Forefoot Amputation Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Gangrene of the right forefoot.

POSTOPERATIVE DIAGNOSIS:
Gangrene of the right forefoot.

PROCEDURE PERFORMED:
Right forefoot amputation and placement of wound VAC.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:
General endotracheal.

ESTIMATED BLOOD LOSS:
Less than 10 mL.

FLUIDS:
700 mL of crystalloids.

SPECIMENS:
Right forefoot.

COMPLICATIONS:
None.

INDICATIONS FOR OPERATION:
The patient is a (XX)-year-old Hispanic female who is status post a right total knee replacement. During the course of this procedure, the patient suffered popliteal artery injury. She subsequently required a right femoral to below the knee popliteal bypass. The patient subsequently demarcated an ischemic area of her right forefoot. This failed to respond to revascularization with the femoral to distal popliteal. The patient was subsequently brought back to the operating room for a right forefoot amputation.

DESCRIPTION OF OPERATION:
After informed consent had been obtained and all risks and benefits had been discussed with the patient and the patient's family, the patient was brought through same day surgery, where her remaining preoperative preparations were made. The patient was then brought to the operating room where she was placed supine on the operating table. General endotracheal anesthesia was administered per Anesthesia without difficulties, and the patient was intubated successfully. The patient was subsequently given 1 g of IV Ancef. Her right lower extremity was then circumferentially prepped with Betadine, and her right lower extremity was draped in the usual sterile surgical fashion using sterile towels and sterile drapes. A timeout was then completed confirming that the patient was present in the room for a right forefoot amputation.

A 10 blade was then used to make a circumferential incision down to the skin and underlying subcutaneous tissues, muscles, and tendons down to the bone at the line of demarcation of the forefoot. Periosteal elevator was used to elevate the periosteum anteriorly and proximally to the incision site. Bone saw was then used to transect the metatarsals and cuneiforms of the right forefoot. Metzenbaum scissors were used to transect the remaining tendon and ligamentous attachments. The forefoot was passed off the table as a specimen.

There was mild bleeding from the skin edges and newly exposed muscle bellies. The exposed cuneiforms and metatarsals were then debrided using rongeurs. The remaining necrotic muscle and tissue were removed sharply using a 10 blade. Hemostasis was then obtained using Bovie electrocautery. The wound was copiously irrigated with Polysporin antibiotic irrigation. Forefoot amputation was completed at the proximal portion of the metatarsal heads and the cuneiform metatarsal joint.

The wound was then dried, and a wound VAC was placed under sterile conditions in the operating room. The patient tolerated the procedure well without difficulties. A strong anterior tibial signal was dopplerable at the end of the case. The patient was extubated in the operating room and transferred to the PACU in good condition. Specimen was sent to Pathology for permanent section. There were no complications.


Lipoma Excision Procedure Medical Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Lipoma of the left upper shoulder.

POSTOPERATIVE DIAGNOSIS:
Lipoma of the left upper shoulder.

PROCEDURE PERFORMED:
Excision of lipoma from left shoulder.

SURGEON:  John Doe, MD

ANESTHESIA:
Monitored anesthesia care with local.

SPECIMENS:
Lipoma from the left shoulder.

COMPLICATIONS:
None.

FLUIDS:
900 mL of crystalloid.

ESTIMATED BLOOD LOSS:
Minimal.

INDICATIONS FOR PROCEDURE:
The patient is a (XX)-year-old Hispanic male with complaints of difficulties raising his left shoulder above his head. He is referred to the general surgery clinic for a small soft tissue mass on the top part of his left shoulder, just above his clavicle. It was explained to the patient that this was most likely a lipoma and was not responsible for his restriction in movement of his left shoulder. However, he was still insistent upon having the mass removed. The patient was subsequently set up for removal as an outpatient on an elective basis. The patient was brought through same-day surgery for excision.

DESCRIPTION OF PROCEDURE:
After informed consent was obtained and all risks and benefits had been discussed with the patient and the patient's spouse, the patient was brought through the same-day surgery center, where remaining preoperative preparations were made. The patient was brought to the operating room, where he was placed supine on the operating table. The correct site was confirmed, and monitored anesthesia care was administered by Anesthesia, and the patient was adequately sedated.

The patient was positioned in the right lateral decubitus position. His neck and upper shoulder were prepped with DuraPrep, and he was draped in the usual sterile fashion using sterile towels and sterile drapes. A time-out was then completed by the surgical team, confirming that the patient was present in the room for excision of a left shoulder lipoma.

Carbocaine 1% was then used to anesthetize the skin overlying the soft tissue mass. A 15 blade was used to incise the skin, and the incision was continued through the dermis using Bovie electrocautery on the subcutaneous tissue. At this point, circumferential flaps were created using the Bovie electrocautery around the soft tissue mass. Once adequate exposure was obtained, an Allis clamp was used to grasp the lipoma and deliver it into the wound. The inferior portion of the lipoma was then dissected free again using the Bovie electrocautery and amputated and passed off the table as specimen. The wound bed was then examined and hemostasis was obtained using Bovie electrocautery.

The defect was then palpated, and there was no evidence of remaining lipoma within the wound. The wound was irrigated and dried. There was no evidence of bleeding. A single deep 3-0 Vicryl suture was placed. The skin edges were then reapproximated using 3-0 Vicryl sutures in an interrupted deep dermal fashion. The skin edges were then closed using a single running 4-0 Monocryl suture in an intracuticular fashion. The wound was then cleaned and dried. Mastisol and Steri-Strips were applied. The wound was then infiltrated again using 1% Carbocaine for postoperative pain control. A total of 16 mL of 1% Carbocaine was used for local. Sterile gauze and Tegaderm were then placed over the wound.

The patient tolerated the procedure well without difficulties. The specimen was sent to Pathology for permanent section. A total of 9 mL of crystalloid was given during the course of the case. Estimated blood loss was minimal. The patient was taken to the PACU for recovery in good condition.

Pterional Craniotomy Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Ruptured anterior communicating artery aneurysm.

POSTOPERATIVE DIAGNOSIS:  Ruptured anterior communicating artery aneurysm.

PROCEDURE PERFORMED:  Right pterional craniotomy for microscopic clipping of anterior communicating artery aneurysm.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal intubation.

TUBES AND DRAINS:  A 7 mm flat subgaleal JP drain.

ESTIMATED BLOOD LOSS:  2000 mL.

COMPLICATIONS:  Intraoperative aneurysm rupture.

CONSENT:  The risks and benefits of the procedure were discussed at length to the patient and his wife, both of whom understand and agree to proceed.

DESCRIPTION OF OPERATION:  The patient was brought into the operating room where he was induced under general anesthesia and intubated. He was placed in the supine position with the head turned slightly to the left and fixed with the Mayfield crown of thorns. Care was taken to ensure that all pressure points were carefully padded and that the limbs were positioned comfortably. A small strip of hair on the right side of his head was shaved and a curvilinear incision was marked on the scalp. This was extended down the forehead in the midline slightly due to the high hairline. The entire site was then prepped and draped in the usual sterile fashion. The indwelling right common femoral artery angiogram sheath was also prepped and draped sterilely.

