERATION PERFORMED:  Excision of corneal and conjunctival lesions, left eye, with placement of amniotic membrane graft, left eye.

SURGEON:  John Doe, MD 

ANESTHESIA:  Monitored anesthesia care with topical anesthesia.

ANESTHESIOLOGIST:  Jane Doe, MD 

SPECIMEN:  Limbal/corneal mass from the left eye submitted to pathology.

ESTIMATED BLOOD LOSS:  None.

COMPLICATIONS:  None.

INDICATIONS:  The patient is a (XX)-year-old male who has a mass in the left cornea, which resembles a premalignant neoplasm. The patient is aware of the risks, benefits, and alternatives to the procedure.  Informed consent was obtained from the patient.

DESCRIPTION OF OPERATION:  The patient was brought to the preoperative holding area, where the operative eye was marked. The patient was then brought to the operating room and placed in the supine position. EKG leads were placed. Intravenous sedation was administered by the anesthesiologist. Topical anesthesia was placed on the ocular surface of the operative eye. A subconjunctival injection of 0.75% bupivacaine and 2% lidocaine was placed in the location of the conjunctival/limbal mass. Using cotton swabs, the limbal/corneal lesion was checked for mobility; it was not mobile. The margins of the tumor were inspected clinically for areas of new involvement. The corneal edge of the lesion was outlined using a Supersharp knife to create a partial depth incision along the anterior edge of the lesion. The posterior edge of the lesion was undermined on the conjunctival side using sharp and blunt dissection, taking care not to disturb any clinically affected areas. Using the angled crescent knife, the posterior edge of the lesion was sharply dissected in the clear cornea to create a superficial keratectomy. This was extended to the previously demarcated anterior edge of the lesion, which was marked using the Supersharp knife. The entire lesion was excised and submitted to pathology. Cautery was applied to achieve hemostasis. The size of the amniotic membrane graft was estimated to be approximately 15 x 15 mm. Tisseel glue was placed on the bed of the incised area. The amniotic membrane was placed into the bed in position. At the conclusion of the procedure, the eye was watertight. The anterior chamber was deep and stable. The intraocular pressure was satisfactory. The amniotic membrane was in good position. The neoplastic tissue was submitted to pathology. The patient tolerated the procedure well and was taken to the recovery room in good condition. Sterile pad and shield were placed on the eye at the end of the procedure. The sponge and needle counts were correct at the end of the case.

Anterior Cervical Diskectomy-Cervical Interbody Fusion Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Cervical spondylosis with myopathy (721.1).
2.  Cervical disk displacement (722.0).
3.  Cervical spinal stenosis (723.0).
4.  Cervical disk degeneration (722.4).

POSTOPERATIVE DIAGNOSES:
1.  Cervical spondylosis with myopathy (721.1).
2.  Cervical disk displacement (722.0).
3.  Cervical spinal stenosis (723.0).
4.  Cervical disk degeneration (722.4).

OPERATIONS PERFORMED:
1.  C5-6 and C6-7 complete anterior cervical diskectomy.
2.  C5-6 and C6-7 anterior cervical interbody fusion.
3.  Anterior cervical spinal instrumentation, C5 to C7.
4.  Insertion of structural allograft bone graft to C5-6 intervertebral space.
5.  Insertion of structural allograft bone graft to C6-7 intervertebral space.
6.  Spinal monitoring.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  150 mL.

URINE OUTPUT:  700 mL.

