History and Physical Medical Transcription Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

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

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

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

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

ALLERGIES:  No known drug allergies.

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

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

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

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

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

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

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

Lumpectomy Sentinel Lymph Node Biopsy Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left breast cancer.

POSTOPERATIVE DIAGNOSIS:  Left breast cancer.

PROCEDURES PERFORMED:
1.  Left needle localized lumpectomy.
2.  Sentinel lymph node biopsy with intraoperative frozen section.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

COMPLICATIONS:  None apparent.

DRAINS:  None.

ESTIMATED BLOOD LOSS:  Minimal.

SPECIMENS:
1.  Sentinel lymph node biopsy, 2 nodes sent.
2.  Left needle localized lumpectomy.
3.  Additional margins including anterior superior as a single and then separate medial, lateral, inferior and posterior.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old woman who presents with a nonpalpable biopsy-proven left breast cancer. After discussion, she elected to proceed with breast conservation with the needle localized lumpectomy and sentinel lymph node biopsy.

DESCRIPTION OF PROCEDURE:  After informed consent was obtained, the patient was taken to the operating room and placed on the operating table in the supine position. Anesthesia was induced. The patient was intubated. The area involving the left breast and axilla were prepped with Betadine and draped sterilely. The localization films were viewed. Methylene blue was injected in the circumareolar position and was allowed to migrate to the axilla. A radiation detector was used to detect the hot spot in the left axilla. An incision was created along the anterior border of the left axilla and an obviously blue and radiative lymph node was identified with an adjacent node being mildly radiative. These 2 nodes were excised. Interrogation with radiation within the axilla showed no other hot spots, and no other blue nodes were detected. The nodes were forwarded to pathology where frozen section showed no evidence of metastatic disease. The wound was inspected for hemostasis, which was excellent. It was closed with interrupted 3-0 Vicryl and running 4-0 Monocryl. An incision was created over the inferior left breast excising the entrant site of the needle, which was located in the inframammary position and extending superiorly over the inferior portion of the breast in the 6 o'clock position. Incision was deepened with electrocautery. The underlying cord tissue surrounding the localization needle was excised. It was forwarded to radiology where specimen radiographs confirmed the presence of the mammographic abnormality and the previously placed clip within the specimen. It was from there forwarded to pathology. Additional margins were taken, marked separately, posterior, medial, lateral, inferior and a combined anterior superior. These were all forwarded, labeled separately, in formalin, to pathology for later analysis. The wound was inspected for hemostasis, which was excellent. It is noted that the deep margin was chest wall as the lesion was quite deep. The wound was closed with interrupted 3-0 Vicryl and running 4-0 Monocryl subcuticular stitch. Benzoin, Steri-Strips and sterile dressings were applied. The patient was awakened and returned to recovery in stable condition having tolerated the procedure well.

Esophageal Manometry and 48 Hour Bravo pH Study Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PROCEDURE PERFORMED:  Esophageal manometric study and a 48 hour Bravo pH study. 

INDICATIONS FOR PROCEDURE:  The patient has poorly controlled esophageal heartburn-type symptomatology and studies are being done to try and determine how much acid the patient gets. The patient ran out of Prilosec, omeprazole about 4 days prior to coming in for placement of the Bravo capsule so the initial part of the evaluation was done off of medication. 

PROCEDURE FINDINGS:  Motility was performed first with no sedation. The lower esophageal sphincter area was in the 42 to 50 cm range and was a fairly quick high pressure zone. The lower esophageal sphincter appeared to relax close to 100% and was in the range of 10 to 14 mmHg. This was seen well on 2 of 3 electrodes. The peristalsis in the body and upper esophagus were evaluated also. Interestingly, on the studies where the lower esophageal sphincter was looked at, the peristalsis did appear to be normal in amplitude and in waveform. This would be the most distal part of the esophagus and was well seen on 2 of the 3 tracings. It did appear to be peristaltic; although, there were occasional simultaneous waves and occasionally some low amplitude contractions too. In the body of the esophagus, one peristalsis was studied directly. There are some peristaltic waves, which are normal amplitude, being about 50 to 60 mmHg and peristaltic. However, most of the waves seem to be fairly low amplitude in the range of about 15 mmHg, but again generally peristaltic. Some of these occurred with dry swallows and some of them were low amplitude with wet swallows, but the patient clearly does have the ability to generate some waves, which are adequate and deepen in the range of 150 mmHg with some normal waveforms with wet swallows. We suspect that in general the peristalsis is probably okay. Reviewing the tracings in the body, the patient does not really get up to 150 mmHg, but there are some tracings where the patient does get up close to 100. For the most part, however, the amplitude is fairly low. 

The Bravo capsule study was done with the patient partly on 20 mg b.i.d. of the omeprazole; although, the patient started this after the Bravo was placed and was certainly off it in the beginning. 

On day 1, the patient’s DeMeester score was 62 with a normal of less than 14.7. There were multiple episodes of reflux, 115 in fact, and the longest duration was 21 minutes. This occluded some significant areas, time frames when his pH was less than 4 at nighttime. There were episodes of heartburn recorded and these in general correlated pretty well with the pH less than 4; although, there were occasional times when the pH was above 4 and he still complained of heartburn. 

