Physical Exam Medical Transcription Samples / Examples

PHYSICAL EXAMINATION:
GENERAL:  Reveals a well-developed, well-nourished, chronically ill-appearing female in no acute distress.
VITAL SIGNS:  Blood pressure 110/76, pulse 82 and regular, respirations 18 and unlabored, temperature afebrile.
HEENT:  Normocephalic, atraumatic. Conjunctivae pink. Sclerae anicteric. Pupils equal, reactive to light and accommodation. Extraocular movements intact. Ears, nose, throat clear. Mucous membranes, oropharynx well hydrated. The patient is missing several teeth.
NECK:  Supple without adenopathy, thyromegaly, JVD or carotid bruits.
CHEST:  Symmetrical.
LUNGS:  Grossly clear to percussion and auscultation with diminished breath sounds at the bases.
HEART:  Normal sinus rate, S1, S2, soft S4 without thrills, murmurs.
ABDOMEN:  Soft, obese, +3. Bowel sounds present without obvious organomegaly, masses, rebound or guarding. Negative for CVA tenderness.
EXTREMITIES:  Left lower extremity reveals a fifth toe amputation. There is marked edema in the knee distally, including pedal edema. This is approximately 2+. Peripheral pulses of the left lower extremity are markedly diminished. The patient does have calf tenderness to palpation. There is no evidence for cyanosis at this time. Right lower extremity reveals partial amputation of the first three toes on the right. Peripheral pulse is diminished but palpable. Distal pulses are diminished but palpable.
NEUROLOGIC:  Grossly intact. Detailed sensory examination of the lower extremities was not performed. Ambulation and gait not tested.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 97.4, pulse 102, respirations 18, pulse ox 98% on room air.
GENERAL:  Alert and oriented x4, no acute respiratory distress, sitting on the bed comfortably in the presence of her husband.
HEENT:  On the scalp, there is a healed, granulated, erythematic abrasion on the right occiput. There is no active bleeding or open lesion. The crown of her head shows marked silver hyperkeratinized skin with white flecks throughout the hair region. The head is normocephalic. Eyes show EOMI, PERRLA. Funduscopic exam shows no hemorrhages, AV nicking or edema. Red reflex present. Sclerae white. Conjunctivae pink and moist. Nares patent. No exudates. TMs are intact without erythema or exudates as is the throat. Buccal mucosa is moist. The patient is nontender around the face.
NECK:  Supple. No lymphadenopathy. There is presence of yellow violaceous ecchymosis on the postauricular region of the patient’s neck. There is no lymphadenopathy. There is some slight tenderness. The patient does have a scar in the anterior region of her neck consistent with an old ACDF. Clavicles are nontender.
CHEST:  Nontender.
HEART:  Regular rate and rhythm, S1, S2. No murmurs, rubs or gallops.
BACK:  No cervical, thoracic, lumbar, sacral tenderness. No CVA tenderness.
LUNGS:  Clear to auscultation. No wheezes, rales or rhonchi.
ABDOMEN:  Positive bowel sounds, no hepatosplenomegaly or masses.
NEUROLOGIC:  Cranial nerves II through XII are intact. Romberg is normal. Gait is normal. Strength is 5/5, equal, upper and lower extremities with full range of motion active and passively. Alert and oriented to person, place, time and situation. Sensation is intact on all distal extremities. Cerebellar functions are normal. No pronator drift.
PSYCHIATRIC:  The patient has a normal affect and responds appropriately.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 132/88, pulse 76, respiratory rate 18, temperature 98.4 degrees, oxygen saturation 100% on room air.
GENERAL:  The patient is able to speak in full sentences.  Not using any accessory muscles of respiration.  Appears to be in no acute distress.
HEENT:  Eyes:  Sclerae anicteric.  There is no conjunctival pallor.  ENT:  Mucous membranes are moist.  No tonsillar enlargement, erythema or exudate.
NECK:  No lymphadenopathy.
RESPIRATORY:  Clear to auscultation bilaterally.
CARDIOVASCULAR:  S1, S2 present.  No murmurs, gallops or rubs.
ABDOMEN:  Soft.  Tender in the left suprapubic and right suprapubic region.  There is no rebound.  There is no guarding.  There is no abdominal distention.  Bowel sounds present in all 4 quadrants.
PELVIC:  Reveals that there is blood in the vaginal vault.  There appears to be a scant amount of mucopurulent discharge in the cervical os.  The patient does display left and right adnexal as well as midline uterine tenderness as well as cervical motion tenderness.
NEUROLOGIC:  Alert and oriented, answering questions appropriately, moving all extremities x4.
PSYCHIATRIC:  The patient's mood is euthymic.  Affect is congruent with mood.

