Thoracic Arteriogram Carotid Vertebral Arteriography Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Symptomatic critically severe left carotid stenosis.
2.  Right internal carotid artery occlusion.
3.  Right vertebral artery occlusion.

POSTOPERATIVE DIAGNOSES:
1.  Symptomatic critically severe left carotid stenosis.
2.  Right internal carotid artery occlusion.
3.  Right vertebral artery occlusion.

PROCEDURES PERFORMED:
1.  Thoracic arteriogram.
2.  Selective right carotid arteriography.
3.  Selective left carotid arteriography.
4.  Selective left vertebral arteriography.

SURGEON:  John Doe, MD

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  None.

PROCEDURE FINDINGS:
1.  Heavily calcified plaque at the origin of the right innominate.
2.  Mild stenosis, origin of the left common carotid artery.
3.  Right vertebral artery occlusion.
4.  Right internal carotid artery occlusion.
5.  EC-IC collateralization with filling of the right middle cerebral and anterior cerebral arteries from the external carotid artery on the right.
6.  No evidence of a patent anterior communicating artery.
7.  Patent posterior communicating artery on the left.
8.  Normal filling of the vertebrobasilar system from the left vertebral artery with some collateralization to the left MCA via the patent posterior communicating artery.
9.  Critically severe 98% stenosis of the left internal carotid artery at the bifurcation with slow flow in the cervical internal carotid artery because of the severity of the stenosis. Evidence of patent internal cerebral and internal carotid artery with delayed but present filling of the left MCA from the left carotid injection.

DESCRIPTION OF PROCEDURE:  The patient was brought to the endovascular suite and placed in the supine position on the angio table. The right groin was sterilely prepped and draped in the usual fashion. The right groin was anesthetized with 1% lidocaine without epinephrine local anesthetic. The patient was given minimal intravenous sedation to keep him completely awake, alert and responsive during the carotid angiography to allow for neuro examination. A microneedle access technique was used in the right femoral artery and a 5 French sheath was placed in retrograde fashion in the right femoral artery. A 5 French pigtail catheter was advanced over a wire and reformed in the ascending aorta. An arteriogram was obtained in the 35-degree LAO and 35-degree RAO oblique positions for imaging of the arch to evaluate the disease at the origin of the innominate and the left common carotid arteries. The pigtail catheter was exchanged for a 3DRC catheter, which was reformed and selectively advanced into the right common carotid artery from the right innominate. Selective right carotid angiography was performed and angio was obtained in the AP and lateral cervical and AP and lateral cerebral views. There was excellent filling of the right middle cerebral artery and the right anterior cerebral artery from EC-IC collaterals from the right external carotid artery. There was no evidence of cross filling to the left cerebral hemisphere. No evidence of a patent anterior communicating artery. The 3DRC catheter was withdrawn into the arch and selectively passed into the left common carotid artery. AP and lateral cervical and AP and lateral left cerebral arteriograms were obtained through hand injection 3DRC catheter. This revealed the critically severe nature of the stenosis of the origin of the left internal carotid artery. There was intraluminal filling defect within the midst of the most severe portion of the stenosis. It was impossible to determine from this angiographic evaluation whether that intraluminal filling defect represented complex plaque or actual thrombus in the lumen just behind the high-grade stenosis of the internal carotid artery. Therefore, it was felt that guidewire traversal across this lesion for placement of the distal cerebral perfusion protection device would not be advisable, and therefore, the patient would be at high risk for CAS. Instead, the patient will be taken for a therapeutic left carotid endarterectomy. The 3DRC catheter was then withdrawn from the common carotid into the arch and selectively matched in the left subclavian artery and using row-mapping technique over a 0.035 wire selectively advanced into the left vertebral artery. There was moderate orificial left vertebral artery stenosis. However, there were no distal tandem lesions in the left vertebral artery. There was patent posterior communicating artery on the left. The 3DRC catheter was withdrawn into the arch and removed over wire. A femoral arteriogram was obtained, which confirmed good placement of the sheath for use of Angio-Seal closure device. The Angio-Seal was used. Good hemostasis was obtained. The patient was returned to the recovery room.


Navicular ORIF With Arthrodesis Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left navicular fracture and dislocation.

POSTOPERATIVE DIAGNOSIS:  Left navicular fracture and dislocation.

OPERATION PERFORMED:  Open reduction and internal fixation, left navicular, with arthrodesis of the navicular to the medial cuneiform using 3.5 cortical screw.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  10 mL.

TOURNIQUET:  Left upper thigh, well padded.

TOTAL TOURNIQUET TIME:  25 minutes, inflated to 350 mmHg.

INDICATION FOR OPERATION   This is a (XX)-year-old female who was involved in a motor vehicle accident about 3 weeks ago and sustained a comminuted navicular fracture and dislocation with subluxation of the talonavicular and navicular-medial cuneiform. The patient was put in a splint and on followup was still found to have subluxation of the navicular-medial cuneiform. The decision was made at this point to proceed with an ORIF.

DESCRIPTION OF OPERATION:  The patient was given 1 gram of Ancef in the preoperative area and was brought to the operating room and placed in the supine position. After satisfactory general endotracheal anesthesia was administered, the left lower extremity was prepped and draped in the usual sterile routine fashion. The mini C-arm was used as a trial of closed reduction and percutaneous pinning was tried, but we could not reduce the navicular back to its anatomic position in regards to the medial cuneiform. The decision at this point was made to proceed with open reduction. The tourniquet was inflated after exsanguination with the Esmarch. A routine incision was performed on the dorsal medial aspect of the foot centered over the navicular-medial cuneiform joint. The incision was taken down to the navicular and cuneiform. The flap was elevated medially and laterally. There was subluxation of the navicular dorsally at the navicular-medial cuneiform joint. There was a lot of comminution in the plantar part of the navicular. Debris was removed with a rongeur and curette and the fracture site irrigated with normal saline. The fracture was reduced back into position using a bone clamp and was confirmed using the C-arm, both AP and lateral, and was in good anatomical reduction. At this point, a rongeur was used to make a trough for the screw, which was placed from distal to proximal through the medial cuneiform into the dorsal piece of the navicular. A 3.5 screw was placed and was confirmed using the C-arm to be in good position with good anatomic reduction of the navicular. The wound at this point was irrigated copiously with normal saline. A dorsal x-ray was taken, which confirmed good placement of the screw and anatomic reduction of the navicular-medial cuneiform joint, which was affixed with the screw. The subcutaneous tissues were closed with 3-0 Vicryl and the skin closed with 3-0 nylon. A dressing was applied in the form of Adaptic, 4 x 4 and sterile Webril. A short leg splint was applied. The patient tolerated the procedure well and was taken to the recovery room in stable condition with no complications.


Normal Review of Systems (ROS) Transcription Samples

REVIEW OF SYSTEMS:
CONSTITUTIONAL:  No fever, chills.
HEENT:  Eyes:  No visual disturbance, no photophobia.  ENT:  No otalgia, no difficulty swallowing or speaking.
CARDIOVASCULAR:  No chest pain.
RESPIRATORY:  No shortness of breath.
GASTROINTESTINAL:  Epigastric pain.
GENITOURINARY:  No difficulty urinating.  No urinary retention or urinary incontinence.
MUSCULOSKELETAL:  No joint pain or swelling.
NEUROLOGIC:  No paresthesias, anesthesias.
SKIN:  No rashes.
PSYCHIATRIC:  No hallucinations or delusions.
Review of systems otherwise negative.

REVIEW OF SYSTEMS:  The patient denies any constitutional symptoms. He does wear glasses. He denies any chest pain or respiratory symptoms. He reports occasional loose stools. No other GI symptoms. He denies any GU symptoms, joint pain, swelling, rashes, skin conditions, neurologic conditions or blood disorders.

REVIEW OF SYSTEMS:  At this point, the patient denies sore throat, nosebleed, hearing loss, dysuria, frequency, fever or chills, loss of appetite, cough, wheezing, headaches, dysphagia, fainting, blurred vision, chest pain, palpitations, shortness of breath, edema, pain or swelling of the joints, abdominal pain, diarrhea, constipation, nausea or vomiting, rashes or warmth. However, the patient had some of these symptoms earlier on during the admission as mentioned above.

REVIEW OF SYSTEMS:  The patient has occasional migraines and occasional non-migraine headaches. No dizziness. No chest pain or shortness of breath. The patient has nausea and vomiting with her migraines but otherwise no dysphagia, heartburn, indigestion, weight loss, fever, lower extremity edema or hematuria.