On day 2, the DeMeester score was 56 so really not that of an improvement. He had 115 episodes of reflux with the longest duration being 7 minutes at that point. Again, there was fairly good correlation with heartburn and decreased pH below 4 and he had regurgitation, which generally tended to correlate fairly well too with the pH less than 4. 

The patient clearly has significant reflux off medications and whether it improves much on medications is unclear from the study. Motility study does not reveal any gross abnormalities. There is some decreased peristaltic intensity in the mid part of the esophagus, but the patient is able to generate fairly good peristaltic waves and lower esophageal sphincter seems to work normally, so it does appear as though in general, the patient’s esophagus probably works okay.

Right Frontotemporoparietal Craniotomy Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Right temporal lobe epilepsy.

POSTOPERATIVE DIAGNOSIS:
Right temporal lobe epilepsy.

PROCEDURE PERFORMED:
Right frontotemporoparietal craniotomy for electrocorticography, anterior temporal lobectomy and hippocampectomy for seizures.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal.

COMPLICATIONS:  None.

INDICATIONS FOR SURGERY:  The patient is a (XX)-year-old woman who has a 3-year history of medically refractory complex partial seizures. The EEG study showed active epileptiform activity including interictal and ictal abnormality arising from the right temporal lobe. Neuropsychological study demonstrated a right temporal lobe dysfunction. The high resolution MRI scan showed that the right side incus and anterior hippocampus was larger than the left one. The patient elected then to proceed with surgical treatment and was informed of the possible risks of surgery preoperatively.

DESCRIPTION OF OPERATION AND FINDINGS:  The patient was intubated for general anesthesia and was placed in the supine position with the head affixed in the 3-pin headrest and turned toward the left. The right side of the head was prepared and draped routinely. Prophylactic antibiotics were given intravenously. A question mark incision was made over the right anterior frontotemporoparietal region. The subcutaneous layer and temporal fascia muscles were divided. An 8 cm size craniotomy was created to expose the right middle cranial fossa as well as inferior frontoparietal region. The above procedure was carried out with the Midas Rex drill. The dura was opened and there was no gross abnormality of the right frontotemporoparietal region.

Intraoperative EEG recording was carried out with a 32 contact subdural electrode grid, which was placed over the right lateral temporal cortex and 4 contact subdural electrode strips inserted through the medial temporal region at 3, 5 and 5.5 cm from the anterior tip. The EEG indicated that active interictal epileptiform discharge was at the anterior part of hippocampus and gradually diminished to 5.5 cm from the tip with 4 contact electrode recording. There was also anterolateral temporal cortex involved at the first 2 cm of the right temporal lobe. The above recording was carried out when the patient’s anesthetic agent was discontinued. The microscope was used for microdissection. The cortical incision line was about 3.5 cm from the right anterior temporal region and through the subcortical region, and peer vessels were cauterized and divided. The superior temporal gyrus was incised at the anterior part, dissection of the subcortical structure with 45 degrees to avoid the cerebral artery trunk and branches. The lateral temporal cortex over the anterior region was resected first. There was marked gerontic change and increased induration of the anterior temporal horn, which extends through the amygdala.

Microdissection was carried out within the pial membrane at the anteromesial temporal tip. Dissection was carried down to the anterior parahippocampal gyrus followed by dissection of the incus until the post inferior choroidal point was exposed. The posterior parietal temporal horn was also opened and about 2.5 cm of hippocampus was harvested. The dissection was carried out within the pia membrane and reflected in the distal hippocampus along with the anterior hippocampus, which was reflected superior and forward, the entire mesiotemporal lobe including a normal brain parenchyma, which was harvested in one block, which included a midline and anterior hippocampus as well.

Hemostasis was accomplished and subdural space was examined, which showed no blood or fluid accumulation. The dura was closed in a watertight fashion. The dural tenting sutures were applied and bone plate was placed and secured with titanium plate and screws. A subgaleal drain was inserted. The temporal fascia and muscles were approximated and the skin flap was closed in two layers. The patient tolerated the procedure well without complications. Blood loss was limited.

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Percutaneous PFO Closure Coronary Angiography Sample

DATE OF PROCEDURE:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

PROCEDURES PERFORMED:
1.  Percutaneous PFO closure.
2.  Coronary angiography.

OPERATOR:  Jane Doe, MD

INDICATIONS FOR PROCEDURE:  Cryptogenic stroke with PFO and PFO with atrial septal aneurysm with right to left shunting and positive bubble study.

DESCRIPTION OF PROCEDURE:  After informed consent was obtained, the patient was sterilely prepped and draped in the usual fashion. Access was obtained to the right femoral artery with a Cook needle insertion of a 7 French introducer sheath via the modified Seldinger technique. No complications. Access obtained to the right femoral vein with a Cook needle insertion of an 8 French introducer sheath via modified Seldinger technique. No complications. Access obtained to the left femoral vein with a Cook needle insertion of an 8 French introducer sheath via modified Seldinger technique. No complications. Lidocaine 2% used for local anesthesia. Selective coronary angiography was performed, 6 French diagnostic JL 3.5 and JR4 catheters were used to engage the left and right coronary arteries respectively. Multiple views were obtained with contrast injection. Following diagnostic procedure, these catheters were removed. An intracardiac echo probe, 8 French, was then advanced via the left femoral venous sheath up to inferior vena cava under fluoroscopic guidance to the right atrium and used to interrogate the intra-atrial septum. Following this, bubble study was performed that showed significant right-to-left shunting with Valsalva. The patient then underwent successful closure of the patent foramen ovale under both fluoroscopic as well as intracardiac echo guidance.

