Cystoscopy Ureteroscopy Retrograde Pyelogram Transcription Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Left proximal ureteral stone.

POSTOPERATIVE DIAGNOSIS:
Left proximal ureteral stone.

OPERATION PERFORMED:
1.  Cystoscopy with left ureteroscopy.
2.  Left retrograde pyelogram.
3.  Left stent placement.

SURGEON:  John Doe, MD

ANESTHESIA:
General.

COMPLICATIONS:
None.

SPECIMEN:
Included urine for culture.

INDICATION FOR PROCEDURE:
The patient is a (XX)-year-old female who was recently seen in-house for left renal colic from a 4 to 5 mm left proximal ureteral stone.  She was initially given a trial of conservative therapy but continued to have symptomatic pain from the stone.  For that reason, it was decided to go ahead and intervene for her symptoms.  The patient has been made aware of the potential risks, benefits, complications and alternatives to undergoing cystoscopy with left ureteroscopy and possible stone extraction, as well as left stent placement.

DESCRIPTION OF PROCEDURE:
The patient was correctly identified and informed consent was obtained.  She was brought to the operating room where, once sufficient anesthesia had been administered, she was prepped and draped in the lithotomy position.

A 21-French rigid cystoscope was passed to the bladder using the obturator.  The bladder was drained and urine was obtained for culture and sensitivity.  A 12-degree lens was then used to perform cystoscopy.  The bladder was unremarkable in appearance.  The left ureteral orifice was identified and was intubated with a 0.038 guidewire.  This was advanced up the ureter under fluoroscopy until a coil was noted in the renal pelvis.  Secondary to tight ureteral opening, the distal ureter was calibrated with a 12-French Nottingham dilator.  At that point, a rigid ureteroscope was passed into the bladder and into the distal ureter without difficulty.  The ureteroscope was advanced up the ureter under direct vision, up to its full length.  Advancement of the rigid ureteroscope as far as it would go did not demonstrate any evidence of stone in that part of the ureter.

At that point, the rigid ureteroscope was removed.  A second guidewire was placed using a dual-lumen ureteral catheter.  A ureteral access sheath was then placed over one of those wires using Seldinger technique.  At that point, a flexible ureteroscope was advanced up the ureteral access sheath into the proximal part of the ureter.  However, secondary to a malfunctioning ureteroscope, which would not deflect, proximal ureteroscopy could not be performed.  Rather than risk injury to the ureter, the ureteroscope and access sheath were removed.

Retrograde pyelogram was performed at that time.  The remaining wire was back-loaded over the cystoscope and a 6 x 22 French was initially attempted to be placed in the left kidney.  However, after placement of the stent, it did appear that it was somewhat short; as such, a grasper was used to remove the stent and this was replaced for a 6 x 24 cm double-J stent.  This was advanced into the kidney without difficulty.  Direct vision confirmed good distal coil in the bladder.  The bladder itself was drained and the scope removed.  Anesthesia was reversed and the patient was taken to the recovery room in satisfactory condition.

DISPOSITION:  The patient is to be discharged home.  Prescription for Levaquin x5 days and Pyridium as needed was given.  We will have her push oral fluids at home and strain urine.  If she has not captured a stone in 2 to 3 weeks, we will repeat upper tract imaging.  Based on stone location at that time, she may be a candidate for ESWL versus definitive ureteroscopy.

Hand Assisted Laparoscopic Nephrectomy Transcription Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left renal cell carcinoma.

POSTOPERATIVE DIAGNOSIS:  Left renal cell carcinoma.

OPERATION PERFORMED:  Hand-assisted laparoscopic left radical nephrectomy.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General plus 20 mL of 0.5% Marcaine.

BLOOD LOSS:  50 mL, per anesthesia.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  The patient was placed initially in the supine position. A Foley catheter was inserted. SCD hose was applied. The patient was then rotated up in about a 60 degree left flank up position. The table was flexed.  An axillary roll was placed under his right axilla. Pillows were placed between his legs. The patient was then taped onto the table. Sandbags were placed behind his back. The patient was then prepped and draped in the usual manner for surgery.