PHYSICAL EXAMINATION:
GENERAL:  Alert and oriented x3, pleasant, cooperative gentleman, somewhat thin looking, does not appear to be in acute distress.
VITAL SIGNS:  Blood pressure 115/70 mmHg, heart rate 55-74 (sinus bradycardia-sinus rhythm), respirations 19-21 breaths per minute.  Afebrile.  Pulse ox 98% on 2 liters per minute of oxygen via nasal cannula continuously.
HEENT:  Normocephalic and atraumatic.  Pupils are equal, round, reactive to light and accommodation.  Extraocular muscles are intact.  Oropharynx clear.  No abnormal deviations.
NECK:  Supple.  No JVD.  No hepatojugular reflux.  No thyromegaly or lymphadenopathy.  No carotid bruits to auscultation.
LUNGS:  Decreased breath sounds bilaterally.  Some scattered expiratory rhonchi bilaterally.
HEART:  Regular rate, bradycardia.  Heart sounds somewhat distant.
ABDOMEN:  Scaphoid in shape.  Bowel sounds are present.  Soft, nontender, nondistended.  No organomegaly.  No costovertebral angle tenderness to percussion.
GENITOURINARY:  Foley catheter is in place.  Signs of gross hematuria.
EXTREMITIES:  No peripheral edema.  Peripheral pulses are present, decreased over both feet.
NEUROLOGIC:  Grossly intact.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 136/84, heart rate 118, respiratory rate 18, temperature 97.8 orally, oxygen saturation 99% on room air.
GENERAL:  A visibly upset and distressed woman found sitting on a stretcher, brought in by squad, breathing normally.
HEENT:  Atraumatic.  Pupils are equal, round and reactive to light.
NECK:  Supple and nontender.  No lymphadenopathy.
PULMONARY:  Chest is atraumatic.  Lungs are clear to auscultation bilaterally.
HEART:  Regular rate and rhythm.  No rubs, murmurs or gallops.
ABDOMEN:  Atraumatic.  Soft and nontender.
SKIN:  No rashes.  Warm, pink and dry.
NEUROLOGIC:  Alert and oriented x3.  Nonfocal.
PSYCHIATRIC:  Mood and affect are appropriate to content.
EXTREMITIES:  Upper extremities:  Atraumatic, warm, pink, 2+ radial pulses, sensation intact to light touch, 5+ motor throughout.  Lower extremities:  Left lower extremity is atraumatic, 5+ motor strength throughout, sensation intact to light touch, 2+ dorsalis pedis pulse.  Right lower extremity:  Atraumatic proximal to the foot.  There is a gunshot wound to the plantar aspect of the right foot with two open wounds.  The fourth toe has a subungual hemorrhage present.  All toes have sensation intact to light touch and the patient is able to move all toes; however, limits the movement due to pain.  Capillary refill is less than 2 seconds in all toes.  There is 2+ dorsalis pedis and posterior tibialis pulse present in the right foot.  The patient is able to dorsiflex and plantarflex her foot with 5+ strength, without any pain.  There is no obvious foreign debris in either of the gunshot wounds.