The skin of the scalp was incised to full thickness with a #10 blade, and hemostasis was maintained with Raney clips. The scalp was reflected inferiorly through the fascia until the temporalis muscle was exposed. The temporalis was then cut, leaving a cuff on the bone and the muscle and scalp reflected inferiorly. They were reflected over a rolled 4 x 4 sponge and held in place with fishhooks. A bur hole was then placed in the frontal keyhole position and over the temporal bone. The underlying dura was stripped free of the inner table with blunt dissection. Care was taken down to frontal bur hole to palpate the floor of the anterior fossa to mark the trajectory of the craniotomy. Using B1 drill bit with the footplate, the craniotomy was turned between both bur holes. The bone over the sphenoid wing was thinned with the B1 drill bit, and the craniotomy was cracked at that point and removed as a single piece. Using a Leksell rongeur and the B1 drill bit, the sphenoid wing was drilled down to a flat trajectory along with the inner table of the frontal bone, and bone wax was applied for hemostasis. The dura was then opened in semilunar fashion and reflected inferiorly with a 4-0 Vicryl suture. The Budde halo was then attached to the Mayfield crown of thorns with two retractors, and the microscope was brought into position.

Under microscopic guidance, the frontal lobe was elevated with the retractors over Telfa strips. The arachnoid was dissected away from the optic nerve to release CSF. The carotid artery was then dissected free of the optic nerve and away from the arachnoid as well to allow proximal control, and then extended arachnoid opening across the midline until the opposite optic nerve could be visualized and then extended back posteriorly until the A1 segment of the right anterior cerebral artery was visualized. At this point, we could identify the recurrent artery of Heubner and therefore the presumed junction of the A1 and A2 segments. We dissected across the midline until the contralateral A1 segment of the anterior cerebral artery on the left was visualized. These were then followed medially until we identified the interhemispheric fissure.

Using microscopic scissors and nerve hook retractor, the interhemispheric fissure of arachnoid was elevated and cut to expose the A2 segment and the anterior communicating artery itself. A dark red blister on the genu of the right A1 and A2 junction was visualized, but this did not follow the trajectory as expected for the aneurysm on the angiogram. For that reason, additional arachnoid dissection was undertaken around this blister and behind it until the more superiorly oriented aneurysm was visualized. We then took time to dissect the plane between the aneurysm neck and the A2 arteries on each side. We first attempted to free the aneurysm with a straight 5 mm permanent clip but found that this would not fit through the dissected space on the aneurysm neck and tended to roll the anterior communicating artery backwards. Therefore, we performed some additional dissection in preparation for placing a side-angled clip.

During dissection, however, the aneurysm ruptured. We placed the permanent side-angled clip across the aneurysm neck with rapid control of the bleeding, but there was still some arterial bleeding from the posterior portion of the aneurysm. To allow better clip placement, temporary aneurysm clips were then placed in both A1 segments of each anterior cerebral artery. The aneurysm clip was then removed and then reapplied more inferiorly across the base of the neck of the aneurysm. Once this was placed, we found no additional arterial bleeding. The temporary aneurysm clips were removed and the aneurysm remained collapsed with no bleeding. We chose then to treat the additional blister aneurysm at the right A1 and A2 junction with a straight 3 mm mini clip. After each of these clips were in place and there was no bleeding ongoing, the A1 and A2 segments on each side were checked by micro Doppler. Good flow was identified in each of the four vessels with no flow signal heard in the aneurysm.

At this point, we placed two small pieces of thrombin-soaked Gelfoam to ensure good hemostasis. A papaverine-soaked Gelfoam was then laid down across the A1 segment. The microscope was then removed along with the retractors and the Telfa strips. The Budde halo was detached. The dura was overlaid with a moist piece of Telfa, and the scalp was temporarily closed with a 2-0 Vicryl suture. An intraoperative angiogram was then performed. As the angiogram demonstrated patency of both A2 segments and occlusion of the aneurysm, we chose to finish with the closure.

The scalp was then reflected back over the 4 x 4 sponges with fishhooks. The Telfa was removed, and the brain was irrigated with lactated Ringer's to remove all blood products. After ensuring good hemostasis, the dura was closed with 4-0 Vicryl sutures. It was overlaid with a Bicol sponge. The bone flap was then fixed back in place with Synthes craniofacial plates and screws. The temporalis muscle was then sewn back to the fascia cuff on the bone with 2-0 Vicryl sutures. A 7 mm flat JP drain was passed through a separate stab incision and cut to length in the subgaleal space. The galea was then closed with 2-0 Vicryl sutures in the simple inverted interrupted fashion, and the skin closed with skin staples. The wound was dressed with Telfa, dressing sponge, and loose Kerlix head wrap after removing the Mayfield crown of thorns. The patient was awakened from anesthesia and extubated without difficulty. The patient was then taken to the postanesthesia care unit in stable condition. There were no additional complications.


Ventricular Tumor Endoscopic Biopsy Third Ventriculostomy Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Third ventricular tumor with hydrocephalus.

POSTOPERATIVE DIAGNOSIS:  Third ventricular tumor with hydrocephalus.

PROCEDURES PERFORMED:
1.  Endoscopic biopsy of third ventricular tumor.
2.  Third ventriculostomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General with endotracheal intubation.

TUBES AND DRAINS:  Ventricular catheter.

ESTIMATED BLOOD LOSS:  10 mL.

COMPLICATIONS:  None.

CONSENT:  The risks and benefits of the procedure were discussed at length with the patient who understands and agrees to proceed.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room where he was induced under general anesthesia and intubated. He was placed in supine position with the head straight and fixed in the Mayfield crown of thorns. Care was taken to ensure that all pressure points were carefully padded and that the limbs were positioned comfortably. The head was elevated, and the anterior portion of the right side of the head was shaved back to just behind the coronal suture. The sutures in the midline were marked and then a transverse incision was marked in front of the coronal suture for planned small craniotomy. The site was then prepped and draped in the usual sterile fashion.

The skin was incised full thickness with a number 10 blade and then hemostasis maintained with bipolar and Bovie electrocautery. Straight self-retaining retractors were placed to open the scalp incision. A single bur hole was placed in the frontal bone in front of the coronal suture with an AM3 drill bit and then the craniotomy turned with a footplate B1 drill bit on the Midas Rex drill. The craniotomy flap was removed as a single piece, and the dura was then opened in cruciate fashion. A cortical entry point between 2 cortical veins was identified as a safe location for entry, and the surface was cauterized with bipolar cautery. The arachnoid was cut with a #15 blade. An introducer sheath was inserted over an obturator into the lateral ventricle until CSF was encountered in the obturator, which was then removed. The sheath was peeled down to a length of 7 cm, and the straight endoscopic camera was then inserted.

Under endoscopic visualization, we identified the foramen of Monro. There appeared to be an entry through the septum pellucidum that allowed us to visualize the contralateral foramen as well. Entering through the right transverse foramen, we could visualize the anterior third ventricular floor and visualize vascular structures in the posterior aspect and visualize the mamillary bodies. Looking more anteriorly, we recognized the infundibular recess. We then coursed backwards through the third ventricle until a soft, pearly white mass was encountered in the posterior third ventricle. We could not visualize the aqueduct. We presumed, therefore, this represented the tumor. Using irrigation to help clear the field, grasping forceps was inserted, but it could not be well visualized and so the entire apparatus was removed. The straight camera was replaced with a 30-degree camera, and the grasping forceps was inserted. The instrument was then reinserted through the sheath. Once again, we found our landmarks in the anterior third ventricle. A small amount of cortical bleeding was controlled with irrigation. The third ventricle was traversed across a blood clot, which did obscure vision slightly; however, we were able to reidentify the tumor. Several small pieces were grasped and obtained. The tumor was noted to be very soft and friable and did bleed slightly when biopsied. These specimens were sent for frozen section.