PROCEDURE FINDINGS:
1.  Coronary angiography.
a.  Right main coronary artery:  The right coronary artery is a moderate caliber dominant vessel. No significant stenosis is seen.
b.  Left main coronary artery:  The left main coronary artery is a large caliber moderate length vessel.
c.  Left anterior descending artery:  The left anterior descending artery is a large caliber vessel with several diagonal branches noted. No disease.
d.  Circumflex coronary artery:  The circumflex coronary artery is a moderate caliber nondominant vessel. No disease.

Intracardiac echo examination of the interatrial septum:  Intracardiac echo examination of the interatrial septum reveals a patent foramen ovale. There is also significant atrial septal aneurysm present with significant bulging of the atrial septum. There is significant right-to-left shunting by bubble study with Valsalva.

Percutaneous closure of the patent foramen ovale:  A 5 French multipurpose catheter was advanced via the right femoral venous sheath up to the inferior vena cava into the right heart under fluoroscopic guidance. The catheter was then used to cross the patent foramen ovale into the left atrium. The catheter was then positioned in the left upper pulmonary vein. A 1.5 mm J-tipped Amplatzer exchange length wire was then advanced into the left upper pulmonary vein. The multipurpose catheter was removed. A PFO assessment balloon was then advanced through the patent foramen ovale and inflated with interrogation of the PFO. Following this, the balloon was removed and percutaneous closure of the PFO was performed.

Patent foramen ovale with septal aneurysm:  Balloon assessment revealed a 12 mm waist, no significant tunneling present. Given the atrial septal aneurysm, which is significant, as well as the fairly large waist and potential diameter of the PFO, it was felt that a 33 mm CardioSEAL device would be appropriate. The assessment balloon was removed and PFO closure was performed.

Percutaneous closure of the patent foramen ovale:  Once the PFO assessment balloon was removed, an 11 mm CardioSEAL delivery sheath system with dilator was advanced over the Amplatzer exchange length wire into the left atrium. The dilator and wire were both removed. A 33 mm CardioSEAL VSD device was then deployed across the intra-atrial septum under both fluoroscopic as well as intracardiac echo guidance. Excellent positioning, which covered the septal aneurysm as well as appeared to be in excellent position, the device was released without complications. Bubble study subsequently revealed no significant right-to-left shunting with Valsalva. Excellent results. No complications.

PROCEDURE SUMMARY:
1.  Normal coronary arteries in this right dominant system.
2.  Patent foramen ovale with significant atrial septal aneurysm present.
3.  Markedly positive right-to-left shunting by bubble study with Valsalva.
4.  Successful PFO closure with a 33 mm CardioSEAL VSD device deployed across the intra-atrial septum under both fluoroscopic as well as intracardiac echo guidance with confirmation of position and essentially complete coverage of the septal aneurysm without complications.
5.  Repeat bubble study at the conclusion of the procedure showed no significant right-to-left shunting.

We will discontinue Coumadin and discharge the patient on aspirin 81 mg as well as Plavix 75 mg a day.

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TAH Bilateral Salpingo-Oophorectomy Operative Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Stage IV endometriosis.
2.  Pelvic adhesive disease.

POSTOPERATIVE DIAGNOSES:
1.  Stage IV endometriosis.
2.  Pelvic adhesive disease.

PROCEDURES PERFORMED:
1.  Total abdominal hysterectomy.
2.  Bilateral salpingo-oophorectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General with endotracheal tube intubation.

ESTIMATED BLOOD LOSS:  Less than 100 mL.

COMPLICATIONS:  Slight blood-tinged urine; however, no obvious bladder injury.

SPECIMENS:
1.  Uterine cervix and fundus.
2.  Bilateral adnexa.