PHYSICAL EXAMINATION:
GENERAL:  Reveals a well-developed, well-nourished female who is quite distraught, but is in no acute distress.
HEENT:  Head normocephalic. Normal hair distribution and texture without masses. The ears are normal. Conjunctivae are noninjected. Sclerae not icteric. The pupils are equal, round and reactive to light. Extraocular movements are full without nystagmus. Visual fields are decreased in the right visual field to confrontation. Fundi are unremarkable. The nose is markedly congested with clear mucoid discharge bilaterally. The uvula elevates in the midline. The tongue protrudes in the midline. There is no injection or exudate. The TMJs are normal without crepitation.
NECK:  Supple without masses, adenopathy or thyromegaly. There is no JVD or HJR. Kernig and Brudzinski signs are negative.
CHEST:  Symmetrical. The chest wall is nontender.
BREASTS:  Symmetrical without masses.
HEART:  Regular rhythm. S1, S2 without S3, S4, murmurs, thrills, rubs or ectopy.
LUNGS:  Clear to P&A.
BACK AND SPINE:  There is no CVA tenderness or spinal deformity.
ABDOMEN:  Soft, warm and nontender without palpable organomegaly or masses. Bowel sounds are present. There are no abdominal bruits. There are no inguinal or femoral hernias or inguinal nodes palpable.
EXTERNAL GENITALIA:  Normal female for age.
SKIN:  No edema, masses or rashes.
MUSCULOSKELETAL:  Unremarkable.
VASCULAR:  Reveals good pulses in the extremities and carotids without bruits.
NEUROLOGIC:  The patient is quite upset but alert, oriented and responsive. Motor strength is 5/5 on the right, 3-4/5 on the left. No involuntary movements or tremors. Sensation is decreased on the left. Cranial nerves II through XII intact. The tongue protrudes to the right, but this is not new. Cerebellum cannot be tested. Gait is not tested. Romberg cannot be tested. Reflexes are 2+ biceps, triceps, brachioradialis. The right toe is downgoing. The left toe is neutral.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.4, pulse 160, respirations 30, 98% on room air, blood pressure 94/52.
HEENT:  Head appears large (95th percentile for age). No tympanic membrane erythema bilaterally. No pharyngeal erythema or exudate. Mucous membranes moist. No nasal discharge or congestion appreciated. No conjunctival erythema or eye discharge.
NECK:  Supple. No lymphadenopathy.
LUNGS:  Good air entry bilaterally. Minimally coarse on expiration. No actual wheezing. No crackles. No retractions. No tachypnea.
HEART:  Regular rate and rhythm without murmur.
ABDOMEN:  Soft. Positive bowel sounds. Nontender.
GENITOURINARY:  Normal male.
SKIN:  Moist. Capillary refill brisk. No rashes appreciated.
NEUROLOGIC:  Alert, appropriate, smiling, laughing, reaches for things. Good muscle tone.

PHYSICAL EXAMINATION:
GENERAL:  The patient is a well-developed, well-nourished male, in no distress. The patient is alert and oriented x3. Affect is normal.
VITAL SIGNS:  Blood pressure 142/72, pulse 72 and regular, respirations normal.
HEENT:  Conjunctivae are pink. Sclerae are white. Skin turgor is normal.
NECK:  No JVD. There is transmitted murmur to his carotids bilaterally. Carotid upstrokes are normal. There is no thyromegaly.
LUNGS:  Significant for crackles bilaterally about one-fourth of the way with no wheezing or rhonchi.
CHEST:  Chest expansion symmetrical.
HEART:  A 3/6 systolic murmur at the base of the heart and right upper sternal border consistent with aortic stenosis as well as a 2/4 diastolic murmur consistent with aortic insufficiency. PMI is normal.
ABDOMEN:  Soft, nontender. No hepatosplenomegaly. There is no pulsatile aorta.
EXTREMITIES:  No clubbing, cyanosis or edema. Motor strength is symmetrical.
SPINE:  There is no kyphoscoliosis. 


Eye Radioactive Iodine-125 Plaque Removal Transcription Sample

PREOPERATIVE DIAGNOSIS:
Choroidal melanoma, left eye.

POSTOPERATIVE DIAGNOSIS:
Choroidal melanoma, left eye.

PROCEDURES PERFORMED:
1.  Removal of radioactive iodine-125 plaque, left eye.
2.  Tumor laser treatment, left eye.