At this point, there continued to be a small amount of bleeding, which was controlled with irrigation. Using grasping forceps, we did remove a small part of solid clot. We reidentified the floor of the anterior third ventricle and then performed our third ventriculostomy. Using the grasping forceps and scissors, the floor of the third ventricle was pierced at the thinned translucent portion. This was opened immediately in front of and above the basilar artery bifurcation, which was then visualized through the hole. With that in full visualization, we were able to advance the scope into the hole to widen it and pull back slightly. The scissors were then inserted and used to spread the hole and then cut a small strand of tissue that was binding the hole. This allowed 2 separate openings with good communication of the subarachnoid space. This was clearly visualized as well as the vascular structures below and noted to be clear.

At this point, we returned to the tumor. Once again, there was some clot in the third ventricle that obscured our vision. We coursed backwards but were able to identify some additional abnormal-looking tissue. Due to some blood staining, it was difficult to distinguish tumor from the choroid plexus, but several additional pieces were obtained. After removing a small amount of clot, the tumor became more obvious and additional 2 larger pieces were obtained from the tumor.

At this point, we ensured that we had good hemostasis within the ventricle. It was irrigated with copious amounts of lactated Ringer's and then the endoscope was removed. The ventricular catheter was then inserted through the peel-away sheath and the sheath removed. The catheter was left in place at approximately 7 cm depth at the cortical margin. CSF did freely flow from the catheter, but was not under high pressure. The catheter was then tunneled to an exit site away from the incision and then capped. The dura was loosely reapproximated with 4-0 Vicryl sutures and then overlaid with a piece of dried Gelfoam. The bone was then thinned on the side of the ventriculostomy catheter to prevent pinching it and then replaced with Synthes craniofacial plates and screws. The galea was then closed with 2-0 Vicryl sutures, and the skin closed with skin staples. The wound was dressed with Telfa dressing, sponge, and paper tape. The patient was removed from the Mayfield crown of thorns and then awakened from anesthesia and extubated without difficulty. The patient was taken to the PACU in stable condition.


Shunt Revision Medical Transcription Sample Report

DATE OF OPERATION:
MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Ventriculoperitoneal shunt malfunction.

POSTOPERATIVE DIAGNOSIS:
Ventriculoperitoneal shunt malfunction.

OPERATION PERFORMED:
Proximal left frontal ventriculoperitoneal shunt revision.

SURGEON:
John Doe, MD

ANESTHESIA:
General with endotracheal intubation.

TUBES AND DRAINS:
Ventricular catheter.

ESTIMATED BLOOD LOSS:
10 mL.

COMPLICATIONS:
None.

DESCRIPTION OF OPERATION:
The patient was brought into the operating room where he was induced under general anesthesia and intubated. He was placed in the supine position with the head in neutral position, resting on a doughnut headrest. Care was taken to ensure that all pressure points were carefully padded and that the limbs were positioned comfortably. The head was carefully marked for the midline, and the previous left frontal incision site prepped and draped in the usual sterile fashion.

After removing the skin staples, the skin was reopened using Metzenbaum scissors to cut the subgaleal sutures with left frontal curvilinear incision. The shunt catheter was identified. We noticed a small amount of bloody CSF in the reservoir. The proximal catheter was disconnected from the valve and was noted not to be draining. A syringe was hooked up to the proximal end of the valve and lightly flushed and was noted to flush very easily and was used to purge the blood and any air. The bur hole was then widened to the left to allow more lateral trajectory with a Midas Rex drill. Care was taken to cover the valve to ensure that no bone dust would be introduced. After copiously irrigating the site with lactated Ringer's, the cover was removed from the valve. The dura was cauterized with bipolar cautery and then opened with a 15 blade.

A new ventricular catheter was then passed from this site. On our first two passes, where we attempted to stay fairly lateral, no CSF was encountered. The third pass, however, which was slightly more medial, reached CSF at 4.5 cm. It was passed without the stylet slightly further to 5.5 cm, but there, it stopped draining. We noticed that with slight withdrawal of the catheter, it would begin draining vigorously at approximately 5 cm. An elbow connector was therefore slid onto the catheter and secured at this position so that with the elbow at the outer table of the bone, the catheter continued to drain. The pressure remained low, however, and drainage had to be confirmed using a Valsalva maneuver.

The catheter was then cut to length and attached to the proximal end of the valve and secured there with a 3-0 silk tie. The skin incision was extended slightly so that we could visualize the catheter at the distal end of the valve. This was due to the fact that we had to pull the valve slightly into the field of view to manipulate it for reattachment, and we wanted to ensure that, with reseating, the distal catheter did not kink. After we repositioned the valve, it was pumped and noted to pump and refill easily suggesting that there was no distal or proximal obstruction.

At this point, we closed the galea with 2-0 Vicryl sutures. An x-ray was obtained in the operating room to ensure that the catheter was not kinked beyond the valve. The skin was then finally closed with skin staples. It was dressed with Telfa dressings, sponge and paper tape. The patient was awakened from anesthesia without difficulty and extubated. The patient was taken to the PACU in stable condition.


Cystoscopy Stone Extraction with Holmium Laser Lithotripsy Transcription Sample Report

DATE OF OPERATION:
MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Left ureteral stone.

POSTOPERATIVE DIAGNOSIS:
Left ureteral stone.

PROCEDURES PERFORMED:
1.  Cystoscopy.
2.  Left ureteroscopic stone extraction with holmium laser lithotripsy and stent change.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  General inhalation.

FINDINGS:  An 8 mm proximal left ureteral stone.

SPECIMENS:  Ureteral stone fragments.

DRAINS:  6 French x 26 cm left double-J ureteral stent.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

DISPOSITION:  Stable.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old Hispanic male with obstructing left ureteral stone, status post stent placement last week. The patient has had intractable pain, nausea, and vomiting. We were unable to discharge him secondary to this. The patient presents for ureteroscopic stone management. The risks and benefits of the procedure, including but not limited to bleeding, infection, damage to the urethra, bladder, ureters, kidneys, failure to diagnose and treat all disease, recurrence of disease, need for further procedures were explained to the patient prior to the procedure, and the patient wished to proceed.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room, and after adequate anesthesia, he was placed in the dorsal lithotomy position on the OR table. The patient’s genital and perineal regions were prepped and draped in the usual sterile fashion. The 21 French cystoscope was manipulated easily through the patient's urethra, which appeared normal, into the bladder. The stent was seen effluxing from the left ureteral orifice, and the end of the stent was removed to the level of the urethral meatus.

A guidewire was then advanced through the stent and passed easily up into the left renal pelvis under fluoroscopic guidance. The stent was then removed. The cystoscope was removed, and a 4 French rigid ureteroscope was then manipulated into the bladder and into the left ureter without difficulty. It was manipulated to the level of the stone without difficulty. A 500 micron laser fiber was then placed, setting of 8 joules, was used to fragment the stone. A Segura mini-basket was then used to remove the fragments from the ureter. The wire was in the correct intraluminal location throughout the length of the ureter. The ureter was examined from the ureterovesical junction to the renal pelvis. No visible stone fragments were seen. The ureter was not perforated or traumatized by the procedure.