DRAINS:  Foley with slight blood-tinged urine.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room and under adequate general anesthesia a Foley catheter was placed. The patient was prepped and draped in the supine position for an abdominal procedure. A low transverse skin incision was made with the knife approximately one fingerbreadth above the pubic symphysis and taken sharply through the subcutaneous tissue to the level of the fascia, which was nicked in the midline. A fascial incision was extended laterally with the Mayo scissors. The underlying rectus muscles were bluntly and sharply dissected free. They were separated in the midline. The underlying parietal peritoneum was entered bluntly. The peritoneal incision was extended superiorly and inferiorly with the Metzenbaum scissors. A self-retaining O'Connor-O'Sullivan retractor was placed. A bladder blade was placed. The bowel and omentum were packed cephalad with moistened laparotomy sponges and held by an additional retractor. The fundus of the uterus was grasped with a Lahey clamp. There was a considerable amount of hemosiderin deposits in the anterior and posterior cul-de-sac consistent with endometriosis. Both ovaries were adherent to the posterior aspect of the uterus; however, they could be easily freed up. The patient had received 3 months of Lupron prior to surgery, and there was evidence that the medication had improved the situation in her pelvis. The sigmoid colon was easily mobilized off the patient's posterior aspect of the uterus. The right round ligament was doubly clamped with Kellys and transected. The retroperitoneal space was dissected; however, the tissues were very, very thick and it was difficult to see through them. Instead, the ureter was palpated and found to be deep in the pelvis and away from our dissection site. The round ligament was suture ligated with 0 Vicryl suture. A defect was made in the broad ligament through which a Heaney clamp could be passed to encompass the infundibulopelvic ligament, which was then transected and suture ligated with 0 Vicryl suture followed by a 0 Vicryl free tie. The same procedure was performed on the contralateral side. The bladder flap was well developed and the bladder was pushed caudally. The uterine vasculature was skeletonized, clamped with Heaney clamps, transected with a knife and suture ligated with 0 Vicryl suture. Sequential bites were taken through the cardinal ligaments with straight Ballentine clamps, transecting the pedicles with a knife and suture ligating with 0 Vicryl suture. At the level of the external cervical os, 2 Heaney clamps were placed in opposition and the cervix was then circumcised off the vagina. The vaginal cuff was closed using 0 Vicryl suture. The angle stitches were placed in a Heaney stitch fashion to provide support to the cuff by anchoring it to the uterosacral ligament. The remainder of the cuff was closed in interrupted figure-of-eight fashion. At this point, we noticed that there was a very small amount of hematuria. The bladder was inspected and there was no obvious injury, and it was felt that most likely this was due to bruising secondary to dissection. The ureters were palpated and the left ureter was actually seen to be peristalsing. The right ureter, due to the thickness of the peritoneum, could only be felt; it could not be seen. The pelvis was irrigated with warm saline. There was no evidence of active bleeding from any of the dissection sites; however, there was a significant amount of raw area at the base of the pelvis. A large piece of Gelfoam was placed to help cut down on the possibility of adhesions forming from the bowel to the pelvic floor. The self-retaining O'Connor-O'Sullivan retractor was removed. The laparotomy sponges were also removed. The parietal peritoneum was closed using 2-0 Vicryl suture in a running fashion. The fascia was closed using 0 Vicryl suture in a running fashion x2, running and meeting in the midline. The subcutaneous tissue was reapproximated using 3-0 Vicryl suture in interrupted fashion. The skin was closed in a subcuticular fashion using 4-0 Monocryl. At the end of the procedure, sponge, instrument and needle counts were all correct. The patient tolerated the procedure well and was taken to the recovery room. The patient will be transferred to the floor when stable.

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Primary Low Transverse Cesarean Delivery Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
A (XX)-year-old with footling breech at term.

POSTOPERATIVE DIAGNOSIS:
A (XX)-year-old with footling breech at term.

PROCEDURE PERFORMED:  Primary low transverse cesarean delivery.

SURGEON:  John Doe, MD

ANESTHESIA:  Spinal.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  500 mL.

ANTIBIOTICS:  Two grams Ancef intraoperatively.

OPERATIVE FINDINGS:  Normal male infant, 3450 grams.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room after having a previous Foley catheter placed and clipper shave. The patient was then given anesthesia. She had a normal fetal heart tracing prior to this. She was then placed in a left uterine tilt and prepped and draped. A Pfannenstiel incision was made and taken down to the rectus sheath with sharp dissection. This was then extended laterally using sharp dissection. Rectus muscles were separated sharply cephalad and caudad. The peritoneum was tented, entered sharply and extended bluntly. After this, the bladder blade was inserted, visceral peritoneum was tented off of the uterus and cut in order to create a vesicouterine reflection and the bladder blade was then reinserted over this. A hysterotomy was done. After this, an amniotomy was done and it was clear fluid. Hysterotomy incision was then extended bluntly. The infant was then slightly rotated to get to the buttocks in the presentation. This was then elevated. After doing this, a nontraumatic delivery to the shoulders was effected, upon which the patient's right shoulder was then brought across midline and out. The baby rotated and the left shoulder was brought out subsequently. At this time, we could easily see there was a nuchal cord x1. The head was easily delivered at this point in time. Nuchal cord reduced. The cord was doubly clamped and cut in between and the infant was bulb suctioned and then handed off to the nurses for warming. Baby was spontaneously crying at this point in time. Cord blood was obtained. Placenta was manually removed. Uterus was wiped free of remaining fragments and closed with 2 layers of #1 Vicryl. Irrigation was applied and removed. It was hemostatic. Fascia was then closed with 0-Vicryl suture followed by a 3-0 subcutaneous followed by a 4-0 subcuticular Monocryl. Steri-Strips placed. The patient tolerated the procedure well. Instrument, sponge and needle counts were correct x2. The patient was taken to the recovery room in stable condition.

MammoSite Catheter Placement Procedure Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Right breast cancer.

POSTOPERATIVE DIAGNOSIS:
Right breast cancer.

PROCEDURE PERFORMED:
Placement of a right breast MammoSite catheter with intraoperative ultrasound.