REVIEW OF SYSTEMS:  Stable weight. Good appetite. No recent fever. Positive chills today. Occasional indigestion or heartburn. Recent chest discomfort. Recent mild dyspnea. No change in bowel habits. Chronic nocturia and frequency but no change. No dysuria. No stroke or TIA type symptoms.

REVIEW OF SYSTEMS:  As above, otherwise negative. The patient denies any urinary symptoms, any frank chest pain or shortness of breath, dizziness or syncopal episodes. No fevers or chills. The patient’s last bowel movement was yesterday, was normal for her. She denies dark tarry or bloody stools.

REVIEW OF SYSTEMS:  The patient denies fever, chills, nausea, vomiting, diarrhea. He denies any bony deformity, ecchymosis, hematoma to the left wrist, hand or digits. He denies any erythema, crepitus or increased joint warmth to the same. He notes pain with active range of motion of the wrist, predominantly with both flexion and extension, though worse with flexion. He otherwise denies numbness, tingling or paresthesias to the same or muscle weakness. The remainder of his review of systems is otherwise negative.

REVIEW OF SYSTEMS:  The patient denies fever, chills, nausea, vomiting. Does note some diarrhea. She denies any headache. Does note some dizziness. Denies blurred vision. She denies focal neurologic deficits, numbness, tingling or paresthesias to her extremities. Does note some increased fatigue and weakness. She denies any upper respiratory symptoms, neck pain, stiffness, chest congestion, cough, chest pain, shortness of breath, wheezing, diaphoresis or palpitations. She notes abdominal pain, which she localizes to her suprapubic area with associated urinary symptomatology. The remainder of review of systems is otherwise negative.

REVIEW OF SYSTEMS:  The patient denies any fever or chills. She does note nausea, vomiting, diarrhea. She denies any headache, dizziness, blurred vision, focal neurologic deficits, numbness, tingling or paresthesias to her extremities. She does note increased fatigue and weakness. She denies any upper respiratory symptoms, neck pain or stiffness, chest congestion, cough, hemoptysis, hematochezia or hematemesis. She does note some chest pain as described above with associated shortness of breath. She denies any diaphoresis. She does note transient sensation of palpitations. She denies any back pain, urinary symptoms or rash. However, she does note some periumbilical abdominal pain, which she localizes around her colostomy site. She does note some abdominal distention as well, which has been gradually increasing over the past several days. She denies any recent significant weight gain or weight loss, as well as any swelling to her extremities. She denies any heat or cold intolerance. Remainder of the review of systems is reviewed and negative.

REVIEW OF SYSTEMS:  The patient denies any decreased sensation or pain radiating down his legs. The patient denies any problems with bowel or bladder. He denies any diplopia. No unilateral weakness or numbness. No trouble speaking or swallowing. He does have a headache. Some neck discomfort, low back pain, more right sided. His pain is worsened with movement, twisting, turning, bending. The patient denies any other injuries. He did not strike his head. He was wearing a seat belt, which he states broke. Otherwise, review of systems negative.

REVIEW OF SYSTEMS:
CONSTITUTIONAL:  Denies fever, chills or weight loss.
HEENT:  Eyes:  Denies visual changes or pain with eye movements.  ENT:  Denies congestion or sore throat. Significant for complaints listed in the HPI.
CARDIOVASCULAR:  No chest pain, palpitations or syncope.
RESPIRATORY:  No shortness of breath, cough, congestion, wheezing or sputum production.
GASTROINTESTINAL:  No abdominal pain, hematemesis or melena.
GENITOURINARY:  No dysuria or polyuria.
MUSCULOSKELETAL:  No muscle or joint pain.
NEUROLOGIC:  No numbness or tingling in her extremities.
ENDOCRINE:  Denies polyuria or polydipsia.
HEMATOLOGIC:  Denies any abnormal bleeding or bruising.

REVIEW OF SYSTEMS:  The patient denies any fevers, chills, sweats.  HEENT:  She denies any headache or photophobia.  CARDIOVASCULAR:  She has the aforementioned chest wall pain though denies any history of chest pain or coronary artery disease.  RESPIRATORY:  Again, she denies any cough or sputum production.  States that she has no history of COPD or asthma.  GASTROINTESTINAL:  The patient denies any abdominal pain, nausea, vomiting, diarrhea or constipation.  The patient's all other review of systems are negative and per the HPI.

REVIEW OF SYSTEMS:  No sore throat, no earaches, no diplopia, no cough or chest congestion of late. She denies any true abdominal pain now and no pain with eating or nausea, vomiting or diarrhea. She denies any bloody or black stools of late. She denies any dysuria now. No wounds or sores that would not heal. Otherwise, she has some frontal headache but no sinus drainage or other nasal discharge.

ROS Examples       ROS Examples 1       ROS Examples 2        ROS Examples 3

Radial to Antebrachial Side-to-Side Fistula Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
End-stage renal disease and need for hemodialysis.

POSTOPERATIVE DIAGNOSIS:
End-stage renal disease and need for hemodialysis.

PROCEDURE PERFORMED:
Left radial to antebrachial side-to-side fistula at the left antecubital fossa.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

COMPLICATIONS:  None.

INDICATIONS FOR PROCEDURE:  The patient presented with end-stage renal disease. She has a need for hemodialysis. Risks and benefits of the procedure were explained to the patient, and she was agreeable to proceed with surgery. Informed consent was obtained. The patient underwent venous mapping of the left upper extremity. The cephalic vein at the distal forearm measured around 1.8 mm. The patient had palpable radial and ulnar pulses. She had codominant superficial palmar arch. The recommendation for proximal radial fistula was given. The patient was agreeable to proceed with surgery.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and placed on the table in the supine position. General endotracheal anesthesia was given to the patient without any problem. The left upper extremity was prepped and draped in the usual sterile fashion. A longitudinal incision was made in the left antecubital fossa. The incision was carried down through the skin and subcutaneous tissue. The antebrachial vein was identified. The deep venous branch was identified. The cephalic vein was identified. The antebrachial vein was dissected. Side branches were ligated. The radial artery was isolated. The side branches were doubly clipped and divided. Vessel loops were placed around the vessels. A longitudinal venotomy was performed. A 2.5 mm dilator was used to destroy the valve of the antebrachial vein between the antecubital fossa and the wrist. Both venous lumens were flushed with saline solution. The radial artery was then clamped between 2 clamps. Longitudinal arteriotomy was performed. Side-to-side anastomosis with 7-0 Prolene was performed. Flow was restored through the vein without any problem. The patient had a nice palpable thrill in proximal cephalic vein. The patient had a nice thrill and flow signal in the antebrachial vein toward the wrist. Due to competitive flow, the deep venous branch was ligated at the antecubital fossa. The subcutaneous tissue was closed with running 3-0 Vicryl. The skin was closed with running 4-0 Vicryl. Steri-Strips were applied to the skin. A 4 x 4 and Tegaderm were applied to the left antecubital fossa. The patient tolerated the procedure well, was extubated in the operating room and was sent to the recovery room in stable condition.

Radial Artery Exploration Embolectomy Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Occluded right radial artery at the wrist.
2.  Severe ischemia with discoloration of the thumb and index finger of the right hand.

PROCEDURES PERFORMED:
1.  Exploration, right radial artery.
2.  Embolectomy, right radial artery with patch angioplasty.
3.  Exploration of right antecubital fossa.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

COMPLICATIONS:  None.

INDICATION FOR PROCEDURE:  The patient is a (XX)-year-old male who presented with pain involving the right thumb and index fingers. The patient had significant discoloration of the index finger from the mid phalanx to the tip and had a patchy area of ischemia involving the plantar aspect of the thumb. The patient had ischemic changes involving the distal aspect of the thumb and was admitted to the hospital and underwent an angiogram of the right upper extremity. This showed an occlusion of the radial artery from the wrist to the elbow, and the patient also had an occlusion of the first and second digital vessels. The patient was recommended to undergo exploration of the radial artery for embolectomy and was agreeable. Informed consent was obtained.