The ureteroscope was then withdrawn, and a fresh 6 French x 26 cm double-J ureteral stent was placed by Seldinger technique without difficulty. The wire was removed with the stent in good position. The bladder was drained. The scope was removed. The external stent tether was taped to the patient's penis in a nonconstrictive fashion. The patient tolerated the procedure well. There were no complications. The patient was awakened and transported to the postanesthesia care unit in stable condition.


Enucleation of Eye with Implantation Transcription Sample

DATE OF OPERATION:
MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Choroidal melanoma of right eye with limited nodular extraocular extension.

POSTOPERATIVE DIAGNOSIS:
Choroidal melanoma of right eye with limited nodular extraocular extension.

PROCEDURE PERFORMED:
Enucleation of right eye with implantation of 22 mm diameter bioceramic sphere.

SURGEON:
John Doe, MD

ASSISTANT:
None.

ANESTHESIA:
General plus retrobulbar Marcaine.

COMPLICATIONS:
None.

DESCRIPTION OF OPERATION:
The patient was brought to the operating room and was positioned on the operating table. Cardiac and blood pressure monitoring devices were applied. General inhalational anesthesia was induced without complications. The patient was prepped and draped in the usual fashion for a procedure of the right eye.

A lid speculum was inserted between the lids of the eye to expose the eye. The fundus was examined by indirect ophthalmoscopy, and the intraocular tumor was verified. The lid speculum was temporarily removed, and retrobulbar injection of 0.75% Marcaine plain was administered at this time. The lid speculum was reinserted between the lids to expose the eye.

A conjunctival peritomy was created with Westcott scissors, and the subconjunctival connective tissues were dissected down to bare sclera in the 4 quadrants. The 4 rectus muscles were sequentially secured with separate 5-0 Vicryl double-arm double locking sutures, and the muscles was then disinserted from the sclera with the Westcott scissors. The superior oblique and inferior oblique muscles were sequentially secured and disinserted from the sclera with Westcott scissors.

Using a hemostat for traction on the stump of the medial rectus muscle, the globe was gently elevated in the orbit. The enucleation scissors were introduced from the medial approach. The optic nerve was cut in the orbit with the enucleation scissors, and the globe was delivered from the orbit. The orbital tissues were compressed for several minutes until hemostasis had been achieved.

A 22 mm diameter bioceramic sphere was inserted into the orbit. The horizontal rectus muscles were secured in near end-to-end apposition over the implant using the previously mentioned 5-0 Vicryl sutures. Similarly, the vertical rectus muscles were secured in near end-to-end apposition over the implant using the previously mentioned 5-0 Vicryl sutures.

The Tenon's tissue was closed with multiple interrupted sutures of 5-0 Vicryl over the implant and muscles. Finally, the conjunctiva was closed with a running suture of 5-0 Vicryl. The lid speculum was removed. Bacitracin-Polymyxin ointment was applied to the surface of the conjunctiva. A large conformer was placed on the surface of the conjunctiva. The lids were patched with a sterile eye pad and Elastoplast tape dressing.

The patient tolerated the procedure well. He was awakened from general anesthesia without difficulty and was transferred to postanesthesia recovery in satisfactory condition.

Rectus Recession Operative Sample Report      Entropion Repair Operative Sample Report

Ophthalmology Operative Samples # 1             Ophthalmology Operative Sample Reports #2

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

Transscleral Fine Needle Aspiration Biopsy Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Choroidal melanoma versus metastatic carcinoma to choroid, right eye.

POSTOPERATIVE DIAGNOSIS:
Choroidal melanoma versus metastatic carcinoma to choroid, right eye.

PROCEDURES PERFORMED:
1.  Diagnostic transscleral fine needle aspiration biopsy of choroidal tumor, right eye.
2.  Implantation of iodine-125, 16 mm diameter plaque, right eye.

SURGEON:  John Doe, MD

ANESTHESIA:  Local/MAC.

COMPLICATIONS:  None.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and was positioned on the operating table. Cardiac and blood pressure monitoring devices were applied. Local anesthesia was administered in the form of a retrobulbar injection of 2% Carbocaine plain for the right eye without complications. The patient was prepped and draped in the usual fashion for a procedure of the right eye.

A lid speculum was inserted between the lids of the eye to expose the eye. A conjunctival peritomy was created with Westcott scissors, and the subconjunctival connective tissues were carefully dissected down to bare sclera in the four quadrants. Separate 4-0 black silk sutures were passed behind the insertions of the inferior, lateral, and superior rectus muscles to serve as traction sutures during the procedure. Transcorneal transillumination of the eye was then performed to cast a shadow of the choroidal tumor onto the sclera in the inferotemporal quadrant. The superior aspect of the tumor shadow extended through the insertion of the lateral rectus muscle. Consequently, the lateral rectus muscle belly was secured with a double arm, double locking 6-0 Vicryl suture and then disinserted from the sclera.

A dummy 16 mm diameter plaque was positioned on the sclera over the tumor as marked on the sclera. Four interrupted sutures of 5-0 nylon were placed as plaque fixation sutures relative to four arms of the dummy plaque. The dummy plaque was then removed. A lamellar scleral flap was raised over the center of the tumor as marked on the sclera. This flap was triangular in shape. Once the flap had been created, the fine needle aspiration biopsy was performed using 25 gauge hollow lumen straight needles and puncturing the residual sclera in the lamellar bed. Once the needle had been positioned with its tip in the substance of the tumor, aspiration was performed. The needle was withdrawn and submitted as a specimen to Cytology. Two additional needles were used to sample slightly different sites within the tumor, also via the lamellar scleral bed.

Once the biopsies had been completed, the lamellar scleral flap was closed with three interrupted sutures of 8-0 nylon. The active 16 mm diameter iodine-125 plaque was then positioned on the eye. The four plaque fixation sutures were passed through the respective holes in the arms of the plaque and tied securely. The globe was rotated back to its normal position. The lateral rectus muscle was secured to the sclera in the superotemporal quadrant. The conjunctiva was closed with interrupted sutures of 7-0 Vicryl. The traction sutures were cut and removed. Bacitracin/Polymyxin ointment was applied to the surface of the eye. The lid speculum was removed. The lids were patched with a sterile eye pad and lead shield dressing. The patient tolerated the procedure well. The patient was then transferred to the postanesthesia recovery in satisfactory condition for radiation monitoring and postoperative care.

Transvitreal Fine Needle Aspiration Biopsy of Choroidal Tumor Sample

Rectus Recession Operative Sample Report      Entropion Repair Operative Sample Report

Ophthalmology Operative Samples # 1             Ophthalmology Operative Sample Reports #2

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

Annual Health Assessment Transcription Sample Report

REASON FOR VISIT:  The patient is here for an annual health assessment.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old woman who is here to have an annual health assessment and meet me as a new primary care physician. The patient was recently evaluated and treated for diverticulitis. She had a subsequent colonoscopy about a week ago that confirmed diverticulosis, but no other colon lesions. She has been doing well since her discharge from the hospital over the summer. She has no particular symptoms referable to that today. The patient is followed by Behavioral Health for depression and anxiety and is doing well on Wellbutrin as well as Ativan at bedtime. She was diagnosed with osteoporosis. She suffered a metacarpal and a metatarsal fracture in the last year. Vitamin D and PTH levels were normal. She does weightbearing exercise several times a week. She is taking actually high doses of vitamin D, up to 2000 international units a day, and is taking sufficient calcium about 1400 or 1500 mg a day. She is also on Fosamax and tolerating that. She has arthritis of her hands and is taking fish oil and seems to be doing well on that.