INTRAVENOUS FLUIDS:  1500 mL.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room. While supine on the operating table, general anesthesia was initiated. All appropriate lines and monitors were placed under sterile conditions, including Foley catheter and an arterial line. An interscapular roll was placed and the patient's head was placed on a well-padded headrest with 10 pounds of head halter traction. Lateral C-arm was brought into position. It was deemed necessary to tape the patient's shoulders distally in order to perform intraoperative lateral fluoroscopy. Utilizing Langer lines and appropriate bony landmarks, skin markings were made for a left-sided anterior approach to the cervical spine. All bony prominences were well padded. The patient's neck was then prepped and draped in standard surgical fashion. Landmarks were identified, and utilizing the previously marked skin incision, the skin and subcutaneous tissues were injected with lidocaine containing epinephrine. The skin was then incised with a scalpel and dissection was carried down carefully through the platysma with Bovie electrocautery. Bovie electrocautery was utilized throughout the procedure to maintain hemostasis, except when within the spinal canal, at which point bipolar electrocautery was utilized. Copious antibiotic irrigation at body temperature was performed at regular intervals throughout the procedure. After the platysma was carefully divided with Bovie electrocautery, blunt dissection was easily performed down to the anterior cervical spine. Stylet from the spinal needle was placed in the disk space and intraoperative x-ray confirmed operative levels. A meticulous subperiosteal dissection was then performed, exposing the inferior half of C5, the C5-6 annulus, the anterior C6, the C6-C7 annulus, and the superior half of the C7, beginning in the midline and then the subperiosteal, dissecting to the sides on both sides. Beginning first at C5-6, blunt self-retaining retractors were applied. The annulus at C5-6 was incised with a scalpel and a meticulous diskectomy was performed with a combination of curettes and pituitary rongeur. The endplates were denuded of any cartilaginous or disk material in preparation for spinal fusion. After all the disk material and cartilaginous endplates were removed, the posterior osteophytes were thinned with a bur and posterior disk fragments were removed with a micropituitary. The posterior osteophytes were removed from the midline with a microcurette and laterally with a micro-Kerrison. There were several midline herniated disk fragments. After the decompression was complete at C5-6, the disk space was copiously irrigated with antibiotic irrigation at body temperature. The retractors were released and reapplied at C6-7 and a similar procedure was performed with a complete anterior cervical diskectomy at C6-7 through the posterior longitudinal ligament with removal of posterior osteophytes and decompression of the spinal cord and the neural elements. Several midline disk fragments were encountered at C6-7 as well. The posterior osteophytes were thinned with a bur and the spinal cord was decompressed with a microcurette in the midline and uncovertebral osteophytes were removed with the micro-Kerrison. The appropriate size trial was chosen and then the appropriate size structural allograft bone grafts were chosen and prepared and covered with demineralized bone matrix. While this was taking place, the endplates at C5-6 and C6-7 were rasped with the appropriate size rasp in order to continue the preparation for spinal fusion. A punctate bur hole was made in the endplate of each vertebral body in preparation for spinal fusion, to allow the structural allograft bone graft access to bleeding cancellous bone. Punctate bur hole was made at C5 inferiorly, C6 superiorly, C6 inferiorly, and C7 superiorly. The disk spaces were again copiously irrigated with antibiotic irrigation and the structural allograft bone grafts were carefully and gently impacted into position, first at C5-6 and then at C6-7. With the structural allograft bone grafts in good position by direct visualization and lateral fluoroscopy, all traction was removed. The appropriate size plate was then chosen, contoured to improve cervical lordosis, and rigidly affixed to the anterior cervical bodies of C5, C6 and C7. All 6 screws had good bite. Lateral fluoroscopy confirmed good position of the instrumentation at C5, C6, and C7 as well as the intervertebral biomechanical structural allografts at C5-6 and C6-7. The locking mechanism was engaged at each level. Final fluoroscopic image was taken in the lateral position. The wound was covered. C-arm brought into the AP plane. This also confirmed good position of the structural allograft bone grafts at C5-6 and C6-7 as well as the instrumentation at C5, C6, and C7. The C-arm was then brought out of the field. The wound was then covered. The wound was again copiously irrigated with antibiotic irrigation. Hemostasis confirmed. A drain was placed just anterior to the plate, exiting posterior superior laterally in line with the skin incision, and the wound was closed in layers. The platysma was reapproximated with 2-0 braided absorbable suture placed in interrupted fashion, incorporating the skin and subcutaneous tissue with every other suture, in order to increase wound repair strength. The skin was then reapproximated with 2-0 braided absorbable suture placed subcutaneously in interrupted fashion and the superficial skin edges were closed with running 4-0 monofilament absorbable suture placed subcuticularly. The skin edges were cleaned and dried. Mastisol and Steri-Strips were applied. A small sterile dressing was applied. The patient was then awakened from anesthesia, extubated and transported to the PACU in stable condition, having tolerated the procedure well. All counts were correct at the end of the case. AP and lateral fluoroscopy confirmed operative level as well as good position of the instrumentation and the structural allograft bone grafts. Spinal monitoring was performed throughout the procedure and demonstrated no significant changes from baseline.

Left Heart Cath and Coronary Angiography Sample / Example

DATE OF PROCEDURE:
MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Inferior wall ST segment elevation myocardial infarction.

POSTOPERATIVE DIAGNOSIS:  Inferior wall ST segment elevation myocardial infarction.

PROCEDURE PERFORMED: 
1.  Left heart catheterization.
2.  Percutaneous coronary angiography via right femoral approach.
3.  Percutaneous transluminal coronary angioplasty.
4.  Implantation of a bare-metal stent.