PROCEDURE FINDINGS:  Thrombosis of the radial artery at the wrist.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and placed on the table in the supine position. General endotracheal anesthesia was given to the patient without any problem. The right arm was prepped and draped in the usual sterile fashion. A longitudinal incision was made along the wrist. This incision was carried down through the skin and subcutaneous tissue. The radial artery was identified. A clot was noted in the radial artery. The radial artery did not have any significant palpable pulse. The patient was given 3000 units of heparin and the radial artery was clamped superiorly. An 11 blade was used to make a 1 cm long arteriotomy of the radial artery at the wrist. A fresh clot was noted at the arteriotomy site. The clot was removed. No back-bleeding was noted. A 3-French Fogarty was introduced into the distal radial artery and embolectomy of that artery was performed. There was good back-bleeding from the hand. The upper radial artery was flushed with adequate blood flow from the top. No injury was noted to the radial artery. The wrist was explored for suitable vein for a patch; we were not able to locate one. Attention was then directed to the antecubital fossa. A small incision was made at the antecubital fossa and a 1.5 cm vein was identified. It was doubly ligated and divided. The subcutaneous tissue was closed with 3-0 Vicryl. The skin was closed with running 4-0 Vicryl. Attention was then directed to the arteriotomy. The vein was opened; it was spatulated. The vein was sutured into the radial artery with 7-0 Prolene suture in a running fashion and 2 sutures were used, 1 for the heel, 1 for the toe. Flow was restored to the right hand without any problem. Doppler probe was used to insonate the distal radial artery with adequate flow. The subcutaneous tissue was then closed with 3-0 Vicryl. The skin was closed with 4-0 Vicryl. Hemostasis was optimal. Dry dressing was applied to the wrist and the antecubital fossa. The patient tolerated the procedure well, was extubated in the operating room and sent to the recovery room in stable condition.

Left STA-MCA Bypass Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Multiple aneurysms.
2.  Left carotid ophthalmic aneurysm.
3.  Right carotid occlusion.

POSTOPERATIVE DIAGNOSES:
1.  Multiple aneurysms.
2.  Left carotid ophthalmic aneurysm.
3.  Right carotid occlusion.

PROCEDURE PERFORMED:
Left STA-MCA bypass.

SURGEON:  John Doe, MD

COMPLICATIONS:  None.

SPECIMENS:  None.

DESCRIPTION OF OPERATION:  The patient was intubated and placed in the supine position with the head tilted to the right. The superficial temporal artery was mapped and the posterior branch was selected. The area was prepped and draped in sterile fashion. An incision was made with a 10 blade, and then with the use of scissors and bipolar coagulation, the posterior branch of the superficial temporal artery was isolated and prepared. Then, the muscle was opened in a cruciate fashion and retracted. The bone was entered with the Midas Rex and a small craniotomy was performed. The dura was opened, and under the microscope with microdissection, a branch of the middle cerebral artery was dissected free and prepared for bypass. At this point, attention was diverted to the superficial temporary artery branch which was also prepared and was cross-clamped and irrigated with heparinized solution. At this point, the superficial temporal artery branch was brought down to the cortical branch, which was again cross-clamped with two 3 mm clips and then opened and the anastomosis performed with interrupted 10-0 Prolene. At the end of the anastomosis, the distal clips and proximal clips were removed from the cortical branch of the MCA and then the clip was removed from the superficial temporal artery. The system appeared to be working perfectly and was confirmed also by Doppler sound. At this point, the area was irrigated with warm lactated Ringer’s. The anastomosis was covered with Surgicel. The dura was partially closed with 4-0 Vicryl. The bone flap was also partially replaced and fixed with mini plates. Muscle was closed with 2-0 Vicryls, subcutaneous tissue with 3-0 Vicryl and the skin closed with 3-0 nylon. At the end of surgery, the Doppler was used to verify the function of the bypass, which appeared to be perfect.

Frontotemporal Craniotomy Clinoidectomy Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Left carotid ophthalmic artery aneurysm.

POSTOPERATIVE DIAGNOSIS:
Left carotid ophthalmic artery aneurysm.

PROCEDURES PERFORMED:
1.  Left frontotemporal craniotomy.
2.  Partial extradural clinoidectomy.
3.  Clipping of the aneurysm.

SURGEON:  John Doe, MD

COMPLICATIONS: None.

SPECIMENS: None.

DRAINS:  Jackson-Pratt.

INDICATIONS FOR OPERATION:
The patient is a (XX)-year-old male who has been found to have a left carotid ophthalmic aneurysm. The patient was evaluated by multiple physicians for possible coiling but was found to be not suitable for that. Discussed with the patient the risks and benefits of the surgery, including but not limited to the risks of stroke, optic nerve neuropathy, hematoma, reoperation, infection, seizures. The patient understood these and wished to proceed with surgery. Informed consent was obtained.

DESCRIPTION OF OPERATION:
The patient was intubated and placed supine in the Mayfield head rest.  The left side was prepped and draped in a sterile fashion.  An incision was made with the 10 blade scalpel and Bovie coagulators and the scalp and muscles were reflected anteriorly and inferiorly.  Subsequently, with the Midas Rex, a craniotomy was performed and the sphenoid wing was drilled off and part of the clinoid was also removed extradurally.  Then, under the microscope for microdissection and illumination, the dura was opened and intradurally the carotid was identified, the cisterns were opened and cerebrospinal fluid was removed.  The aneurysm was immediately found, was dissected and easily clipped with a slightly angled 5 mm clip.  The dura was closed with a 4-0 Vicryl.  The dura was also tacked up to the skull and then the bone flap was replaced and affixed with mini plates.  The skull defect was also repaired with a small piece of titanium mesh.  Then, the muscle was closed with 2-0 Vicryls.  The subcutaneous tissues were closed with 3-0 Vicryls and the skin was closed with staples.  A Jackson-Pratt drain was left in the subgaleal space.

Neurosurgical Operative Samples #1          Neurosurgery Operative Sample Reports #2

Suboccipital Craniotomy and Resection Sample Report

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Cimino-Brescia Arteriovenous Fistula Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Chronic renal failure.

POSTOPERATIVE DIAGNOSIS:
Chronic renal failure.

PROCEDURE PERFORMED:
Left Cimino-Brescia arteriovenous fistula.

SURGEON:  John Doe, MD

ASSISTANT:
None.

SEDATION:
IV sedation plus local.

COMPLICATIONS:
None.

ESTIMATED BLOOD LOSS:
Nil.

SPECIMENS:
None.

INDICATIONS FOR PROCEDURE:
This is a (XX)-year-old female diagnosed with chronic renal failure approximately a year ago. The patient has had a catheter placed and has been receiving hemodialysis since that time, now presents for fistula placement.

DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room, placed in the supine position and given IV sedation. The left arm was prepped and draped sterilely. An incision was created in the medial aspect of the wrist. The subcutaneous tissue was dissected. A sizable cephalic vein was identified and skeletonized over a length of approximately 10 cm. All side branches were ligated with small clips. The radial artery was identified and appeared to be quite small in size. It was approximately 1.6 to 2.2 mm in size despite the large size of the vein. The artery was then skeletonized over a length of approximately 3.5 cm. A small arteriotomy was created after bulldog clamps were applied to occlude the arterial lumen. The vein was occluded proximally with a bulldog clamp. The vein was cut to size. An end-to-side anastomosis was created between the vein and the artery with nitinol U-clips. A total of 13 clips were applied to create a circular anastomosis. Just prior to completion of the anastomosis, 2 coronary dilators were passed both proximally and distally in the artery to be sure there was no evidence of occlusion and the artery was cannulated as well. The procedure was completed. There were no complications. There was no evidence of bleeding from the anastomosis. The wound was irrigated. The skin was closed with 4-0 Vicryl subcuticular sutures and a sterile dressing was applied. There were no complications.

Psychiatric Consultation Medical Transcription Sample

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Consultation was requested for evaluation and management of suicidality.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male who was admitted subsequent to ongoing difficulties with heavy alcohol consumption. The patient had seizures and loss of consciousness and was transferred to this facility for further cardiac evaluation. The patient states that he is now feeling much better and that the initial problems have been resolved and does not know why he is still in the hospital. The patient has been having difficulties with increased irritable mood and becomes easily upset. He has had difficulties with initiating sleep, stating that at times he will stay up late in the night and also reports that he sleeps most of the day. The patient had reported also maintaining interest in pleasurable activities.  He presents with some issues of low self-esteem, but reports that he maintains hope that things are going to get better now that he is getting medical care.  The patient presents with lowered energy levels. He describes some difficulties with concentration. He reports no major changes with his appetite; although, his wife states that he was eating less and less every day. The patient presents with psychomotor activity, which is within normal limits. He maintains fair eye contact. He denies having homicidal or suicidal thoughts at this time. He reports that he did make a statement to the effect that if his health was not going to get better, then there was no reason to continue to live in this fashion, but he reports no particular plan of wanting to harm himself or anyone else. He denies having auditory or visual hallucinations.

PAST PSYCHIATRIC HISTORY:  The patient has no previous history of inpatient or outpatient psychiatric care. He has been on no psychotropic medications previously.

FAMILY HISTORY:  The patient denies any family history of psychiatric, addictive or neurologic disorders.

PAST MEDICAL HISTORY:  The patient has a history of coronary artery disease. He had seizures secondary to alcohol withdrawal.