SURGEON:  John Doe, MD

ANESTHESIA:  Local/MAC.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and was positioned on the operating table. Cardiac and blood pressure monitoring devices were applied. Intravenous sedatives were administered and a retrobulbar and supratrochlear injection of Carbocaine 2% plain was administered without complications. The patient was prepped and draped in the usual fashion for a procedure of the left eye. A lid speculum was inserted between the lids of the left eye to expose the eye. The conjunctival sutures from the recent prior procedure were cut and removed. The conjunctiva was reflected into the superotemporal quadrant to reveal the plaque fixation sutures and radioactive plaque. The three plaque fixation sutures were cut and removed. The plaque was then slid away from its apposition to the sclera and transferred off the table to the lead carrier. The conjunctiva was closed with interrupted sutures of 7-0 Vicryl. The laser treatment was then performed using the argon green indirect ophthalmoscope laser with 20 diopter lens. The spot size on the retina was adjusted to between 0.25 and 0.5 mm on the retina during the treatment. The power setting was 300 milliwatts on continuous duration exposure. The end point of treatment was dull white discoloration of the entire juxtapapillary portion of the choroidal tumor. The total treatment time was approximately 12 minutes. Following completion of the laser therapy, the lid speculum was removed. Bacitracin, polymyxin ointment was applied to the surface of the eye. The lids were patched with a sterile eye patch. The patient tolerated the procedure well and was transferred to same day surgery in satisfactory condition for postoperative care.

Transvitreal Fine Needle Aspiration Biopsy of Choroidal Tumor Sample

Trabeculectomy Sample Report

Radical Pterygium Excision with Conjunctival Graft Sample

Ophthalmology Operative Samples # 1          Ophthalmology Operative Sample Reports #2

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Sole Therapy Laser Transmyocardial Revascularization Sample

PREOPERATIVE DIAGNOSIS:
Chronic medically refractory angina.

POSTOPERATIVE DIAGNOSIS:
Chronic medically refractory angina.

PROCEDURE PERFORMED:
Minimally invasive sole therapy laser transmyocardial revascularization.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

COMPLICATIONS:  None.

DRAINS:  One 19 French Blake drain.

DESCRIPTION OF PROCEDURE:  The patient was identified and placed on the operative table in the supine position. General endotracheal anesthesia was induced. The left chest and groin were prepped and draped in the normal sterile fashion. The patient was given IV antibiotics prior to start of the case. A standard 2 inch incision was made below the left breast and dissection was carried down through the fifth interspace. Once we entered the chest, we amputated the pericardial fat pad and identified the pericardium. We made a window in the pericardium and used stay sutures to make a well around the pericardium. Scarred ends of the lung were scarred down and we pushed this out of the way. Once we had a pericardial stay suture in place, we then meticulously took down all the adhesions around the left ventricle, freeing up the left ventricle all the way over to the great cardiac vein on the inferior wall, anteriorly to the level around the apex, anteriorly to the level of the LAD and then laterally out to the level of the vein graft. We then proceeded to place 35 laser TMR channels, doing 5 at a time and using a 2 to 3 minute rest period in between each set of 5 channels. Each channel was placed about 1 cm apart from each other to cover the entire ischemic area along the left ventricle. We did do most of the channels in the area of the right coronary distribution and in the LV apex, 35 channels were done in all. Once this was done, we then checked for bleeding. After several minutes pressure, there was no evidence of any bleeding. We coated the heart with Tisseel and loosely closed the pericardium over the top of the heart. We then placed a 19 French Blake drain along the pericardium and then we injected the wound with 0.25% Marcaine. We then placed a PainBuster pain device within the subpleural space along the incision, and we then closed the incision using one interrupted #2 Vicryl stitch. We then closed the pectoral muscle over the top of this in one layer using running 0-Vicryl and then subcutaneous tissue and the skin. The wounds were cleaned and dried. Sterile bandages were placed. All needle, sponge and instrument counts were correct at the end of the case. The patient tolerated the procedure well.


Cystoscopy and Transplant Stent Removal Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  End-stage renal disease, status post transplant.
2.  Indwelling ureteral stent.

POSTOPERATIVE DIAGNOSES:
1.  End-stage renal disease, status post transplant.
2.  Indwelling ureteral stent.