PAST MEDICAL HISTORY:  Diverticulitis, diverticulosis, depression and anxiety, osteoarthritis, osteoporosis, basal cell skin carcinoma and actinic keratoses for which she sees a dermatologist yearly. She has had a trigger release, bunion surgery, fractures of her metacarpal and metatarsal bones. She has had a breast augmentation. She is status post C-section x3.

ALLERGIES:  No known drug allergies.

MEDICATIONS:  Fish oil, selenium, Wellbutrin 200 mg daily, calcium with vitamin D 1400 mg/2000 international units, I have asked that she decrease her vitamin D level to about 1000 units a day. Fosamax 70 mg weekly, acyclovir 400 mg daily for HSV prophylaxis, Colace, and lorazepam 1 mg at bedtime.

FAMILY HISTORY:  Notable for diabetes, heart disease, hyperlipidemia, hypertension, skin cancer, breast cancer and asthma. No family history of colon, ovarian, or prostate cancer.

HEALTHCARE MAINTENANCE:  The patient is a nonsmoker. One drink a week. No illicit drug use. She does weightbearing exercise 3-4 times a week and walks twice a week. She gets calcium and vitamin D in her diet and a supplement. She is good about seat belts, regular dental care and flossing. She uses sunscreen always. No history of tattoos. No blood transfusions. She is in a monogamous relationship with a man. No history of sexually transmitted diseases other than HSV. HIV negative in the past with no interval risk. Paps have all been normal, and she is requesting referral to a gynecologist.

CANCER SCREENING:  Last Pap was one year ago, and she is going to repeat with a new gynecologist. Last mammogram was normal. Last breast exam was fine. Colonoscopy last month was negative. Bone density, 6 months ago, showed osteoporosis.

IMMUNIZATIONS:  Tetanus booster last year. She had a history of varicella vaccine. She gets a flu vaccine regularly.

PHYSICAL EXAMINATION:  Blood pressure 86/72, 122 pounds. Afebrile, well-appearing woman. Oropharynx:  Clear. Anicteric sclerae. Neck:  No lymphadenopathy. Normal thyroid. Axilla:  No lymphadenopathy. Lungs:  Clear. Heart:  Regular rate and rhythm. No murmurs. Breasts:  Exam deferred to gynecologist at the patient’s request. Abdomen:  Soft, nontender, no organomegaly. Extremities:  Show no edema. Skin:  Shows marked sun damage. Neurologically nonfocal.

IMPRESSION AND PLAN:  The patient is a (XX)-year-old woman who is generally doing well, although she has history of multiple issues.
1.  Health maintenance:  Her vaccines are up to date. I recommended a flu shot. Cancer screening is up to date, and she has plans to see the gynecologist for annual Pap smear. Her lipids last year were fine with an LDL 146, HDL of 70, triglycerides of 54. I recommended repeat this fasting, sometime in the next 6-12 months. We talked about appropriate amounts of calcium, vitamin D and weightbearing exercise for her osteoporosis. She is going to continue the Fosamax, which she is tolerating. Repeat bone density due in 18 months.
2.  Diverticulosis:  We reviewed the colonoscopy report from her recent scope. We talked about high-fiber diet. We have e-mailed her the up-to-date handout on diverticulosis. We discussed that if she gets recurrent lower abdominal symptoms, especially fever or persistent pain, then she should be evaluated as she is at risk for recurrent bouts of diverticulitis.
3.  Depression and anxiety, seem well controlled on her current regimen.
4.  Skin cancer history:  Reinforced sunscreen, and she sees a dermatologist regularly.

The patient is going to return to see me for an annual health assessment.

Hemilaminotomy Diskectomy Medical Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Lumbar epidural abscess.
2.  Lumbar diskitis, L4-5.
3.  Lumbar vertebral osteomyelitis, L5.
4.  Lumbar vertebral osteomyelitis, L4.

POSTOPERATIVE DIAGNOSES:
1.  Lumbar epidural abscess.
2.  Lumbar diskitis, L4-5.
3.  Lumbar vertebral osteomyelitis, L5.
4.  Lumbar vertebral osteomyelitis, L4.

OPERATION PERFORMED:
1.  Right L4 hemilaminotomy.
2.  Right L5 hemilaminotomy.
3.  Diskectomy, right L4-5.
4.  Decompression of spinal canal at L4-5 purulent sanguineous material and scant disk debris.

OPERATIVE FINDINGS:
1.  Sanguineous purulent material was in the canal with scant disk debris.
2.  Tethered nerve root and dura dorsally and laterally prior to decompression.
3.  Freely mobile nerve root and gently pulsatile dura and nerve root following decompression.
4.  No evidence of CSF leak or bleeding upon Valsalva maneuver.
5.  No gross necrotic material outside the canal, deep in the wound or superficial in the wound.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  Less than 200 mL.

DRAINS:  Two drains sutured in, one deep to the fascia and one subcutaneously.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  After consent was obtained, the patient was administered IV access and transported to the operating room and administered general endotracheal anesthesia.  Under sterile condition, Foley catheter was applied.  Lower extremity compression garments were applied.  The patient was placed prone on the Wilson laminectomy frame and secured with leather straps.   All bony prominences were well padded.  The Wilson laminectomy frame rested on the Jackson table.  Wilson laminectomy frame was cranked into a flexed position.  The lumbar spine was sterilely prepped and draped in the normal fashion.  Then, 18 gauge needles were placed for localizing radiographs.  After satisfactory anesthesia was obtained, the procedure was commenced.

An approximately 4 cm longitudinal incision was made over the L4-5 interspace with the #10 blade scalpel.  Electrocautery was used to divide the deep subcutaneous tissues and lumbodorsal fascia.  Subperiosteal dissection was performed from the right of the midline at L4 and L5.  The ligamentum flavum was identified.  It was removed using multiple passes of Kerrison and pituitary rongeurs.  Lateral recess was taken down.  The disk space was identified.  There was fluid and scant debris emanating from the disk contained by the posterior longitudinal ligament that was decompressed.  Prior to this decompression, the nerve root was tethered just medial to lateral recess and dorsally.  Following the decompression, the nerve root was freely mobile to 1.5 cm to the center of the canal.  The dura itself was pulsatile and found to be normal in appearance.  A Penfield 4 was used to probe the posterior aspect of the L4 and L5 vertebral body.  Very scant debris was revealed, but a predominance of sanguinopurulent material.

Following this, attention was then directed toward the L4-5 interspace.  Multiple passes of micro and regular pituitaries were made to decompress the disk space.  The disk space was copiously irrigated with sterile saline solution, impregnated with bacitracin, as was the canal and the deep wound.  Following the decompression and irrigation, the nerve root was freely mobile.  Dura was pulsatile.  Dura and nerve root showed micro pulsations.  Valsalva was negative for any CSF leak or any epidural bleeding.  Whatever epidural bleeding there was, was addressed with bipolar cautery within the canal.  Bleeding outside the canal was addressed with unipolar cautery.  Wound was copiously irrigated with sterile saline solution.