SUBSTANCE ABUSE HISTORY:  The wife reports that the patient was drinking on a daily basis from approximately noon until the night. The patient was drinking mostly whiskey. The patient denies any other drug consumption. He reports no previous rehabilitations or detoxifications.

REVIEW OF SYSTEMS:  As per the attending physician.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  The patient reports that he was born and raised in (XX). The patient states he has been married on 3 occasions and worked (XX) years as a (XX). The patient states that he has 4 children and he is currently married. He is living with his wife. All of his children are adults. He is now retired.

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old male who appears older than his stated age. He presents with psychomotor activity, which is decreased. He was dressed in a hospital gown, in bed, is cooperative with the examiner. His speech is of normal tone. It is coherent, relevant, goal directed and logical. His mood is angry. His affect is appropriate to his mood and thought content. He denies having auditory or visual hallucinations and he denies any plans or intent of harm to self or to others. He reports no homicidal or suicidal thoughts. He is alert and oriented to person, place and partially to time. Immediate recall is intact for 3 objects. Recent recall is limited to 2 of 3 objects at 5 minutes. Remote recall is grossly intact. Attention and concentration are limited. Fund of knowledge is adequate for the patient's level of education. Insight is limited. Judgment is fair. Impulse control is fair.

DIAGNOSTIC IMPRESSION:
Axis I:  Depressive disorder, not otherwise specified. Alcohol dependence.
Axis II:  Deferred.
Axis III:  Status post alcohol withdrawal with delirium tremens, coronary artery disease.
Axis IV:  Moderate for social and health care issues.
Axis V:  Global Assessment of Functioning of 45.

RECOMMENDATIONS:  The patient at this time does not meet criteria for involuntary hospitalization and states that he has no interest in remaining in the hospital for any type of care that is not essential. The patient could benefit from the use of antidepressant medications but states that he has no interest in taking any medications and will not, if in fact they will not help his overall mood. He states that what is keeping his mood irritable is the mere fact of being in the hospital. The patient at this point should have further outpatient psychiatric followup upon his discharge from the hospital for further assessment of need of psychotropic medications.

Thank you very much for allowing me to participate in the care of your patient.


Mental Status Examples                                 Psychiatric Discharge Summary Sample

Retrocalcaneal Exostectomy Transcription Operative Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Retrocalcaneal exostosis/Haglund deformity, left heel, with enthesopathy tendo Achilles, left heel.

POSTOPERATIVE DIAGNOSIS:
Retrocalcaneal exostosis/Haglund deformity, left heel, with enthesopathy tendo Achilles, left heel.

OPERATION PERFORMED:
Exostectomy, retrocalcaneal, with repair of Achilles tendon/tenolysis.

SURGEON:  John Doe, DPM

DESCRIPTION OF OPERATION:  The patient was prepped and draped in the usual aseptic manner.  The patient was placed under general anesthesia, was placed in a prone position and a tourniquet was inflated to 300 mmHg of pressure after exsanguinating the leg with a Martin bandage.  A curvilinear incision was made running from superior medial to plantar posterior lateral.  Incision was deepened including help with the Bovie.  Sharp and blunt dissection was carried down to the paratenon tendon apparatus of the tendo Achillis.  A vertical incision was then made through the tendo Achillis down to the bone and the paratenon and tendo Achillis were split in half and retracted medially and laterally.  Sharp and blunt dissection allowed visualization of the posterior aspect of the calcaneus on both the superior and inferior portion medial and lateral aspects.  Hypertrophic bone was noticed throughout the area, especially on the posterior, superior and lateral aspects.  The area was remodeled using a combination of sagittal saw and rotary bur.  Once the adequate contouring was accomplished and the area was made smooth, it was checked with FluoroScan throughout the procedure.  The area was palpated, and once the adequate contouring had been completed, the area was copiously flushed with saline irrigation.  The tendo Achillis was palpated and noted scar tissue and fibrosis along the anterior aspect of the tendo Achillis.  A tendon debridement was then performed on the tendo Achillis, removing all sharp and fibrotic tissue from that posterior aspect, at which time the area was copiously flushed with an antibiotic GU irrigation.  Fluoroscopic views were taken again to assure adequate positioning and alignment, at which time the tendo Achillis repair was accomplished using 2-0 Vicryl in a Krackow-type stitch.  The Krackow stitch ran from superior to mid portion and then was tied and then a second Krackow stitch was started, running from mid portion to inferior aspect.  Silk of interrupted sutures were also employed to close any deficits to the tendo Achillis on the inferior aspect.  Prior to closure, after flushing the area, bone wax was introduced to cover the raw bony surfaces of the calcaneus to minimize the bleeding.  Once the tendon was coapted properly and foot was tested, Thompson test was normal and dorsiflexing the foot showed the tendo Achillis to be intact and functioning well.  A spider washer, the medium size, was placed over the posterior central region of the calcaneus.  This was checked with fluoroscopic views.  A K-wire was introduced through the center to act as a guidepin and measurement for a cannulated screw.  A #34 was selected and the cannulated screw was then driven into the washer and into the posterior aspect of the calcaneus allowing the compression of the spider washer against the tendo Achillis.  It was able to secure and pass the tendo Achillis to the calcaneus without over compressing the area.  Two-finger tightness was used.  The area was checked again with fluoroscopic views.  The area was copiously flushed once more.  The subcutaneous tissues were then closed with 3-0 Dexon and then skin was coapted with staples.  The tendo Achillis and paratenon were sutured as a unit just as they were dissected as one unit.  Tourniquet was released.  The patient tolerated the procedure well.  Decadron was injected peritendinous to the area.  A compressive dressing was applied.  Foot and ankle were placed in a gravity equinus position.  A BK posterior splint/cast was applied to hold the ankle in position.  Tourniquet was released.  CFT was normal to toes and the patient was then given a femoral nerve block to render postoperative anesthesia.  The patient tolerated the procedure well and left the OR in good condition.


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Dorsal Ganglion Excision Carpal Tunnel Release Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Left carpal tunnel syndrome.
2.  Left wrist dorsal ganglion.
3.  Recurrent mild right carpal tunnel syndrome.

POSTOPERATIVE DIAGNOSES:
1.  Left carpal tunnel syndrome.
2.  Left wrist dorsal ganglion.
3.  Recurrent mild right carpal tunnel syndrome.

OPERATION PERFORMED:
1.  Left wrist dorsal ganglion excision.
2.  Left carpal tunnel release.
3.  Corticosteroid injection, right carpal tunnel.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  General.

TOURNIQUET TIME:  45 minutes on the left forearm.

FLUIDS GIVEN:  Lactated Ringer's.

SPECIMENS:  Dorsal wrist mass, left, sent to pathology.

ESTIMATED BLOOD LOSS:  Minimal.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old with a history of bilateral carpal tunnel syndrome. The patient had a recurrence on the right and underwent a revision carpal tunnel release with improvement. He now developed mild symptoms and also has been complaining of increasing left carpal tunnel symptoms and has also developed the dorsal ganglion on the left wrist as well. Despite nonoperative treatment including splinting, anti-inflammatory medicines, previous corticosteroid injections, the patient still has persistent symptomatology. The patient now presents for operative treatment. The risks and benefits of the surgery including infection, bleeding, recurrence, possible incomplete relief of symptoms and possible need for repeat surgery were explained to the patient. The patient understood the risks and benefits and wished to proceed.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and placed on the operating table in the supine position. General anesthesia was induced. A total of 1 mL of Depo-Medrol and 3 mL of Marcaine was injected into the right carpal tunnel under sterile conditions. Attention was then turned to the left upper extremity. This was prepped and draped in the usual sterile fashion. The limb was exsanguinated and the tourniquet was inflated to 250 mmHg.

At this point, a longitudinal incision was made in the base of the palm in line with the fourth ray. This incision was carried through skin and subcutaneous tissue. The superficial fascia was divided. Transverse carpal ligament was identified and divided. At this point, a KMI SafeGuard carpal tunnel guide was placed deep to the transverse carpal ligament and the remaining proximal portion of the ligament was divided with the KMI SafeGuard carpal tunnel knife. At this point, the entire ligament was completely divided and the median nerve was found to be completely free without injury. At this point, the wound was copiously irrigated with normal saline. The skin was closed with 4-0 nylon vertical mattress sutures. Attention was then turned to the dorsum of the left wrist. A transverse incision was then made over the area of the dorsal ganglion. This incision was carried through skin and subcutaneous tissue. Blunt and sharp dissection was performed. The mass was identified and found to be adherent to the underlying extensor tendon sheath. The extensor tendon sheath bent over the EPL and ECRL and ECRB was then incised along with the mass. The mass was then traced back to the area of the scapholunate interval and the entire mass along with the stalk was excised along with a piece of the dorsal capsule.