PROCEDURES PERFORMED:
1.  Cystoscopy.
2.  Removal of transplant stent.

SURGEON:  John Doe, MD

ANESTHESIA:  IV sedation.

FINDINGS:
1.  Transplant stent removed intact without difficulty.
2.  Negative cystoscopy.

ESTIMATED BLOOD LOSS:  Minimal.

DRAINS:  None.

COMPLICATIONS:  None.

DISPOSITION:  Stable.

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old female, status post renal transplant, who presents for stent removal. Risks and benefits of the procedure including bleeding, infection, damage to the urethra, bladder, ureter or kidney, failure to diagnose or treat disease, recurrence of disease or need for further procedures were explained in detail to the patient prior to the procedure. The patient wished to proceed.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room, and after adequate anesthesia, the patient was placed in the dorsal lithotomy position on the operating room table. The genital and perineal regions and urethra were prepped and draped in sterile fashion. A 21 French scope was manipulated easily into the patient's urethra and into the bladder without difficulty. The stent was easily visible on the dome of the bladder and was removed with a flexible grasper. No other foreign bodies or mucosal lesions were seen within the bladder. The bladder was drained and the scope was removed. The patient tolerated the procedure well. There were no complications. The patient was awakened and transported to the postanesthesia care unit in stable condition.

Circumcision Sample Reports        Urology Operative Sample Reports #1

Cystourethroscopy Retrograde Pyelography Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Recurrent dysuria.
2.  Left urolithiasis.

POSTOPERATIVE DIAGNOSES:
1.  Recurrent dysuria, most consistent with interstitial cystitis.
2.  Left urolithiasis.

PROCEDURES PERFORMED:
1.  Cystourethroscopy.
2.  Bilateral retrograde pyelography.
3.  Bladder hydrodilation.
4.  Bladder biopsies.

SURGEON:  John Doe, MD

SEDATION:  General.

DESCRIPTION OF PROCEDURE:  The patient was brought to the cystoscopy suite, and after adequate instillation of general anesthesia, the patient was placed in the lithotomy position. He was prepped and draped in the usual sterile fashion. The patient was examined preprocedure. His physical examination included digital rectal examination with the procurement of expressed prostatic secretions for smear and culture. The patient was again prepped and draped. With the patient adequately prepped and draped, a 21-French cystoscope with a 12-degree lens was inserted through the urethral meatus and advanced under direct visualization with continuous irrigation. The anterior urethra was normal. The posterior urethra revealed changes consistent with benign prostatic hypertrophy; specifically, there is mild enlargement of the lateral lobes, but no significant elevation of the median bar. The supramontanal length is 2-3 cm. The prostatic urethra was visually obstructed. The cystoscope was advanced past an intact bladder neck into the bladder. Urine was obtained for culture and cytology. Bladder volume was approximately 30 mL. The bladder was thoroughly visualized with the 12- and 70-degree lenses. The cystoscopy was unremarkable. The trigone of the bladder was normal. The ureteral orifices were in orthotopic position and effluxed clear urine; specifically, there was clear efflux from the left ureteral orifice. The anterior wall, posterior wall, lateral wall and dome of the bladder were all visualized. The bladder was without significant trabeculation, cellularity and/or diverticula. The bladder was without stone. The bladder mucosa was without lesion; specifically, there was no evidence of bladder tumor, acute/chronic inflammatory stigmata and/or mucosal changes to suggest carcinoma in situ. Once cystoscopy was completed, attention was turned to the trigone. Bilateral retrograde pyelograms were obtained using an 8-French cone-tip catheter. The right collecting system was normal based on retrograde pyelography. The left retrograde pyelogram images a 10 mm calcification in the left lower calix. Once the retrogrades were completed, the decision was made to proceed with lateral hydrodilation and biopsies in an effort to include intersitial cystitis. Standard bladder hydrodilation was performed. Anatomic bladder volume was 800-900 mL. A terminal bloody efflux was appreciated at the time of bladder emptying after bladder hydrodilation. Revisualization of the bladder following bladder hydrodilation revealed diffuse submucosal glomerulation. Hunner ulcers were not appreciated. Due to clinical uncertainty, biopsies were obtained from the posterior wall and lateral walls of the bladder and biopsies were obtained from areas of highest concentration of submucosal glomerulations. The biopsies were sent to Pathology in anatomically labeled container. The biopsy sites were fulgurated with electrocautery. At the completion of the procedure, the biopsy sites were nonbleeding. With the procedure completed, the bladder was emptied and the cystoscope was removed under direct visualization with continuous irrigation. In an effort to optimize the patient's postoperative course, a 16-French Foley catheter was placed into the bladder. It was placed through the urethra into the bladder and placed to gravity drainage after instilling the Foley balloon with 10 mL of sterile water. Drainage from the Foley catheter was blood-tinged; therefore, the patient received 5 mg of Lasix IV push by the anesthesiologist. The patient tolerated the procedure well, was awakened in the operating room, accompanied to the recovery room in stable condition. The estimated blood loss was negligible. He received approximately 700 mL of crystalloid. The procedure was performed without transfusion. The procedure was performed without identifiable complications. Specimens include expressed prostatic secretions, urine culture, urine cytology and bladder biopsies. At the completion of the procedure, there were no dressings. Drains include a 16-French Foley catheter to gravity drainage.