Deep fascia was reapproximated over a single Hemovac drain, which was made to exit to wound to the right of midline.  The lumbodorsal fascia was reapproximated using 0 Vicryl as a simple running stitch.  Deep subcutaneous tissues were reapproximated using 2-0 Vicryl as inverted interrupted stitches.  Deep dermis was reapproximated using 2-0 Vicryl as inverted interrupted stitches.  The subcutaneous was closed over a single Hemovac drain, which was made to exit the wound to the left of midline.  Skin edges were reapproximated using 2-0 Vicryl as interrupted vertical mattress stitches.  A sterile nonadherent dressing was applied.  Light compression dressing was applied.  Hemovacs were sewn to the skin, and the Hemovacs were placed to suction and secured with tape.  The patient was transported to the hospital gurney and aroused from her anesthesia and was found to have all motor units firing and was transported to the recovery room in satisfactory condition, after having tolerated the procedure well.  At the end of case, sponge and needle counts were correct.  There were no obvious complications.


AV Graft Removal Transcription Operative Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Clotted arteriovenous graft of left upper arm.

POSTOPERATIVE DIAGNOSIS:
Clotted arteriovenous graft of left upper arm.

OPERATION PERFORMED:
Removal of AV graft, left upper arm, and repair of brachial artery with end-to-end anastomosis.  

SURGEON:  John Doe, MD

ANESTHESIA:
MAC.

DESCRIPTION OF PROCEDURE:
With the patient on the operating table, in supine position, the left arm to her side, was sterilely prepped with Betadine from hand to the axilla and draped. Marcaine 0.5% without epinephrine was used for local anesthesia. The old arterial incision was opened and extended medially and distally slightly. The dissection was carried through the subcutaneous tissues with electrocautery and needle-tip Bovie. The proximal artery and distal artery were then dissected out and controlled with vascular loops. The graft was dissected free and then bulldog clamps were placed across the artery proximally and distally, and the graft was opened in the transverse direction about 5 mm beyond the anastomosis.

Thrombus was removed from the anastomotic area, and using another #3 Fogarty, the Fogarty was passed proximally and distally in the artery, and no thrombus or clots were found in the artery. The graft itself was then declotted using Fogarty catheters. However, we were not able to pass the catheter through the anastomosis. Therefore, we felt that we needed to open the venous end, but prior to doing that we went ahead and closed the arteriotomy and the graft with interrupted 6-0 Gore-Tex sutures. The bulldogs were then removed from the artery, reestablishing flow to the hand.

Next, the old incision in the axilla was opened and the graft identified and traced down to its venous anastomosis. There was a fairly intense inflammatory response around the graft, and there was a thick sheath around the graft that, when incised, actually was not adherent to the graft. There, however, was no evidence of purulent exudate present. We did culture the graft at this location and then attempted to dissect out the proximal vein. This, however, was difficult as there were several bundles of the brachial plexus around this vein and we decided to abandon dissecting directly on the vein more proximally and instead opened the graft to try to do a thrombectomy of the graft through the graft itself.

A longitudinal incision was made on the hood of the graft, but we were only able to pass at most a 1 mm dilator through the anastomotic area. We were also able to pass a #4 Fogarty through this area, but it would only go up 5 cm to at most 10 cm, and on attempting to deploy the balloon, it was apparent that this proximal vein was actually entirely sclerosed. Therefore, we had to abandon the revision and thrombectomy of the graft and decided instead, since the graft did not seem to be well healed even at the venous end and may actually be infected, to go ahead and remove the graft. The graft was then cut from the venous anastomosis, and the vein itself was oversewn with the 3-0 Vicryl suture to prevent any backbleeding. The arterial end was then exposed once again. The graft artery anastomosis was excised, leaving an end-to-end portion of the artery for reanastomosis. The artery was mobilized proximally and distally and then end-to-end anastomosis was performed with running 6-0 Prolene sutures.

On release of the bulldog clamps on the artery, there was good flow reestablished through it with no leakage. The artery was wrapped with Surgicel for security purposes and then the graft itself was removed from the tunnel by stripping the tissues away from the graft, and actually just with gentle traction, it broke free of its attachments, again making it suspicious that the graft may have been actually infected. The tunnel was then packed with half-inch iodoform gauze just as a thin ribbon and both ends being brought out through a counter incision in the mid portion of the graft, so that the tunnel itself would be allowed to drain if need be.

The wounds were then closed after irrigating with antibiotic solution. A 3-0 Vicryl was used for the subcu and the axilla, running 4-0 Vicryl subcuticular with Mastisol and Steri-Strips, antecubital area. After subcu was closed, nylon sutures were used in a running fashion for the skin closure. A small counter incision in the mid portion of the graft was left open, and the two ends of the gauze were pulled through it. Sterile dressing and bacitracin ointment on the antecubital incision and gauze and Kerlix was applied. The patient tolerated the procedure well. Estimated blood loss was about 25 mL.

Dog Bite Emergency Room ER Transcription Sample

CHIEF COMPLAINT:  Dog bite to right cheek.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old who was bitten in the right cheek by her neighbor's dog. Mother states the dog's immunizations are up-to-date as well as the child's. The patient presents mostly with some scrape wounds, but then a small puncture wound was noted to the inferior aspect of the right cheek. There is minimal bleeding.

REVIEW OF SYSTEMS:  Otherwise negative.

PAST MEDICAL HISTORY:  No major illnesses.

ALLERGIES:  None.

CURRENT MEDICATIONS:  None.

PHYSICAL EXAMINATION:  Temperature 99.2, pulse 96, respirations 22, BP 98/64. Examination of the face shows multiple abrasions of most of the right maxillary region with a less than 1 cm superficial laceration noted at the right cheek just lateral to the right side of the lips. This does not involve the lips or the vermilion border. There is minimal depth to this.

PROCEDURE:  The area was prepped and draped in sterile fashion. It was cleansed appropriately. It was closed with Dermabond with good cosmetic appearance. This was discussed with parents prior to closure, of whether to use Dermabond or sutures, and they preferred Dermabond. They were also instructed on the possibility of infection due to the fact that this is a dog bite wound.

IMPRESSION:
1.  Dog bite to right cheek.
2.  Laceration with repair, less than 1 cm.

PLAN:
1.  Dermabond instruction sheet was given.
2.  Return as needed.
3.  Follow up with family medical doctor.
4.  Given a prescription for Augmentin.

Sample #2

CHIEF COMPLAINT: Dog bite.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old Hispanic male who was attempting to restrain his dog from going outside. He states the dog then bit him on his right foot at the fifth toe. He states when he reached down to pull the dog off of his foot, the dog then bit him in the left hand, in the webspace between his thumb and second digit. The patient states the bleeding is now under control. He denies any numbness, tingling or weakness of his hand or foot.

IMMUNIZATION STATUS:  Last tetanus shot was less than 5 years ago.

PAST MEDICAL HISTORY:  None.

MEDICATIONS:  None.

ALLERGIES:  None.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  Nonsmoker, drinks alcohol occasionally, denies any illicit drug use.