SURGEON:  John Doe, MD

ANESTHESIA:  Local.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  Minimal.

PATHOLOGY SPECIMENS:  None.

DRAINS:  None.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and placed in the supine position. The right breast was prepped and draped in the sterile fashion. An ultrasound was used to identify the lumpectomy cavity and the depth of clearance again assessed. The depth to the lumpectomy cavity appeared to be greater than 1 cm in all locations, and the patient was felt to be a good candidate for a MammoSite. Lidocaine 1% with epinephrine was used to make a small incision in the inferior aspect of the breast. Using ultrasound guidance, the tract to the lumpectomy cavity was also anesthetized. A #10 blade was then used to make a small counterincision and then the MammoSite trocar used to carefully advance into the lumpectomy cavity under ultrasound guidance. The lumpectomy cavity was aspirated of its seroma. A 5-6 cm MammoSite balloon was used. This was tested on the back table and the first MammoSite catheter that was opened was found to inflate unevenly and was thus passed off the table to be sent back to the manufacturer. A second MammoSite catheter balloon was found to inflate satisfactorily and this was the one that was used. The trocar was removed and the MammoSite balloon advanced into the lumpectomy cavity. This was then inflated with 70 mL of Isovue with saline mixture. The ultrasound was then used to assess placement. The balloon showed good tissue conformance, as well as good symmetry and good placement. The catheter was then sterilely dressed and labeled with the fill volume. The patient tolerated the procedure well and was transported to the postanesthesia care unit in stable condition.  Sponge and needle counts were reported correct at the end of the case.

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Lysis of Adhesions and Placement of G and J Tube Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Chronic nausea and inability to eat.

POSTOPERATIVE DIAGNOSIS:
Chronic nausea and inability to eat.

PROCEDURES PERFORMED:
1.  Exploratory laparotomy with lysis of dense adhesions.
2.  Placement of a gastrostomy tube.
3.  Placement of a jejunostomy tube.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  75 mL.

SPECIMENS:  None.

DRAINS:  An 18 French Foley catheter as a gastrostomy tube and 14 French MIC jejunostomy tube.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room and placed in the supine position. After successful introduction of general endotracheal anesthesia, the patient's abdomen was prepped and draped in a sterile fashion. A #10 blade was used to make a vertical midline incision through the previous scar. Dissection was taken down through the subcutaneous tissue to the level of the fascia, which was divided cautiously and the old PDS sutures removed. The peritoneum was cautiously entered to avoid an inadvertent enterotomy and then Metzenbaum scissors used to sharpy dissect the adhesions. The patient had significant adhesions of the stomach to the liver, as well as to the anterior abdominal wall. The lysis of adhesions was extensive and took approximately 1-1/2 hours to free up the bowel sufficiently to allow for identification of the proximal jejunum. Once the adhesions of transverse colon and omentum had been freed up satisfactorily, we were able to identify with certainty the ligament of Treitz. In this location, the small bowel was free flowing with no evidence of adhesions. This was traced distally a distance of 15 cm and this was chosen as the site of the jejunostomy. We opted not to do a full lysis of adhesions of the small bowel since we knew from preoperative testing that the patient had no obstructing lesions and that extensive lysis of adhesions could result in obstructive adhesions, as well as prolonged postoperative ileus. A 3-0 PDS was used to make a pursestring suture in the antimesenteric aspect of the jejunum. A small hole was then made in the bowel within the pursestring and then a 14 French MIC jejunostomy was placed into the defect so that the distal-most flange was within the small bowel. The pursestring suture was then tied down. A Witzel tunnel was then created to the level of the more proximal flange using 3-0 PDS sutures. Before bringing the jejunum up, we opted to place a gastrostomy tube. This would obviate the need for prolonged nasogastric tube decompression and also give the option on a more chronic basis for gastric decompression for the patient’s chronic nausea if needed. A place on the anterior aspect of the stomach was chosen for the gastrostomy tube. An 18 French Foley catheter was brought in through a separate stab wound in the left upper quadrant. Two concentric pursestring sutures of 3-0 PDS were used on the anterior aspect of the stomach to make a standard Stamm gastrostomy. A small defect in the stomach was then created concentric to these pursestrings and the Foley catheter placed into this defect and the balloon inflated with 15 mL of saline. The two pursestring sutures were then tied down, securing the gastrostomy tube in place. The stomach was then tacked circumferentially to the anterior abdominal wall using interrupted 3-0 PDS sutures. Attention was then returned back to the jejunal feeding tube. A small incision was made in the left mid quadrant and then the jejunostomy brought through the abdominal wall using the tunneling device, tunneling the jejunal tube in the rectus sheath before exiting the skin. The jejunostomy tube was then tacked to the anterior abdominal wall using 3-0 PDS, first to tack the proximal flange and then to tack the bowel circumferentially. The bowel was tacked a little more distally to prevent torsion of the jejunum. After completion, both tubes were inspected and irrigated and found to be satisfactorily positioned. The abdomen was then carefully inspected. The areas where adhesions had been lysed were inspected and there was no evidence of enterotomies noted. The wound was then closed using a running #1 Prolene for the fascia, followed by surgical staples for the skin. The patient tolerated the procedure well and was awakened and extubated without difficulty. The patient was transported to the postanesthesia care unit in stable condition without any complications apparent.