Left Heart Cath Selective Coronary Angiography Sample Report

PROCEDURES PERFORMED:
1.  Left heart catheterization.
2.  Selective coronary angiography.

INDICATION FOR PROCEDURE:  Non-ST elevation MI.

DESCRIPTION OF PROCEDURE:  The patient was brought to the cardiac catheterization lab in fasting state, informed consent was obtained and the patient was prepped and draped in sterile fashion. Mild sedation was administered via IV Versed and fentanyl with attending present during administration of sedation. The right common femoral region was then anesthetized via 10 mL of 2% lidocaine and the right common femoral artery was accessed via single wall puncture technique and a 4-French femoral arterial sheath was advanced over a guidewire using modified Seldinger technique. Next, a 4-French angled pigtail catheter was advanced over a guidewire to the level of the ascending aorta. This catheter was used to cross the aortic valve and enter the left ventricle where hemodynamic measurements were obtained. Due to significantly elevated left ventricular end-diastolic pressures, no left ventriculography was performed. The pigtail catheter was then used to obtain hemodynamic measurements upon pullback across the aortic valve into the ascending aorta. This pigtail catheter was then subsequently withdrawn over a guidewire. Next, a 4-French 3DRC catheter was advanced over a guidewire to the level of the ascending aorta. This catheter was used to selectively engage the right coronary artery. The right coronary artery and its branches were then imaged in multiple planes and views. The 3DRC catheter was then withdrawn over a guidewire. Next, a 4-French JL4.5 catheter was advanced over the guidewire to the level of the ascending aorta. This catheter was used to selectively engage the left main coronary artery. The left main coronary artery and its branches were then imaged in multiple planes and views. The JL4.5 catheter was then withdrawn over the guidewire. At the conclusion of the procedure, the patient had the femoral arterial sheaths removed in the cardiac catheterization lab with hemostasis obtained via manual compression, and the patient was transferred to the coronary care unit for further observation and care.

SELECTIVE CORONARY ANGIOGRAPHY:
1.  Left main:  The left main bifurcates into the left anterior descending and circumflex coronary artery. The left main is angiographically free of significant stenosis.
2.  Left anterior descending:  The left anterior descending coronary artery is noted to provide two diagonal branches and terminates as the apical recurrent branch. The proximal LAD after this first small caliber diagonal branch is noted to have a 90-95% stenosis.
3.  Circumflex:  The circumflex coronary artery is noted to provide four obtuse marginal branches with OM2 being largest caliber obtuse marginal branch. This OM2 branch is noted to have subtotal occlusion proximally.
4.  Right coronary artery:  The right coronary artery is dominant and is noted to be completely occluded in its mid segment after supplying an acute marginal branch. Also noted is the presence of bridging collaterals that faintly fill the distal vessel. Additionally, during left coronary injections, the presence of left to right collaterals from the apical LAD supplying the distal right coronary artery is also noted.