REVIEW OF SYSTEMS:  As above. Otherwise negative, per patient.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 128/84, pulse 72, respirations 22, temperature 98.6, O2 sat is 100% on room air.
GENERAL:  A well-developed, well-nourished male, in no acute distress.
HEART:  Regular rate and rhythm. No murmurs, gallops or rubs.
LUNGS:  Clear to auscultation bilaterally.
EXTREMITIES:  The patient does have an approximately 2.5 cm in diameter laceration to his left hand, on the dorsal aspect of his hand, in the webspace between the thumb and index finger. The wound is slightly gaping. There is no involvement of tendons or any vasculature. He has full range of motion of his thumb and second digit, 2+ pulses bilaterally. He does have a fairly extensive 2.5 cm laceration noted to his right foot on the plantar aspect, just proximal to his fifth digit. The wound is fairly deep but does not extend into the tendons or vasculature. The patient has full range of motion of his toes. He has capillary refill less than 2 seconds.
NEUROLOGIC:  He is alert and oriented x 4. Gross sensation is intact. Strength is 5/5 bilaterally.

EMERGENCY DEPARTMENT COURSE:  The patient's nursing notes were reviewed. The patient did have a right foot x-ray. X-ray negative for any fracture or foreign bodies.

PROCEDURE PERFORMED:
The wound on the patient's hand was anesthetized using approximately 3 mL of 2% lidocaine without epinephrine. The area was then copiously irrigated with normal saline. It was then prepped and draped in a sterile fashion, and one simple interrupted suture was placed using 4-0 Ethilon to approximate the wound. The remainder of the wound was left open in order to avoid trapping any bacteria. The wound was then covered with a sterile dressing. Attention was then turned to the patient's right foot. This area was anesthetized using approximately 3 mL of 2% lidocaine without epinephrine. That area was then copiously irrigated with normal saline. The wound was then explored to reveal a fairly deep wound. Did not appear to involve any deeper structures, but we did consult Podiatry given the high risk of infection.

Podiatry came and evaluated the patient. Dr. John Doe did apply bacitracin as well as a sterile dressing and Coban. The patient was given a cast shoe and crutches in order to remain nonweightbearing on the foot. They did not close the wound with any sutures.

MEDICAL DECISION MAKING:  At this time, the patient does have 2 dog bites that do have a high risk of infection. At this time, we will place the patient on Augmentin, and he will be followed closely by Podiatry. We will have him keep an eye on his wound to ensure there are no signs of infection.

DIAGNOSIS:  Dog bite to left hand and right foot.

PLAN:
1.  The patient is given Augmentin and Vicodin #10.
2.  The patient is to keep the area clean and dry.
3.  He is to change his dressing, of his foot, daily with bacitracin, 4 x 4, and Ace wrap.
4.  He is to wear his cast shoe and use crutches until he follows up with Podiatry. He is scheduled to follow up with Podiatry. He is to call for an appointment.
5.  He is also to call a community clinic of choice for an appointment to have his sutures removed in 10 to 14 days.
6.  Again, the patient was instructed to watch the wound closely for any signs of infection, redness, swelling, pus drainage, increased pain or fever.
7.  The patient is to return to the emergency room for any signs of infection or any other concerns.

CONDITION:  Good.

DISPOSITION:  The patient was discharged home.

ER Sample Reports       ER Sample Reports # 1

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

Cystourethroscopy Hydrodistention Transcription Sample

DATE OF PROCEDURE:
MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Pelvic pain, rule out interstitial cystitis and urethral syndrome.

POSTOPERATIVE DIAGNOSIS:
Interstitial cystitis and urethral syndrome.

PROCEDURES PERFORMED:
1.  Cystourethroscopy.
2.  Hydrodistention of the bladder.
3.  Urethral dilatation.

SURGEON:
John Doe, MD

ASSISTANT:
None.

ANESTHESIA:
General LMA.

COMPLICATIONS:
None.

INDICATIONS FOR PROCEDURE:
The patient is a (XX)-year-old female with a history of significant bladder pain and pelvic pain, of unclear etiology. Upon examination in the office, the patient was noted to have an exquisitely tender bladder and urethra and the question of interstitial cystitis was raised. The patient has had a history of a lot of irritative voiding symptoms as well. A cysto hydrodistention and urethral dilatation was recommended. Alternative treatments including the risks, benefits, and expected outcome of each were discussed in detail with the patient, and the patient desired to proceed with the planned operation.

DESCRIPTION OF PROCEDURE AND FINDINGS:
After thorough preoperative evaluation, the patient was taken to the cysto room and placed in the supine position on the cysto table. A general LMA anesthesia was administered. The patient was placed in the dorsal lithotomy position, and the external genitalia and perineum scrubbed with povidone-iodine scrub solution followed by sterile draping with towel and drapes in the usual fashion.

The 20-French cystoscope sheath and 30-degree lens with video camera was advanced through the urethra and into the bladder. The urethra showed evidence of inflammatory polyps at the bladder neck but was otherwise normal. The bladder was drained of any residual urine and urine for cytology obtained. The bladder was carefully examined. There was no evidence of neoplasm, stones, or other abnormalities. Both ureteral orifices were intact with clear efflux of urine.

The bladder was then hydrodistended at 80 cm of water pressure for 5 minutes, drained, and then re-examined. Upon re-examination, the final effluent was noted to be pink and the bladder capacity was 800 mL. Upon re-examination of the bladder, there were multiple glomerulations noted throughout the bladder wall suggestive of intersitial cystitis.

After completion of the inspection of the bladder, the bladder was left partially full and cystoscope removed. The urethra was then sequentially dilated with Walther dilators from 24 to 36 French with moderate difficulty. A small amount of bleeding was noted from the urethra after completion of the urethral dilatation.

At this point, the bladder was eventually drained of any residual urine and dilator removed. The patient was taken out of the dorsal lithotomy position and returned to postanesthesia recovery room in stable condition.


Needle Localized Excisional Breast Biopsy Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Left breast mass associated with a papilloma on core biopsy.

POSTOPERATIVE DIAGNOSIS:
Left breast mass associated with a papilloma on core biopsy.

PROCEDURE PERFORMED:
Needle localized excisional left breast biopsy.

SURGEON:  John Doe, MD

ANESTHESIA:
Local, 11 mL of 0.5% lidocaine with 0.25% Marcaine at final concentration, with monitored anesthesia care.

ESTIMATED BLOOD LOSS:
Less than 20 mL.

COMPLICATIONS:
None.

INDICATIONS FOR PROCEDURE:
The patient is a (XX)-year-old Hispanic female with family history of breast cancer. She recently underwent an ultrasound-guided left breast core biopsy for a complex cyst that she had palpated prior. A papilloma had been identified and core biopsied, and this can be associated with up to 10% chance of an associated malignancy, specifically there being a sampling error. Consequently, a needle-localized excision was recommended as this was no longer palpable with resolution of the cyst on prior core biopsy.

INTRAOPERATIVE FINDINGS:
The excised specimen was oriented with a short suture placed superiorly and a long suture placed laterally. The abnormality was identified within the intraoperative specimen mammogram.

DESCRIPTION OF PROCEDURE:
The patient was brought initially to the imaging center, where needle localization under ultrasound guidance took place in the upper outer quadrant of the left breast. The patient was then brought back to the same day surgery area and then to the operating room, where she was placed in the supine position. After administration of IV sedation, her left breast with needle inserted was carefully prepped and draped in the usual aseptic fashion.