An incision was made just at the level of his umbilicus and carried down towards the feet for a total of 8 cm. It was carried down into his abdominal cavity. A 12 mm trocar was then placed just below the anterior iliac crest and just off the midline. A second trocar was placed lateral, almost at the level of his anterior iliac crest. These were both placed with a hand in the abdominal cavity. Ports were then placed. A Gelport was then placed in the abdominal wound. The abdomen was insufflated with CO2.

An incision was made along the line of Toldt and the colon was reflected medially. The area between the anterior layer of Gerota's and posterior peritoneum was readily identified and separated out very nicely. The lateral margin of the kidney was freed up slightly. The inferior margin of the kidney was then freed up basically with blunt dissection. The ureter was identified but not transected at this point. The incision was then carried up along the medial aspect of the kidney until the artery was identified. It was separated from the surrounding tissues. The renal vein was identified just above this, and it was also separated out from the surrounding tissues. There was a small branch of the renal vein, which goes down along the renal artery and then swings around the base of it, probably a lumbar vessel.

An attempt was made to pass the staple gun across the artery, but there was not quite enough room to do so. The artery was clipped with large Ligaclips x2 on the proximal side and once on the distal side of the artery. The staple gun was then passed across the left renal vein and fired and transected. There was good hemostasis. The artery was then stapled with a staple gun. There was good stapling of the artery and there was no bleeding. The kidney was then fully mobilized on its lateral superior margin. Predominately with blunt dissection, small vessels were fulgurated. The adrenal gland was identified on its inferior margin and left in place. Specimen was then freed up. On the inferior aspect, the ureter was transected across Ligaclips. The pressure in the abdomen was then decreased from 15 cm to 5 cm of pressure.

Reinspection of the wound demonstrated no evidence of any apparent bleeding. The ports were then removed. The kidney was removed out through the hand port and the GelPort was also removed. The 12 and 10 mm lap ports were oversewn with a figure-of-eight 0 Vicryl suture. The fascia was closed with a running 0 Vicryl suture. Before closure of the vessels, a total of 20 mL of 0.5% Marcaine was injected in all of the wounds. The skin was then approximated with skin clips. The patient tolerated the procedure well. Blood loss per anesthesia was 50 mL, and no complications were encountered during the procedure.


Laparoscopic Appendectomy Medical Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Acute appendicitis.

POSTOPERATIVE DIAGNOSIS:
Acute appendicitis.

OPERATION PERFORMED:
Laparoscopic appendectomy.

SURGEON:  John Doe, MD

ANESTHESIA:
General with endotracheal intubation.

COMPLICATIONS:
None.

BLOOD LOSS:
Minimal.

FLUIDS:
Crystalloid 1000 mL intraoperatively.

INDICATION FOR OPERATION:  The patient is a (XX)-year-old female who presented to the emergency room following approximately 6 hours of acute abdominal pain, which localized to her right lower quadrant. The patient underwent laboratory and x-ray studies, which had findings consistent with acute appendicitis. The patient now presents at this time for laparoscopic appendectomy.

DESCRIPTION OF OPERATION:  The patient was placed on the operating table in the supine position, and following induction of adequate general anesthesia, she was prepped and draped in the usual sterile fashion. Veress needle technique was used to insufflate the abdomen to 15 mmHg with carbon dioxide gas. A supraumbilical approach was taken. Once the abdomen was adequately insufflated, the Veress needle was replaced with a 5 mm blunt trocar placed under direct visualization. The abdomen was visually explored, and of note, there were adhesions between the area of the cecum and the anterolateral abdominal wall. No other gross abnormalities were readily identified. A 5 mm trocar was placed in the deep right pelvis and a 12 mm trocar was placed in the deep left pelvis.

The patient was placed in a mild Trendelenburg position and the adhesions were bluntly stripped from the anterior abdominal wall. The stiff and inflamed appendix was readily identified. It was curled upon itself, but after gentle dissection, it was able to be fully extended. There was no evidence of frank gangrene or perforation on initial visualization. Dissection with Maryland forceps and the base of the appendix created a tunnel between the appendix base and its mesoappendix. A 45 mm EndoGIA with a blue load was then fired across the base of the appendix to divide it. There were several attachments between the body of the appendix and cecum. These thin attachments were taken down with blunt and electrocautery dissection. Once the mesoappendix was freed, it was divided using the EndoGIA with a gray load.