Once this was done, the wound was copiously irrigated with normal saline. The base of the capsule was cauterized with Bovie electrocautery and the skin was closed with 4-0 Vicryl single interrupted sutures and 4-0 nylon running subcuticular suture. This was done after the wound was copiously irrigated with normal saline. Bulky sterile dressing and a volar splint was applied. The patient tolerated the procedure well and was taken to the recovery room in stable condition.


Mental Status Examination Medical Transcription Examples

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old male.  No particular mannerism noted.  He was cooperative.  His speech was relevant and coherent.  Affect was full and congruent to the content of thought.  Mood depressed on and off.  He denied suicidal and/or homicidal thoughts.  He denied paranoia.  No thought or perceptual disorder noted.  No obsessive-compulsive symptoms evidenced.  No panic disorder symptoms reported.  No period of mania or hypomania reported.  Alert and oriented.  Memory functioning is intact.  Judgment and insight seemed reasonable.

MENTAL STATUS EXAM:  The patient presents as a (XX)-year-old male who appears slightly older than his stated age.  He is of a slim build but adequately nourished body habitus.  He wears his clothes inappropriately.  He is polite, reserved and laughs politely and easily.  He is able to give answers to simple questions such as his date of birth, the home address, the street address of his home.  The patient presents as ingenious and child-like.  On answers to questions he is not able to give, he does not appear to embroider answers.  He will make repetitious attempts asking for validation of each of his guesses, and then before validation is given, stating “no, I know that’s not right.”  He does not appear to be particularly concerned when he is not able to give an appropriate answer to simple questions.  The patient does not present any overt delusions, paranoia or unreasonable fears.

MENTAL STATUS EXAMINATION:  The patient presents as an adult male who appears to be about his stated age.  He has excellent personal hygiene and grooming.  When I called his name in the waiting area, he came to the interview area with a smooth, fluid gait.  He was pleasant, cooperative throughout the interview.  His speech was of normal tone and volume and productivity.  He was serious but future oriented.  He presented no blocking of thoughts, circumstantiality, perseveration.  He presented with no flight of ideas, grandiosity or distractibility.  He showed a fair range of affect, generally appropriate to context.  He became more somber and serious when speaking of the impending birth of his child and his legal problems and was less somber when speaking of potential for early resolution of those legal problems.  He presented no apathy, extreme flattening of affect, disorganization, apparent response to internal stimuli, paranoia or delusion.  He did not present any obvious cognitive deficit.

MENTAL STATUS EXAMINATION:  The patient presents as a (XX)-year-old man who still appears slightly older than his stated age.  He is polite, calm, almost placid and unconcerned throughout the interview process.  He is able to give an organized, lucid, coherent and generally consistent history, which is consistent with the psychiatric history he has given.  He reports that in the past he used to worry that he did not have the memory he had before his accident.  After asking specific questions such as his social security number, events in the past, major events in his life, which he is able to identify readily, he laughed and said “may be I still remember things.”  The patient was able to readily answer historical questions for distant past events with relative consistency.  He was able to discuss intermediate and short-term events with equal ease and facility.  Based on his vocabulary, usage and fund of general information, I assess him to be of approximately average intelligence.  The patient presents no entitlement, irritability, pressured speech, flight of ideas or delusional grandiosity.  He presents no extreme disorganization, involution, flattening of affect or disorganization.  The patient denies any current suicidal ideation, presents himself as future oriented and optimistic in spite of his relatively unconcerned affect.

MENTAL STATUS EXAM:  The patient appears to be about his stated age.  He is adequately nourished, neatly dressed, has excellent hygiene and grooming.  He appears to be somewhat sleepy and sedate.  He freely acknowledges that since he has been taking the Thorazine, that he has been sleeping a lot and he is very lethargic during the daytime.  He reports that he is very appreciative of the sleep he gets from the medication at night but would like to be more alert during the day.  He is able to confirm and deny some historical details that I referred to on the chart.  He volunteers very little new information.  His speech, although somewhat sparse, is organized and coherent and internally consistent, is consistent with previous documentation.  His affect is bland and unconcerned.  He denies any suicidal or self-harmful ideation.  He presents no pressured speech, flight of ideas or delusional grandiosity.  He presents no disorganization, apparent response to internal stimuli, extreme withdrawal or extreme flattening of affect.  He presents no apparent response to internal stimuli or paranoid delusional system.  From his understanding of vocabulary and words, he has the potential for average IQ.

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old male.  His speech was noted to be logical and goal oriented.  Content was with past allegations of psychotic features; although, these sound more like voices that are “inside my head” and consistent with thoughts.  He denied thought broadcasting, thought insertion, paranoid ideation, bizarre delusions or other psychotic symptoms.  His mood was self-described as “normal.”  His affect was appropriate.  The patient was fully oriented.  His memory was 2/3 after 5 minutes.  He performed reasonably well with past presidents and serial 7s.  Test judgment was intact.  Insight was fair.

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old male who is very difficult to interview.  He answers questions briefly.  He becomes argumentative.  He is paranoid.  His mood is of irritability with underlying anger and sarcasm.  He does not want to give information.  He states that he hears voices.  He at times laughs and talks to the interviewer, and when the interviewer asks questions, he states that he was not talking to the interviewer.  He specifically denies voices talking to him or commanding him.  They are just “screaming at me.”  He is alert and oriented.  He is not suicidal.  He is not homicidal at this time.

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old male who looks his stated age.  No particular mannerism noted.  His speech was relevant and coherent.  Affect was congruent to the content of thought.  The patient denied being homicidal and suicidal.  No formal thought disorder noted.  No perceptual disorder noted.  The patient denied ideas of reference, thought broadcasting, thought insertion, experiences of influence.  No obsessive-compulsive symptoms evidenced.  The patient was alert and oriented.  Memory functioning intact.  Judgment good.  Insight was good.

Pancreatic Necrosectomy J Tube Placement Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Pancreatic necrosis and abscess.
2.  Shock.

POSTOPERATIVE DIAGNOSIS:
Pancreatic necrosis.

PROCEDURE PERFORMED:
1.  Exploratory laparotomy with pancreatic necrosectomy and debridement.
2.  Jejunostomy tube placement.
3.  Placement of sump drain at the pancreatic bed.

SURGEON:  John Doe, MD

PROCEDURE FINDINGS:
1.  Two liters of cloudy ascitic fluid.
2.  No evidence of bowel ischemia.
3.  No evidence of bowel perforation.
4.  Necrosis of the pancreas secondary to severe pancreatitis.

ESTIMATED BLOOD LOSS:  Approximately 100 mL.

CONDITION:  Critical.

DESCRIPTION OF PROCEDURE:  Informed consent was obtained. The patient was taken to the OR and prepped and draped in sterile fashion. An upper midline incision was made. Upon entering the abdominal cavity, approximately 2 liters of cloudy, yellowish ascitic fluid was immediately aspirated. The liver appeared to have nodular appearance consistent with cirrhosis. We began the procedure by inspecting the entire GI tract. The GE junction was identified. Anterior aspect of the stomach, pylorus and duodenum were all identified. There were no signs of perforations or ulcerations. Ligament of Treitz also identified. The bowel was run distally until the terminal ileum. Again, there were no signs of ischemia. No signs of perforation. The cecum was inspected. The ascending colon, transverse colon, descending colon and rectum were all inspected and there were no signs of perforations or ischemia. We began with the next step and continued with entering into lesser sac. The omentum was dissected off the inferior surface of the transverse colon to gain entrance into the lesser sac. The stomach appeared to be densely adherent to the underlying pancreatic tissue. We were finally able to get through after dissection with the Harmonic scalpel. There was a large cavity with cloudy semisolid tissue consistent with pancreatic necrosis. All these areas were then irrigated with saline solution. All the necrotic semisolid material was removed. The mesocolon was also divided at this location to gain better entrance of this cavity. The ascitic fluid and the pancreatic fluid were all submitted for cultures. The abdominal cavity was irrigated with copious amount of saline solution until clear.  Next, we continued with placing a J-tube. Two pursestring 3-0 silk sutures were placed in the anterior aspect of the distal stomach. Gastrostomy was opened. A 16-French Foley was then brought out through a separate stab incision in the left lower quadrant and placed into the stomach. The balloon was inflated to 10 mL. The stomach was then tacked up to the anterior abdominal wall with multiple circumferentially placed 3-0 silk sutures. Next, an Abramson sump drain was then brought in through a stab incision in the left mid abdominal area. The drain was then placed into the lesser sac aiming towards the head of the pancreas. Additionally, a 10 mm flat JP drain was then placed into the pancreatic cavity and placed distally and brought through a separate stab incision on the patient's right side. Additionally, the proximal jejunum was identified. Again, two 3-0 silk pursestring sutures were then placed in the anterior aspect. Again, a 16-French Foley catheter was then brought in through a separate stab incision, this time in the left mid abdomen and introducing to the lumen. Then, 3 mL of balloon was inflated only. This loop of small bowel was also tied up to the anterior abdominal wall. The fascia was then reapproximated with #1 Vicryl placed in an interrupted fashion. Three #2 nylon suture were used as retention suture to close in a full-thickness fashion. The skin was approximated with skin staples. The patient returned to the intensive care unit, but remained in critical condition.