Vaginal Hysterectomy Anterior Colporrhaphy Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Symptomatic pelvic organ prolapse.
2.  Pelvic pressure.
3.  Third-degree cystocele.

POSTOPERATIVE DIAGNOSES:
1.  Symptomatic pelvic organ prolapse.
2.  Pelvic pressure.
3.  Third-degree cystocele.

PROCEDURES PERFORMED:
1.  Laparoscopically-assisted total vaginal hysterectomy.
2.  Bilateral salpingo-oophorectomy.
3.  Anterior colporrhaphy.

SURGEON:  John Doe, MD

ANESTHESIA:  General with endotracheal tube intubation.

ESTIMATED BLOOD LOSS:  Less than 100 mL.

COMPLICATIONS:  None.

DRAINS:  Foley with clear urine return.

SPECIMENS:
1.  Uterine cervix and fundus.
2.  Bilateral adnexa.
3.  Redundant vaginal mucosa.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and prepped and draped in the dorsal lithotomy position for vaginal and abdominal procedures. A red rubber catheter was used to drain the patient's bladder. Two vaginal retractors were placed in the vagina to visualize the cervix, which was grasped on the anterior cervical lip with a single-tooth tenaculum. A Hulka uterine manipulator was inserted into the endocervix, attached to the anterior cervical lip. The single-tooth tenaculum was removed as well as the vaginal retractors. Focus was then turned toward the abdominal portion of the procedure. A subumbilical skin incision was made with the knife. The abdomen was tented up and an 11 mm bladeless trocar was inserted under direct visualization with the laparoscope. CO2 gas was used to create a pneumoperitoneum and the bowel and omentum underlying the insertion site were inspected and found to be free of injury. Two additional trocars were placed, one in each midclavicular line, half the distance from the pubis to the umbilicus, by scoring the skin with a knife and inserting 12 mm bladeless trocars under direct visualization with the laparoscope. A laparoscopic Babcock was used to grab the ovary and to place traction on the infundibulopelvic ligament. Endo-GIA was inserted and the infundibulopelvic ligament was stapled and transected. An additional fire was performed to get the round ligament and some of the broad ligament. The same procedure was performed on the contralateral side. There was no evidence of active bleeding. At this point, focus was returned back to the vaginal portion of the procedure. The Hulka manipulator was removed from the patient's cervix. Vaginal retractors were re-placed. The cervix was grasped anterior to posterior with two single-tooth tenacula. A posterior colpotomy was made with Mayo scissors and the peritoneal cavity was entered. A stitch of 0-Vicryl suture was placed at 6 o'clock to attach the peritoneum to the vaginal cuff. A Heaney retractor was placed in the peritoneal cavity to hold the bowel posteriorly. A knife was used to cut the cervix off the vagina. The endopelvic fascia was then bluntly dissected. The uterosacral ligaments were clamped with Heaney clamps, transected with Mayo scissors and suture ligated with 0-Vicryl suture in Heaney stitch fashion. Bites were taken through the cardinal ligaments with Heaney clamps, transecting the pedicle with Mayo scissors and suture ligating with 0-Vicryl suture. The anterior cul-de-sac was entered sharply. An additional Heaney retractor was placed to hold the bladder anteriorly. The remainder of the bites was taken in such as fashion as to reapproximate the anterior and posterior leaflets of the broad ligament. The uterine vasculature was clamped with Heaney clamps, transected with Mayo scissors and suture ligated with 0-Vicryl suture. An additional bite was taken above through the utero-ovarian pedicle, transecting the pedicle with a knife and suture ligating with 0-Vicryl suture. There was a small attachment for each ovary to its broad ligament, which was clamped with Kelly clamps, transected and suture ligated with 0-Vicryl suture. The pedicles were inspected and found to be hemostatic. The peritoneum was closed in a pursestring fashion using 2-0 Vicryl suture. The vaginal mucosa overlying the cystocele was undermined and incised sharply in the midline and extended until approximately 2 cm from the urethral meatus. Sharp and blunt dissection of the endopelvic fascia dissecting the vagina off the bladder was then performed. Stitches of 2-0 Vicryl suture were placed in a Kelly plication fashion to reapproximate the endopelvic fascia to provide support to the bladder neck. Redundant vaginal mucosa was trimmed. The anterior vaginal wall incision was closed using 2-0 Vicryl suture in a running locked fashion to the level of the vaginal cuff. A Foley catheter was placed and clear urine was appreciated. The remainder of the cuff was closed using 0-Vicryl suture in interrupted figure-of-eight fashion. The vagina was packed with 1 inch Iodoform tape. Again, the focus was turned to the abdominal portion of the procedure. The CO2 gas was allowed to reaccumulate and the pelvic contents were inspected. There was no evidence of bleeding from any pedicle. The trocars were removed after letting the CO2 gas escape. The skin incisions were closed using 4-0 Monocryl in subcuticular fashion. At the end of the procedure, sponge, needle and instrument counts were all correct. The patient tolerated the procedure well and was taken to the recovery room, will be transferred to the floor when stable.