At this point, the appendix was completely freed and it was removed from the abdomen in an EndoCatch pouch through the 12 mm trocar site. The surgical bed was then copiously irrigated with saline solution and all of the fluid was aspirated. The surgical staple line was then inspected and noted to be intact and hemostatic. The remainder of the surgical bed was irrigated and all the fluid was aspirated clear.

At this point, the procedure was terminated. Each trocar site was then infiltrated with a 50:50 mixture of 0.5% plain Marcaine and 1% plain Xylocaine. The 12 mm trocar site was then closed at the level of the anterior abdominal fascia using a 2-0 Vicryl with a figure-of-eight stitch. Each trocar site was then closed at the level of the skin using 4-0 Monocryl with a running subcuticular stitch. Benzoin, Steri-Strips, and sterile dressings were applied.

The patient tolerated the procedure well. She received approximately 1000 mL of crystalloid intraoperatively. Blood loss was minimal. There were no complications. Sponge, needle and instrument counts were noted to be correct. At this point, the patient was extubated in the operating suite and transported in hemodynamically stable condition to the PACU.

EGD Radiofrequency Ablation Using HALO Medical Transcription Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  This is a (XX)-year-old woman who presents for her 2-month surveillance upper endoscopy due to a history of Barrett esophagus with low-grade dysplasia/indefinite for dysplasia. The patient has undergone 3 prior HALO procedures and now presents for her 2-month surveillance esophagogastroduodenoscopy with possible HALO.

POSTOPERATIVE DIAGNOSES:
1.  Barrett esophagus with low-grade dysplasia/indefinite for dysplasia, status post HALO, radiofrequency ablation.
2.  Small sliding hiatal hernia.
3.  Minimal antral gastritis.

PROCEDURE PERFORMED:
Esophagogastroduodenoscopy with focal ablation of the distal esophagus utilizing the HALO system.

ENDOSCOPIST:  John Doe, MD

SEDATION:  Monitored anesthesia care per anesthesiology department.

COMPLICATIONS:  None.

DESCRIPTION OF PROCEDURE:  The risks and benefits of the procedure have been discussed in the past with the patient during her prior procedures as well as in the office. All questions were answered and informed consent was obtained. The patient was placed in the left lateral decubitus position and sedated as outlined above.

The video endoscope was inserted through the mouth and advanced to the descending portion of the duodenum under direct visualization without any difficulty. Duodenoscopy revealed a normal-appearing postbulbar duodenum as well as duodenal bulb. The scope was then withdrawn into the stomach. Gastroscopy revealed minimal antral erythema, edema, and friability. Otherwise, the remainder of the visualized mucosa of the gastric body and retroflexed views of the gastric cardia and fundus were unremarkable. A small sliding hiatal hernia was noted. Scope was then withdrawn into the distal esophagus. The Barrett tissue was once again closely inspected. There continues to be one tongue of ectopic mucosa, which is approximately 1.4 to 2.2 cm in size. The top of the intestinal metaplasia is at approximately 40 cm and the top of the gastric folds is at approximately 42 cm.

The endoscope was then removed and reintroduced with the ablation electrode attached. The Barrett tissue was targeted, proximal to distal treatment of the ectopic mucosa. The ablation electrode was positioned under direct visualization so that the electrode was in contact with the Barrett tissue. Energy was applied twice at approximately 100 watts/sq. cm at a setting of 15 joules/sq. cm.  Ablation was repeated until all visible Barrett tissue was ablated.  A second ablation was done adjacent to the first one due to a very small tongue of ectopic mucosa. Once again, it was applied twice at the same settings as detailed above. The ablation zone was then cleaned of any coagulative debris. The ablation electrode and the endoscope were then removed. The patient tolerated the procedure well and there were no apparent complications noted.