Esophagogastroscopy With Foreign Body Removal Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Esophageal foreign body.
2.  Hiatal hernia.

POSTOPERATIVE DIAGNOSES:
1.  Esophageal meat impaction.
2.  Hiatal hernia.
3.  Ulcer at stricture.

PROCEDURE PERFORMED:
Esophagogastroscopy with foreign body removal.

ENDOSCOPIST:  John Doe, MD

ANESTHESIA:  Demerol 50 mg IV push in divided doses, Versed 4 mg IV push in divided doses, oxygen by nasal cannula.

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old male who experienced an esophageal meat impaction yesterday.  He is now undergoing therapeutic endoscopy.

INSTRUMENT:   Olympus GIF-160.

DESCRIPTION OF PROCEDURE:  After obtaining informed consent, the patient was turned in the left lateral decubitus position and sedated.  The endoscope was passed through the bite block into the oropharynx and into the esophagus while the patient was encouraged to swallow.  The scope was passed under direct visual guidance.  Upon entering the esophagus, there was thick liquid material.  This was aspirated.  The scope was advanced distally.  The top of the gastric folds were at 31 cm.  The apparent lower esophageal sphincter was 33 cm.  Beyond this was a large hiatal hernia.  At the distal aspect of the hernia was an esophageal meat impaction.  Adjacent to this impaction was a deep and broad ulceration.  There was no active bleeding but blood was present on the meat impaction.  The meat impaction was firmly in place and initially did not pass with pressure from the scope.  The plan was to grasp it with a 5-pronged foreign body removal instrument, but this was not available.  While looking for the Roth retrieval net, the foreign body passed spontaneously into the stomach.  As noted above, there was a deep and broad ulceration at the site where the foreign body was impacted.  This was approximately 18 mm x 15 mm.  There was no active hemorrhage.  The remainder of the hiatal hernia was unremarkable.  The scope was passed into the stomach.  The gastric mucosa was carefully evaluated with straight on and retroflex viewing.  No additional abnormalities were identified.  The scope was withdrawn after washing the remaining material from the esophagus into the stomach and aspirating the residue.  The patient tolerated the procedure well.

COMPLICATIONS:  None.

SPECIMENS:  None.

RECOMMENDATIONS:
1.  Start Protonix 40 mg b.i.d.
2.  Carafate suspension 1 g p.o. q.i.d.
3.  Clear liquid diet.
4.  Monitor overnight.
5.  Repeat upper endoscopy in 1 month.

Colonoscopy Sample Report       Colonoscopy and ERBE Argon Laser Cautery Sample

Colonoscopy and EGD Sample Reports

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Proximal Row Carpectomy Radial Styloidectomy Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Scapholunate advanced collapse degenerative arthritis, right wrist.

POSTOPERATIVE DIAGNOSIS:
Scapholunate advanced collapse degenerative arthritis, right wrist.

OPERATION PERFORMED:
1.  Right wrist proximal row carpectomy.
2.  Right radial styloidectomy.
3.  Right posterior interosseous neurectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  Axillary block.

COMPLICATIONS:  None.

OPERATIVE FINDINGS:  The patient presented with scapholunate advanced collapse degenerative arthritis of the right wrist with marked degenerative changes at the radioscaphoid joint and scapholunate dissociation. Exploration revealed that the articular surface of the lunate fossa at the distal radius and capitate head was well preserved. The scapholunate interosseous ligament was disrupted with scapholunate diastasis and rotatory subluxation of the scaphoid.

DESCRIPTION OF PROCEDURE:  Prophylactic IV antibiotic was given. Axillary block anesthetic was administered by the anesthesiologist. The right upper extremity was prepped and draped sterilely. A tourniquet was inflated on the upper arm following exsanguination of the limb.  A longitudinal incision was made over the dorsal aspect of the right wrist centered at the radiocarpal joint. The subcutaneous tissue was dissected.  Superficial veins were ligated with bipolar cautery. Skin flaps were elevated off of the extensor retinaculum.  The extensor pollicis longus tendon was retracted safely in the interval between the second and fourth, and fourth and fifth extensor compartments were developed. A T-shaped capsulotomy was made in the dorsal capsule to expose the radiocarpal and midcarpal joints. The articular surfaces were inspected. Reconstruction with proximal row carpectomy was felt to be appropriate.

The scaphoid bone was exposed by elevating the capsule sharply and scaphoid was excised in piecemeal fashion. Care was taken to preserve the important radiocarpal and extensor ligaments, which were preserved. The lunate and triquetrum bones were also exposed by elevating the capsular flaps and both bones were also excised in piecemeal fashion. The bone fragments were collected and sent to pathology as specimen.  The capitate was allowed to assume its position at the lunate fossa of the distal radius. Wrist motion was checked and the flexion and extension arc was found to be satisfactory, approximately equal to the patient's preoperative motion. Radial deviation of the wrist was limited due to the prominent radial styloid. Therefore, radial styloidectomy was needed. The styloid was exposed by elevating the capsule and the prominent portion of the styloid was excised using an osteotome. Care was taken to preserve the extrinsic ligament attachment, which was preserved. FluoroScan views were obtained to confirm adequate resection of the radial styloid. The position of capitate head at the distal radius was confirmed.  Next, the terminal branch of the posterior interosseous nerve was dissected. The nerve was transected for partial denervation of the wrist.

The field was irrigated thoroughly with antibiotic solution. The capsular flaps were reapproximated and sutured with 3-0 Vicryl sutures. Skin edges were reapproximated with nylon sutures. A sterile bulky gauze dressing was applied followed by forearm-based plaster splint to maintain the wrist in neutral alignment. The tourniquet was deflated. Circulation returned to the right hand with normal capillary refill in all digits. The patient was transferred to the recovery room in stable condition. The patient tolerated the procedure well. There were no complications.

ORIF of Phalanx Intra-Articular Fracture Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Comminuted intra-articular fracture dislocation, right middle finger proximal phalanx.

POSTOPERATIVE DIAGNOSIS:
Comminuted intra-articular fracture dislocation, right middle finger proximal phalanx.

OPERATION PERFORMED:
Open reduction internal fixation of intra-articular fracture dislocation, right middle proximal phalanx.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

COMPLICATIONS:  None.

OPERATIVE FINDINGS:  The patient sustained a comminuted intra-articular fracture of the base of the right middle finger proximal phalanx with dislocation of the metacarpophalangeal joint.  Exploration revealed extensive comminution of the articular surface with 4 main articular fragments.  The largest fragment involved the dorsal ulnar aspect of the joint, which was dislocated dorsal ulnarly.  The articular surface of the metacarpal head was intact.  The fracture was displaced, comminuted and unstable.

DESCRIPTION OF PROCEDURE:  Prophylactic IV antibiotic was given and the patient was taken to the operating room.  An axillary block anesthetic was administered by the anesthesiologist and the right posterior limb was prepped and draped sterilely.  A tourniquet was inflated at the upper arm following exsanguination of the limb.  The right middle finger was viewed under fluoroscopy.  Closed reduction could not be achieved.  Therefore, open reduction was needed.  A dorsal longitudinal incision was made over the right middle finger from the proximal phalanx across the metacarpophalangeal joint.  Subcutaneous tissue was dissected.  Superficial veins were ligated with bipolar cautery.  The extensor mechanism was visualized.  The capsule was disrupted with dislocation of the base of the proximal phalanx dorsal ulnarly.

The central slip of the extensor mechanism was incised longitudinally in the midline to permit exposure of the fracture site.  The fracture fragments were debrided of hematoma and irrigated with antibiotic solution.  The major articular fragments were retained.  One fragment involving the dorsal central portion of the articular surface was a loose fragment devoid of any soft tissue attachment and impacted into the metaphyseal region.  Another fragment involved the palmar ulnar aspect of the articular surface, attached to a remnant of the collateral ligament.  The fracture was reduced provisionally, including the comminuted articular fragments.  The alignment was checked radiographically using fluoroscopy.  Fixation was then carried out using stainless steel 1.5 mm and 1.3 mm screws.  The screws were first inserted transversely at the base of the proximal phalanx to stabilize the articular fragments.  Additional screws were used in the metaphyseal and diaphyseal region to stabilize the 2 main fracture fragments in that region.