LEFT HEART CATHETERIZATION:
Left ventricular end-diastolic pressure 27 pre-A wave and 40 post-A wave. There was no gradient noted upon pullback.

FINAL DIAGNOSIS:
1.  Severe three-vessel coronary artery disease in a diabetic patient.
2.  Significantly elevated left ventricular end-diastolic pressures.

PLAN:  The patient was referred for coronary artery bypass grafting and received IV Lasix in the cardiac catheterization lab given his significantly elevated left ventricular end-diastolic pressures.


M2A Capsule Endoscopy Procedure Transcription Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  
Anemia.

POSTOPERATIVE DIAGNOSIS:
Scattered red specks throughout the small bowel suggestive of small bowel arteriovenous malformations. No evidence of active bleeding.

PROCEDURE PERFORMED:
M2A capsule endoscopy.

SURGEON:  John Doe, MD

DESCRIPTION OF PROCEDURE:  After an overnight fast, informed consent was obtained from the patient explaining the risks, benefits and possible complications of M2A capsule endoscopy. The patient expressed understanding and agreed to undergo the procedure. Informed consent was obtained. The patient was brought to the endoscopy suite and placed on appropriate monitors and swallowed the M2A capsule. The patient swallowed the capsule without complications. The total gastric passage time was 12 minutes. The total small bowel passage time was 2 hours and 30 minutes. The cecum was reached. Within the small bowel, there were a few scattered reddish specks which were thought to represent small bowel arteriovenous malformations. No evidence of active bleeding was identified. The blood indicator was positive on several occasions. However, no source of active gastrointestinal bleeding was identified. The cecum, as described above, was reached.

IMPRESSION:  Scattered red specks throughout the small bowel suggestive of small bowel arteriovenous malformations. No evidence of active bleeding.  There is no evidence of active gastrointestinal bleeding on this examination. Multiple red areas, which were suggestive of arteriovenous malformations, were identified.

RECOMMENDATIONS:
At the present time, would recommend continuing to monitor the patient's hemoglobin.

Forearm Cimino AV fistula Surgical Procedure Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Impending renal failure.

POSTOPERATIVE DIAGNOSIS:
Impending renal failure.

TITLE OF OPERATION:
Left forearm Cimino arteriovenous fistula.

SURGEON:  John Doe, MD

ANESTHETIC:  MAC, local.

ESTIMATED BLOOD LOSS:  Minimal.

DESCRIPTION OF PROCEDURE:  After informed consent was obtained, the patient was brought to the operating room and placed on the operating room table in the supine position. After induction of MAC anesthetic, the left arm was prepped and draped in the usual sterile fashion. A longitudinal area of skin was anesthetized with local anesthetic between the level of the left radial artery and the cephalic vein. An approximately 3 to 4 cm incision was then made with #15 blade scalpel. Sharp dissection was used to isolate a suitable vein, which was freed up, small branches being clipped for a distance of approximately 5 to 6 cm up the arm. Once this was complete, the distal aspect of the vein was triple-clipped and then cut at that point. Attention was then turned to the radial artery, which was isolated, with care taken to not injure the intervening sensory nerve located between the vein and the artery. Radial artery had a good pulse, was soft and was mobilized for a segment of approximately 2 to 3 cm. Bulldog clamps were then placed for proximal and distal control and a small arteriotomy was made with a #11 blade scalpel. This was then lengthened to approximately 4 mm using a Potts scissors and the cut end of vein was then appropriately cut to length and spatulated. The anastomosis was then performed with interrupted #20 U clips. Approximately 12 U clips were used to perform the anastomosis in interrupted fashion. At the conclusion of the anastomosis, the bulldog clamps were released and there was good arterial flow noted through the radial artery into the hand, as well as pulsatile flow through the cephalic vein back up into the arm. In addition, a U clip was placed for hemostasis, and Doppler evaluation as well as palpation confirmed good flow to the radial artery to the hand, as well as good flow through the fistula. There was a strong ulnar pulse as well. Wound was then irrigated, suctioned dry, inspected for adequate hemostasis and the skin was closed in subcuticular fashion with 4-0 Vicryl suture. The patient tolerated the procedure well and was brought to the recovery room without incident.

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