Crash Low Transverse Cesarean Section Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Term gestation.
2.  Nonreassuring fetal condition with fetal bradycardia.
3.  Placental abruption affecting approximately 50% of the placenta.

PROCEDURE PERFORMED:  Crash low transverse uterine incision cesarean section.

SURGEON:  John Doe, MD

ANESTHESIA:  Epidural anesthesia.

ESTIMATED BLOOD LOSS:  800 mL.

COMPLICATIONS:  Hematuria.

DRAINS:  A transurethral Foley was placed after the procedure.

PROCEDURE FINDINGS:
1.  Normal pelvic anatomy.
2.  Live male infant delivered at 0930 weighing 6 pounds 13 ounces, receiving Apgars of 3 at one minute and 6 at five minutes.
3. Placenta showing both organized and fresh blood on approximately 50% of the maternal side.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room with a functional epidural in place after four pushes resulting in a fetal bradycardia. Once the patient was on the operating room table, attempts were made to find fetal heart tones; however, none could be found. For this reason, instead of electing to perform a forceps delivery since the patient did not have a proven pelvis, we elected to proceed with a crash cesarean section due to the urgency and uncertainty of the baby's condition. Attempts were made to place a Foley catheter, which had been removed just prior to starting to push. It was noted at that time there was already a small amount of blood in the urine. The patient's abdomen was quickly prepped and the patient was draped. A skin incision was made with a knife and taken sharply down to the level of the fascia, which was extended manually. The rectus muscles were separated manually and the underlying parietal peritoneum was entered manually. A bladder blade was placed. The uterine incision was made above the reflection of the bladder peritoneum on the anterior uterine wall and extended manually. The infant was delivered from a vertex presentation. The cord was doubly clamped and cut. The infant was passed off to the awaiting neonatologist for further assessment. A sample of cord was obtained for cord gases. Cord blood was obtained. The placenta was manually extracted. The uterus was exteriorized, all clot and debris wiped from the endometrial cavity. The uterine incision was closed using 0 Monocryl in a running fashion, a second layer was a running imbricating stitch. The uterus was easily made hemostatic and placed back in the abdominal cavity in its normal anatomic position. The gutters were explored, all clot and debris removed. The uterine incision was again inspected and found to be hemostatic. The rectus muscles were reapproximated with a single stitch of 0 Monocryl incorporating the underlying parietal peritoneum. The subfascial space was inspected and found to be hemostatic. The fascia was closed in a running fashion from angle to angle using 0 PDS. The subcutaneous tissue was reapproximated using 3-0 Vicryl suture in interrupted fashion. The skin was closed in subcuticular fashion using 4-0 Monocryl. Following the procedure, a Foley catheter was placed and blood-tinged urine was returned as was expected. The bladder was evaluated intraoperatively and there was no obvious injury; however, this will be monitored closely in the recovery area. At the end of the procedure, an x-ray was performed as there was no time for a count, which showed no evidence of a foreign body. The patient was taken to the recovery room for observation and the patient will be transferred to the floor when stable.

ORIF Irrigation and Debridement Humerus Fracture Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Right grade IIIA distal humerus fracture with intra-articular extension.

POSTOPERATIVE DIAGNOSIS:  Right grade IIIA distal humerus fracture with intra-articular extension.