The fracture was viewed under fluoroscopy and the alignment of the articular surface appeared satisfactory.  There was no significant articular step-off.  The fracture was stable with range of motion and rotation of the finger was normal and symmetric.  The palmar ulnar fragment of articular surface was too small to permit correct fixation.  This was stabilized as the dorsal capsule was repaired using multiple Vicryl sutures.

The field was irrigated with antibiotic solution.  Repeat fluoroscopy views were obtained, which showed stable fracture alignment and satisfactory fixation.  The extensor mechanism was repaired using running 4-0 Supramid suture and the skin edges were reapproximated with 5-0 nylon sutures.  Sterile bulky gauze dressing was applied followed by a forearm-based plaster splint for protection of the fracture.  The tourniquet was deflated.  Circulation returned to the right hand with normal capillary refill in all digits.  The patient was transferred to the recovery room in stable condition.  The patient tolerated the procedure well with no complications.

Normal Review of Systems Transcription Samples

REVIEW OF SYSTEMS:  No weight changes, no headaches, no dizziness, no fainting, no trouble with hearing or vision, no trouble with swallowing. No cough, no chest pain, no trouble with exertion, shortness of breath, no heartburn. No abdominal pain. Normal bowel movements, no bloody bowel movement. No trouble with urination. No joint pain. No lumps or growths. No sweats or fevers.

REVIEW OF SYSTEMS:  Cardiac:  No chest pain or palpitations. Pulmonary:  No shortness of breath, orthopnea or wheezing. Gastrointestinal:  No constipation, diarrhea, nausea, vomiting. Genitourinary:  No dysuria or discharge. The patient has had no history of clotting disorders. She has no family history of any clotting disorders. She has good exercise capacity.

REVIEW OF SYSTEMS:  Significant for intermittent headaches, not well defined or characterized by the patient. She does not report associated symptoms such as photophobia, phonophobia, osmophobia, nausea, vomiting or visual disturbance. She has memory loss. She has trouble walking due to the severe osteoarthritis in her knees. She has history of depression.

REVIEW OF SYSTEMS:  The patient denies any recent weight loss, decreased appetite, or fatigue. The patient does report significant low back pain, which requires her to ambulate with the use of a cane secondary to her spinal stenosis. She otherwise has no chest pain, dizziness, lightheadedness, nausea, vomiting or abdominal pain. The remainder of the review of systems is otherwise unremarkable.

REVIEW OF SYSTEMS:  No alopecia, sicca or Raynaud's, pleuropericarditis, kidney disease. No eye problems, ear problems, sinus problems, neuropathy, seizure, psychosis, bleeding, bruising, diabetes, abdominal pain, hematemesis or bright blood per rectum.

REVIEW OF SYSTEMS:  No blood clots, pregnancy loss, no hair loss, no Raynaud's, no photosensitivity, no discoid lesions, no pleuropericarditis or nephritis. No seizures, psychosis, depression, wheezing, chest pain, diabetes, thyroid disease, bleeding, bruising, or weight loss. Overall, she said she feels well.

REVIEW OF SYSTEMS:  No changes in his hearing or vision. No cough or shortness of breath. No rashes, abdominal pain, nausea, bowel pain, bright red blood per rectum, hematemesis. No urinary frequency, dysuria, no acute joint issues, no headache, numbness or tingling.

REVIEW OF SYSTEMS:  No chest pain, palpitations, no shortness of breath, no hemoptysis, no cough, no vomiting, no diarrhea, no GI distress, no urinary discomfort, no dysuria, no polyuria, no hematuria, no neurological complaints, no headache, no confusion, no focal neuro symptoms.  No recent weight loss.  She does report that she has had decreased p.o. intake secondary to decreased appetite over the past couple of weeks.  There has been no weight change, no rashes or bruising.

REVIEW OF SYSTEMS:  Significant for multiple symptoms including weight gain/loss, loss of energy, sleep disturbance, loss of interest, heat/cold intolerance, change in hair/nails, headache, abdominal pain, change in bowel/bladder habits, nausea/vomiting, personality change, visual change, hearing loss and dizziness. All other systems are negative.

REVIEW OF SYSTEMS:  Weight loss secondary to exercise and diet. Occasional symptoms of dizziness, feelings of near fainting, no symptoms recently, complained of this previously after a vigorous workout. No loss of consciousness. She wears glasses. She is due to see the dentist. Symptoms of heartburn, indigestion, epigastric discomfort as discussed above. Bowel movements are normal. No blood on stool, toilet tissue or in toilet bowl. No black stool. No urinary problems. No vaginal complaints. Ongoing low back discomfort, notices improvement with working out and stretching. Joints are occasionally stiff and crack. Concerned regarding blemish near her right axilla. Complains of fatigue. Also symptoms of depression. No suicidal or homicidal ideations. Decreased libido. No concerns with menses. All other systems reviewed today and are unremarkable.

REVIEW OF SYSTEMS:  HEENT:  She does have astigmatism.  Cardiovascular:  No anterior neck, chest or arm discomfort.  Her last dobutamine echo was 2 years ago.  Respiratory:  She has shortness of breath when she walks from the bed to the bathroom at night sometimes and occasionally while climbing stairs.  Gastrointestinal:  No change in her bowel habits, blood in her stools, abdominal pain, nausea, vomiting or diarrhea.   Genitourinary:  She has no blood in urine.  She has no history of kidney failure or kidney stones.  Musculoskeletal:  She has some arthritis, which she has had for years, no long bone pain or back pain.  Neurologic:  She had TIAs 2 years ago, she states no TIAs since.  Se has had no stroke.  She had no evidence of syncope or seizure disorder.  Endocrine:  No diabetes or thyroid disease.  Hematology:  No history of anemia or bleeding disorder.

REVIEW OF SYSTEMS:  She is obese and has gained 9 pounds. She is also tired. HEENT:  Eye checkup as she needs glasses. Has decreased hearing. Has occasional headaches. No dizzy or fainting spells. Lungs:  No cough or wheeze. Heart:  See above. Gastrointestinal:  No indigestion or dysphagia, regular bowel movements. Genitourinary:  Nocturia. Increased urination. Bones plus joints:  See above concerning neck and thigh. Allergies:  Penicillin produced vomiting and rash, but she is able to tolerate amoxicillin. Neurologic/Psychiatric:  See above. Gynecologic:  She is going to make an appointment to see Dr. Doe.

REVIEW OF SYSTEMS:  Neurologic:  The patient denies any history of seizures, headaches, muscle weakness or numbness. Respiratory:  He denies any symptoms of asthma, chronic obstructive pulmonary disease or chronic cough. Cardiac:  No symptoms of chest pain, shortness of breath or edema. Abdomen:  He denies any nausea, vomiting, diarrhea, constipation or bleeding per rectum. Urinary:  He denies any burning on urination and no blood in the urine. Musculoskeletal:  He previously had symptoms of left foot pain that has resolved. He has no pain in his back, hips or knees.

REVIEW OF SYSTEMS:  He had an episode of apparent tachycardia.  His heart rate got up to 170 when he went to the emergency room where he was evaluated.  He eventually had a normal Holter and echocardiogram.  He has no history of diabetes, cancer, hypertension, anemia or blood disorder, kidney or bladder disease, liver disease or hepatitis, orthopedic problems, glaucoma or cataracts, thyroid disease, arthritis, migraines, seizures or depression.

REVIEW OF SYSTEMS:  On comprehensive review of systems, he denies any fevers, chills, fatigue, loss of appetite, blurred vision, double vision, chest pain, palpitations, heart attacks or any shortness of breath. Psychologically, he is generally happy. He has never had any severe depression, never considered suicide, never had anxiety and does not have any difficulty sleeping. He has no GI related system issues. He does not have a current PSA to evaluate. His urine dip today showed trace blood.

REVIEW OF SYSTEMS:  The patient describes 3/10 pain that can be sharp, aching and tender, most pronounced when she has to urinate. In general, her symptoms are alleviated with urination. On comprehensive review of systems, she has had fatigue, sore throat, sinus trouble, shortness of breath, anxiety, difficulty sleeping and rash. She has had heartburn, diarrhea, constipation, neck pain, back pain, hematuria, painful urination, frequent urination, difficulty with urination and urinary infections. Urine dip today showed glucose negative, ketones trace, pH 5.6, blood moderate, nitrites negative, leukocytes negative and protein negative. On postvoid residual bladder scan, a urine volume of 90 mL was identified.