PROCEDURE FINDINGS: 
1.  Diagnostic catheterization:  The right coronary artery is occluded at the level of AV groove. Multiple stents are seen, at least 3 are visualized in the right coronary artery; these stents are patent. No flow is present past the level of the AV groove. The left main coronary artery is normal. The circumflex coronary artery has a stent in the mid/distal vessel. This circumflex truck, however, is occluded after the level of a small septal perforator and it is occluded at the level of the stent. An obtuse marginal vessel is visible. High-grade lesion is present in the obtuse marginal. This is a small vessel of approximately 1.5 mm dimension. The lesion is a tapered lesion of about 95%. The area that was previously treated by Dr. Doe with stent implantation in the left anterior descending coronary artery is widely patent. Multiple stents are seen in the left anterior descending coronary artery and just past the stent, a 2.75 mm stent that was implanted by Dr. Doe, there is a small waist-like lesion of approximately 50%. There is a mismatch between the size of the stent and lumen of the vessel. There is a high-grade lesion distally in the left anterior descending coronary artery near the apex with 99% stenosis at that point. TIMI grade 3 flow is present to that lesion and TIMI grade 2 flow is present past that lesion. The diagonal subdivisional left anterior descending coronary artery has a high-grade ostial lesion of approximately 90%. TIMI grade 3 flow is present in the diagonal coronary artery.
2.  Left ventriculogram was not performed.
3.  Left ventricular end-diastolic pressures are significantly elevated at 30 mmHg. 

DESCRIPTION OF PROCEDURE:
From the right femoral approach, a 6-French sheath was placed in the right femoral artery. Angiography confirmed AngioSeal placement for hemostasis postprocedure would be appropriate. A 6 French 4 cm left diagnostic catheter was used to obtain coronary angiograms of the left coronary system and then 6 French 4 cm Judkins right guide catheter was selected and passed as near coaxial manner as possible to the right coronary ostium. BMW guidewire was passed into the distal right coronary artery using the support of a 2.0 x 8 mm semi-compliant balloon. The wire passed easily through what appeared to be a fresh thrombus in the occluded area. The balloon was inflated multiple times to 16 atmospheres and withdrawn. This predilation angioplasty having been performed, there appeared to be a high-grade lesion at the level of the AV groove, which was 95% and quite short, approximately 6 mm in length. There was a poststenotic dilatation in the right coronary artery. A 2.75 x 8 mm Vision bare-metal stent was selected and passed over the wire and positioned carefully under fluoroscopic magnification views. It was inflated to a maximum of 14 atmospheres several times and the balloon carrier system was withdrawn. Excellent reformation of the lesion was achieved. All catheters and guidewires were removed after fluoroscopic visualization demonstrated no evidence of dye extravasation or other complications. An AngioSeal device was placed in the femoral artery and the patient returned to the room in stable condition having suffered no complications.

IMPRESSION:
The patient with occluded right coronary artery, requiring percutaneous revascularization. Multiple stents are present, 2 in the left anterior descending, 1 in the circumflex coronary artery, and at least 3 in the right coronary artery. This patient has extensive disease and continues to smoke and may eventually require either maximal medical management alone or coronary bypass grafting.


CT Angiogram of Abdominal Aorta Transcription Sample Report

DATE OF STUDY:  MM/DD/YYYY

STUDY PERFORMED:
CT angiogram.
  
REASON FOR STUDY:
Status post SMA stent, belly pain, abdominal pain.

ORDERING PHYSICIAN:
John Doe, MD

PRIMARY CARE PHYSICIAN:
Jane Doe, MD

PROCEDURE TECHNIQUE:
Standard CT angiogram of the abdominal aorta with run-off to the iliac arteries was performed. Optiray 130 mL was used for contrast.

PROCEDURE FINDINGS:
1.  Mesenteric vessels.  The celiac artery has a mild stenosis at the ostium.  The superior mesenteric artery has a widely patent stent within the proximal portion to the ostium.  There is very minimal restenosis in the stent.  There is no lesion distally or proximally.  The inferior mesenteric artery is patent with no evidence for stenosis.
2.  Renal arteries.  The left renal artery has a widely patent left renal artery stent.  There is no restenosis of the stent.  The vessel bifurcates immediately after the stent.  The right renal artery is widely patent as well.  It comes out superior to the left.  There is an accessory renal artery to the right kidney, which comes off in the mid abdominal aorta.  It is free of any significant disease, feeds the inferior pole of the right kidney.
3.  Abdominal aorta.  The abdominal aorta has diffuse plaquing throughout with mild to moderate calcification.  There is no dissection, no aneurysm noted.
4.  Iliac arteries.  The left common iliac artery has a widely patent stent; it is just proximal to the internal iliac artery.  There is no stenosis in the stent.  The internal iliac artery is patent with mild disease.  The external iliac artery is patent with no significant disease.  The left common iliac artery has calcified plaquing but no significant stenosis.  The right internal iliac artery is widely patent.  The right external iliac artery is patent.

CONCLUSION:
1.  Patent superior mesenteric artery stent.
2.  Patent left renal artery stent.
3.  Two renal arteries to the right kidney, which are both free of significant disease.
4.  Patent left common iliac artery stent.

Radiology overread is pending.

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