PROCEDURES PERFORMED:
1.  Irrigation and debridement of right distal humerus fracture.
2.  Open reduction and internal fixation of right distal humerus fracture.
3.  Application of VAC sponge.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  300 mL.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and laid supine on the operating room table. After general anesthesia was induced, the patient was turned to the lateral decubitus position with the right arm up on a bean bag. The right upper extremity was placed on a lateral arm post. The right arm was then prepped and draped in the usual sterile fashion after all bony prominences were well padded. Next, the open wound, which measured approximately 6 x 10 cm, was debrided of all necrotic skin and subcutaneous tissue as well as fascia and necrotic muscle. After thorough debridement, the wound was thoroughly irrigated with 9 liters of normal saline, the middle 3 liters of which contained 100,000 units of bacitracin. The fracture end surfaces were exposed and irrigated thoroughly. After thorough debridement and irrigation, the incision was extended distally as well as proximally. An olecranon osteotomy was performed using a TPS saw at the level of the joint. The ulnar nerve was isolated and identified and protected throughout the remainder of the procedure. The olecranon osteotomy was elevated and the triceps muscle was carefully lifted off of the distal humerus, taking care to protect the ulnar nerve. Next, the fracture was brought into full visualization. The fracture was highly comminuted in the metaphysis with two intra-articular pieces. Reduction of the articular surface was performed. The reduction was held with 1.25 mm K-wires. Two lag screws were placed, one from lateral to medial and one from medial to lateral, holding the articular surface reduced. Next, there was noted to be a large piece of bone that had been outside the wound prior to initiation of the procedure. This piece of bone was dirty and contaminated and therefore it was decided not to use this necrotic piece of bone because of risk of infection. The remainder of the metaphysis was highly comminuted and unsalvageable. Therefore, it was decided to restore the shaft to the articular surface. To do this, we had to accept a certain degree of shortening of the humerus. Therefore, the shaft was brought into contact with the distal humeral surface. Two Synthes small fragment locking plates were then contoured, one for the medial side and one for the lateral side. The lateral plate was advanced up into the humeral shaft after the radial nerve was identified and protected. Three screws were placed in the distal fragment followed by five screws in the proximal fragment holding the shaft reduced to the distal humeral segment. Next, the medial plate was contoured and also secured using three screws distal in the distal fragment and five screws in the proximal fragment. Excellent stability was obtained after placement of all screws on both the medial and lateral sides. The radial nerve was protected throughout the procedure. Next, the wound was thoroughly irrigated. The olecranon osteotomy was then repositioned and the 7.3 mm cannulated Synthes screw was reinserted. Prior to making the osteotomy cut at the beginning of the procedure, a 7.3 mm partially threaded screw, which was 100 mm in length, had been inserted into the olecranon tip into the ulnar shaft. This screw was reinserted. The repair was reinforced with 18 gauge stainless steel wire through a drill hole in the ulnar shaft and the wire was twisted in a figure-of-eight fashion around the olecranon screw at the tip of the olecranon. Once the screw was fully tightened, this wire was also tightened and crimped, obtaining excellent stability of the olecranon osteotomy repair. Once this was done, the elbow was taken through a full range of motion. No mechanical block was noted. The articular surface was restored as best as the injury allowed. Approximately 2 cm of shortening of the humerus had to be accepted due to significant comminution in the metaphysis, which was unreconstructable. The wound was then thoroughly irrigated again with normal saline. Closure was initiated using 0 Vicryl suture for the deep layer, which included the fascia of the triceps tendon. The subcutaneous layer was closed with 3-0 Vicryl suture in inverted fashion. An approximately 4.5 x 4.5 cm area was not able to be closed and therefore a VAC sponge was applied through this area. Staples were applied to the remainder of the incision. A tourniquet was used for this procedure, and prior to closure, the tourniquet was deflated and hemostasis was obtained. Sterile dressings were applied followed by a posterior plaster splint. The patient was then turned over to the supine position, extubated and transferred back onto a stretcher and taken to the PACU for recovery. There were no complications during the procedure. EBL was 300 mL.

Radius ORIF Wound Irrigation and Debridement Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left Galeazzi fracture to necrotic and infected left ankle wound.

POSTOPERATIVE DIAGNOSIS:  Left Galeazzi fracture to necrotic and infected left ankle wound.

PROCEDURES PERFORMED:
1.  Open reduction and internal fixation of left radius.
2.  Irrigation and debridement of left ankle wound without placement of a VAC sponge.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  Less than 200 mL.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and laid supine on the operating room table. General anesthesia was induced. The dressing on the patient's left ankle was removed, and it was noted that the left ankle incision had a significant amount of necrotic skin associated with some purulent drainage. The patient had not been consented for irrigation and debridement of the ankle preoperatively; however, it was noted that the ankle did require irrigation and debridement of the necrotic skin. Attempts were made intraoperatively to contact the family; however, we were unable to do so. Due to the necessity of this procedure, we proceeded with irrigation and debridement. The left lower extremity was therefore prepped and draped in the usual sterile fashion. The wound was covered. The left upper extremity was also prepped and draped in the usual sterile fashion after a tourniquet was placed high up on the left arm. Attention was first directed to the left upper extremity. A volar incision was made in the distal forearm. Dissection was carried out and the flexor carpi radialis tendon was retracted ulnarly. The flexor digitorum superficialis and the flexor pollicis longus muscles were retracted ulnarly as well. Care was taken to protect the radial artery during the dissection. Dissection was carried down to the bone. The fracture was easily reduced anatomically. A Synthes small fragment locking plate was then contoured to sit flush on the volar aspect of the distal radius. Four screws were then placed proximal to the fracture followed by three screws distal to the fracture. Two of the distal screws were locking screws and two of the screws proximally were locking screws. All screws were placed in the standard AO fashion. Excellent reduction was obtained. C-arm fluoroscopy was used to confirm excellent position of all screws as well as the plate. Clinical examination of the distal radioulnar joint did not reveal any instability. Radiographs also did not show any instability of the distal radioulnar joint; therefore, the decision was made not to perform pinning of this joint. Next, the wound was thoroughly irrigated with normal saline. The pronator quadratus was reattached using 2-0 Vicryl suture. The skin was closed in the subcutaneous layer with 2-0 Vicryl suture in inverted fashion. Staples were placed for the skin. Sterile dressings were applied and a volar splint was applied to the left forearm. Attention was then directed to the left ankle. The sutures were removed. A minimal amount of drainage was expressed from the wound. There was noted to be a large amount of necrotic skin; however, the extent of necrosis had not yet declared itself fully. Therefore, some of the necrotic skin was removed. The wound was thoroughly irrigated with 9 liters of normal saline, the middle 3 liters of which contained 100,000 units of bacitracin. After thorough debridement of all necrotic tissue, a VAC sponge was placed and a vacuum-type seal was obtained. The plan is for the patient to return to the operating room in 48 hours for repeat irrigation and debridement of the left ankle wound. After the irrigation and debridement was completed, the patient was transferred back onto the stretcher and taken to the surgical intensive care unit for further recovery. There were no complications.

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