REVIEW OF SYSTEMS:  The patient denies any current pain. On comprehensive review of systems, she has had fatigue, loss of appetite, sore throat, sinus trouble, leg pain, shortness of breath, wheezing, anemia, easy bruisability, depression, difficulty sleeping, heartburn, nausea, vomiting, diarrhea, constipation, neck pain, joint pain, back pain and most notable frequent urination. In GU related systems, she does describe some frequency of urination. She gets up 4 times per night to urinate. She will drink 3 coffees in the morning. Occasionally, she does leak with coughing, sneezing and exercise.

REVIEW OF SYSTEMS:  No nasal congestion. No history of jaw trauma. No history of hypothyroidism. Weight as above. He does complain of some memory and attention-concentration problems. History of depression. No anxiety disorder. Cardiovascular review of systems is notable for hypertension only. No history of coronary disease. No history of stroke. Respiratory review of systems is notable for mild exertional dyspnea, but no cough, wheezing, sputum production or hemoptysis. No history of chronic lung disease. No history of recurrent chest infections. Neurologic review of system is negative for history of any cerebrovascular disease. Endocrine review of system is negative as above other than dyslipidemia and diabetes mellitus. He does complain of joint pains.

Physical Exam Template Format Medical Transcription Examples

PHYSICAL EXAMINATION:  On admission to the ED today, his temperature was 98.4, blood pressure was 116/76, pulse was 120, respiratory rate was 18, O2 saturation was 98% on room air. The patient is a (XX)-year-old well-developed, well-nourished male. He is clearly uncomfortable but in no acute cardiopulmonary distress. He is awake, alert and oriented x3. He is pleasant and cooperative with the exam. He has been drinking a little bit of wine this night though he is not clinically intoxicated. His head is normocephalic and atraumatic. Pupils are equal, round and reactive to light and accommodation. Extraocular muscles are intact. The patient has some minimal photophobia to the right eye but no consensual photophobia. Initially, checked the visual acuity and it was 20/25 in the left eye and 20/100 in the affected right eye. However, at this point, the patient had a lot of tearing to the eye and was unable to really open the eye very well. Here in the ED, his globe is intact. Tetracaine was used to numb the eye with good anesthetic effect obtained and the patient was able to open the eye and feels much better following this. Following tetracaine administration, his visual acuity was 20/50 in the right eye and 20/20 in the left eye. With fluorescein staining, the patient was noted to have a 3 to 4 mm corneal abrasion to the center of his vision running along the vertical axis. On slit-lamp examination, however, the globe is intact. There is no cell or flare and no other abnormalities other than this corneal abrasion. There is no evidence for retained foreign body and his upper and lower lids were everted and swabbed with a cotton swab. The rest of his exam is unremarkable.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 97.8, pulse 66, respirations 21, BP 130/78, pulse oximetry 98% on room air.
GENERAL:  The patient is a well-developed, well-nourished, nontoxic, ambulatory (XX)-year-old male. The patient is alert and oriented x3. His Glasgow coma scale is 15.
HEENT:  Normocephalic, atraumatic facies. Ears, eyes, nose, throat all within normal limits. Mucous membranes are moist and pink. Sclerae are nonicteric. Pupils are equal, round, reactive to light and accommodation. Funduscopic examination reveals no evidence of obvious floaters. Cup-to-disk ratio appears to be grossly normal and there is no evidence of AV nicking or other exudate. The patient exhibits equal ocular movements as well. Visual fields were tested which revealed no evidence of deficit.
NECK:  Supple, nontender. No meningismus. Trachea midline.
LYMPHATICS:  The patient exhibits no lymphadenopathy.
CHEST:  Reveals equal bilateral breath sounds. Clear to auscultation with normal chest wall excursion.
CARDIOVASCULAR:  Regular rate and rhythm without murmur, rub or gallop.
ABDOMEN:  Benign.
EXTREMITIES:  Examination reveals full range of motion of all extremities without deficit. The patient exhibits strong distal pulses, brisk capillary refill.
NEUROLOGIC:  Reveals no gross motor or sensory deficits. The patient is alert and cooperative. Cranial nerves II through XII are grossly intact. Cerebellar function intact as well. Motor strength 5/5 in all extremities. Deep tendon reflexes 2+ and equal in all extremities and he exhibits intact distal sensation in all extremities as well.
SKIN:  No rash or lesions. Skin is warm and dry to touch with normal tone and turgor.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 170/86, heart rate 96, respirations 18, temperature 98.4 and O2 sat is 100%.
GENERAL:  The patient is in no acute distress.
HEENT:  Normocephalic and atraumatic. Oropharynx is pink. Mucous membranes are moist. TMs are clear. Ocular exam:  Lids, lashes and nasolacrimal ducts are normal. There is no conjunctival injection. There are no corneal epithelial defects. The cornea is not cloudy; it is very opaque. There is no evidence of any cell or flare in the anterior chamber. Funduscopic exam is limited by the fact that she is not dilated. I do not appreciate disk margins well. Extraocular motion is full. The pupil is 4 mm, reactive to 2 mm. There is no APD. Visual acuity in the affected eye is at this point 20/200. She is able to read the E on the eye chart. The left is 20/30. These are both with correction.
NECK:  No stridor, no JVD, no bruit, no thyromegaly and no nuchal rigidity.
CHEST:  Clear to auscultation and percussion.
HEART:  Regular rate and rhythm.
ABDOMEN:  Bowel sounds are positive. Nontender and nondistended. No hepatosplenomegaly.
MUSCULOSKELETAL:  Joints have full range of motion. There is no clubbing, cyanosis or edema.
LYMPHATIC:  No axillary or cervical lymphadenopathy.
SKIN:  No petechial or purpuric rashes.
PSYCHIATRIC:  The patient is alert and oriented.
NEUROLOGIC:  Strength is 5/5.

PHYSICAL EXAMINATION:  On physical examination, the patient has exquisite pain with internal rotation of the right hip in about 5 degrees of internal rotation. External rotation is about 20 degrees and has pronounced pain greater than with anterior impingement.  The patient has a positive posterior impingement sign.  Left hip, the patient has about 5 degrees of internal rotation and 25 to 30 degrees of external rotation, but this is not painful.  The patient has 5/5 iliopsoas, quad and hamstring strength.  The patient has 5/5 EHL, TA, gastrocsoleus and peroneal strength bilaterally. The patient has 2+ pulses.  Bilateral sensation is intact to light touch of both lower extremities.  On her right side, she has about 15 cm distance between the table and her knee during a fabere/Patrick test, which is positive as well and this is significantly different than the left side where she can get down to about 5 inches.  The patient has no pain with log roll with either side, and when she lies flat with her leg externally rotated, she does note an ache in the posterior part of her buttocks, which may or may not correlate with this posterior impingement sign.

PHYSICAL EXAMINATION:  VITAL SIGNS:  Per nursing record with the exception of blood pressure of 142/86 and a pulse of 102.  GENERAL:  The patient appears well hydrated and well nourished. Alert and oriented x4, cooperative and in no apparent distress.  HEENT:  The patient's extraocular movements are intact. Pupils are equal, round and reactive to light and accommodation, 3-2 mm bilaterally. The patient's nasopharynx shows no visible deformity. There is some dried blood in the right naris and a small amount of tacky blood in the left naris. There is no visible septal hematoma. There is no tenderness to palpation of the nose. The patient's oronasopharynx shows pink moist mucosa. It is not erythematous, no exudate appreciated. There is no blood seen in the posterior oropharynx. NECK:  Supple. There is no posterior midline tenderness. There is no JVD or carotid bruits appreciated. HEART:  Regular rate and rhythm present, S1 and S2 present without any extra sounds or murmurs appreciated. LUNGS:  All fields are clear to auscultation bilaterally with good air movement in all fields bilaterally. There is resonance to percussion in all fields. THORAX:  There is no midline or costovertebral angle tenderness. There is no axillary lymphadenopathy present. ABDOMEN:  Soft and nondistended with positive bowel sounds in all 4 quadrants. The abdomen is nontender without guarding, rebound or organomegaly present. EXTREMITIES:  There is 5+ strength, intact distal pulses and sensation intact to light touch in all 4 limbs. NEUROLOGIC:  Cranial nerves II through XII are intact bilaterally. The patient responds appropriately to questioning with normal thought content and process. There are no focal neurologic deficits. The patient is able to walk with a normal gait. PSYCHIATRIC:  Normal mood and affect.

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