IMPRESSION:
1.  Barrett esophagus with low-grade dysplasia/indefinite for dysplasia, status post HALO, radiofrequency ablation x4 treatments.
2.  Small sliding hiatal hernia.
3.  Minimal antral gastritis.

PLAN:
1.  Have contacted office to arrange for the patient to have a repeat upper endoscopy with biopsies in 2 months.
2.  Will give the patient prescriptions today for Zofran, acetaminophen/codeine elixir, GI cocktail, as well as Carafate.  Also advised her to continue taking her Prevacid.
3.  Will also advise the patient to contact the office if she has any postoperative complications, including increasing abdominal pain, chest pain, bleeding, fevers, or chills.

Dr. Doe, thank you very much for allowing me to participate in the care of this patient. Should you have any questions, please do not hesitate to contact me.

Colonoscopy Sample Report       Colonoscopy and ERBE Argon Laser Cautery Sample

Colonoscopy and EGD Sample Reports

Medical Transcription Word Seeker - Google Search for MTs - Searches just Medical Websites

Doctor Report Letter Worktype Medical Transcription Sample

LETTER TO PROVIDER SAMPLE

Month Date, Year



John Doe, MD (Addressee)
Street Address
City, State  Zip Code

RE:  LAST NAME, First Name (Patient Name)

Dear Dr. Doe:

I have evaluated the patient for her complaints and symptoms. Her evaluation included another MRI of the brain for her facial numbness with and without contrast along with complete metabolic profile, liver function, lipids, urinalysis, and chest x-ray. These were all done as she had various coughs and pains in her chest, and she was having some flank pain. In addition, the patient tells me that she may have sleep apnea symptoms.

In this regard, I have booked a sleep study for which she will return, and fortunately, the MRI is normal. Urinalysis is normal. Liver function was normal. Her lipid profile, however, is mildly abnormal with a cholesterol of 221 and an LDL of 154. I will leave this to you as to how to manage this.  Her hemoglobin A1c was 5.4. CBC was otherwise normal.

I am not sure what is actually causing the patient's symptoms of numbness. She does have some anxiety and may be using benzodiazepine somewhat regularly, but I am not certain of this. To see if we can afford some empiric relief of these symptoms, I will start her on Neurontin 300 mg at bedtime, and she will be in touch with me as to how she is doing in these regards. She is also going to be seeing an ophthalmologist as she had some minor visual symptoms. I suspect she has presbyopia.

Thank you for sending the patient to me for evaluation. If there are any questions, please do not hesitate to contact me. I will be mailing the patient her lab results directly.

Sincerely,



Jane Doe, MD

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

TO WHOM IT MAY CONCERN SAMPLE REPORT

To Whom It May Concern:

This is a patient under my care who has a history of low back pain and leg pain, which can be as severe as a 9-10/10. The patient has known degenerative disk disease with a possible annular tear in the past as well as spondylosis. For these reasons, the patient is unable to sit for any prolonged period of time and therefore should be excused from jury duty. If there are any questions, do not hesitate to contact me at XXX-XXX-XXXX.

Sincerely,



Jane Doe, MD

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

LETTER TO PATIENT SAMPLE

Month Date, Year



Patient Name (Addressee)
Street Address
City, State  Zip Code

Dear (Patient Name):

I hope this letter finds you well. Thank you for having your outside laboratory studies checked recently. I did receive a copy of these. These show that you have normal vitamin D levels with the vitamin D total level being 51, which is considered within normal range. Your liver tests are all acceptable, except for your alkaline phosphatase, which is elevated at 142. This is an enzyme that is produced by the liver as well as by the bone. It is a bit on the high side. You do not have any evidence of anemia on your complete blood count, I am pleased to say.

In reviewing your chart, it does look like this single liver enzyme has crept up slightly over the past few years. I know you have a visit coming up with me in the near future, and I would like to repeat blood testing at that time to see where alkaline phosphatase is. If it is still borderline elevated, we may need to talk about possibly some followup testing as well. This is a very mild elevation, however.

I look forward to seeing you at our upcoming appointment and hope you are well.

Sincerely,



Jane Doe, MD

Subscribe to: Posts (Atom)