A time-out was called and the patient's identity as well as the procedure planned, site, and side confirmed before we proceeded. The needle localization site was relatively short and straight forward. We then planned our incisions through the needle insertion site in the upper outer quadrant. It was drawn on the skin with a sterile skin marker. Local anesthetic was used to infiltrate the underlying dermis and subcutaneous tissues. The incision was made with a #15 blade scalpel and then extended through the remainder of the dermis using electrocautery, maintaining hemostasis as we progressed. It should be noted that local anesthetic was used to infiltrate each plane of dissection before the dissection was performed in order to maintain adequate anesthesia.

Skin flaps were raised both medially and laterally for the extent of the excision for a diameter of 1 to 1.5 cm about the needle hub and the tissue carefully excised. Two Allis clamps were then placed about the needle as it inserted into the breast tissue in order to maintain that relationship and keep the needle in place. Once excised, the tissue was oriented with a short suture placed superiorly and a long suture placed laterally. This was then passed off the field for intraoperative specimen mammogram.

The operative field was inspected for adequacy of hemostasis. Small points of bleeding were easily controlled with electrocautery. The wound was then inspected for adequacy of hemostasis. Having obtained excellent hemostasis, we then proceeded to close the skin in two layers, having received word from intraoperative specimen mammogram that the abnormality was present within the specimen mammogram.

The patient tolerated the procedure well. Sponge, needle, and instrument counts were all correct at the end of the procedure. The patient was brought back to the PACU at the end of the procedure, awake, and in good condition. Estimated blood loss was less than 20 mL, and there were no complications.

Total Mastectomy Medical Transcription Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Multicentric ductal carcinoma in situ of the right breast.

POSTOPERATIVE DIAGNOSIS:  Multicentric ductal carcinoma in situ of the right breast.

PROCEDURE PERFORMED:  Left and right total mastectomy with skin-sparing incision.

SURGEON:  John Doe, MD

ANESTHESIA:  General with endotracheal intubation.

ESTIMATED BLOOD LOSS:  Less than 50 mL.

COMPLICATIONS:  None.

INTRAOPERATIVE FINDINGS:  The left breast was excised and oriented with a short suture placed superiorly and a long suture placed laterally as was the right breast.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and placed in a supine position. After induction, she was carefully endotracheally intubated and administered general anesthesia. Her arms were placed on arm boards at less than a right angle to her body and secured. Both breasts as well as the lateral thoraces, shoulders, and neck were carefully prepped and draped in the usual aseptic fashion. Skin-sparing incisions were planned and drawn on the skin with small ellipses at the very edge of the areolar border bilaterally. We began on the left using a 15 blade scalpel. A time-out was called, and the patient's identity as well as the procedure, sites, and sides confirmed before we proceeded. The left breast incision was made with a 15 blade scalpel, then extended through the remainder of the dermis using electrocautery, maintaining hemostasis as we progressed. Skin flaps were raised circumferentially in the plane between the investing adipose of the skin and the investing adipose of the breast. Being that the patient was rather thin, there was very little distance between the actual breast tissue itself and the overlying skin, making for a very narrow target throughout the procedure. Skin flaps were raised down to the chest wall in the superior, medial, and inferior positions, and down to the lateral border of the latissimus dorsi muscle laterally. Once this was reached, the breast was taken off the chest wall in a superior to inferior, medial to lateral approach using electrocautery. The anterior fascia investing the pectoralis major muscle was included with the specimen and the breast mobilized laterally. On reaching the lateral border of the pectoralis major muscle, this fascia was also incised. The breast was then taken off the axilla superficially so as to not interrupt the long thoracic or the thoracodorsal neurovascular bundles. Once the breast was excised, it was delivered through the periareolar incision and the tissue oriented. A short suture was placed on the skin ellipse superiorly and a long suture placed on the skin ellipse laterally. This left breast was then passed off the field as specimen for evaluation by pathology. The skin envelope was then inspected for adequacy of hemostasis. Small points of bleeding were easily controlled with electrocautery. The wound was then irrigated with sterile saline and inspected again. Having obtained excellent hemostasis, a laparotomy sponge soaked in sterile saline was then placed within the skin envelope in order to prevent desiccation. This was then covered with a sterile towel and our attention turned to the contralateral side. Gloves as well as instruments were changed in approaching the right side. Again, the right breast was approached through a skin ellipse as well as drawn on either side of the areolar border. The skin incision was made with a 15 blade scalpel, then extended through the remainder of the dermis using electrocautery, maintaining hemostasis as we progressed. Skin flaps were raised circumferentially between the investing adipose of the skin and the investing adipose of the breast. Like the left side, there was very little distance between the actual breast tissue itself and the skin proper. The raising of the skin flaps was complicated by the fact that previous nipple exploration with duct excision had previously taken place as well as sentinel node biopsy within the low axilla. However, this was taken down to the chest wall in the superior, medial, and inferior position, and down to the lateral border of the latissimus dorsi laterally. The breast was then taken off the chest wall, including the anterior fascia investing the pectoralis major muscle. This was done in a superior to inferior and medial to lateral fashion, traveling parallel to the muscle fibers. Once the breast was mobilized laterally, the lateral border of the fascia along the pectoralis major muscle was also incised with electrocautery. The breast tissue was then taken off the axilla superficially, and once excised, was delivered through the periareolar incision. Like the left side, this was then oriented with a short suture placed superiorly on the skin ellipse and a long suture placed laterally on the skin ellipse. This was passed off the field for evaluation by surgical pathology as the right breast. The operative field was then inspected for adequacy of hemostasis. Small points of bleeding were easily controlled with electrocautery. The wound was then irrigated extensively with sterile saline and inspected again. Having obtained excellent hemostasis, this wound too was packed with sterile saline soaked laparotomy sponge and covered a sterile dry towel. The case was then turned over to Dr. Jane Doe who then proceeded with the tissue expander placements, drain placements, and skin closure. The patient tolerated the procedures well. Sponge, needle, and instrument counts up to this point were not done until the close of the case. Complications up to this point were none. Estimated blood loss up to this point was less than 50 mL.

Plastic Surgery Operative Sample Reports      Plastic Surgery Operative Sample Reports #2

Medical Transcription Word Seeker - Search Just Medical Sites - Custom Search for MTs

Port-A-Cath Insertion Medical Report Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  History of resected cholangiocarcinoma.

POSTOPERATIVE DIAGNOSIS:  History of resected cholangiocarcinoma.

PROCEDURE PERFORMED:  Port-A-Cath insertion via the right internal jugular vein.

SURGEON:  John Doe, MD

ANESTHESIA:  Local, 18 mL of 0.5% lidocaine with 0.25% Marcaine at final concentration, with monitored anesthesia care.

ESTIMATED BLOOD LOSS:  Less than 20 mL.

COMPLICATIONS:  None.

INTRAOPERATIVE FINDINGS:  Intraoperative fluoroscopy demonstrated that the tip of the catheter was in the proximal superior vena cava. There was no evidence on intraoperative fluoroscopy for a hemothorax or pneumothorax. There were no kinks in the lines. The catheter accessed with a Huber needle, could be easily aspirated as well as flushed with heparinized saline. Postoperative chest x-ray also demonstrated good placement of the tip of the catheter and the port itself with no evidence of pneumothorax or hemothorax.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and placed in the supine position. His arms were tucked and a small roll placed between his scapulae along his spine. The bed was then adjusted to Trendelenburg position. Right side of the chest, the neck, and upper arm were then prepped and draped in the usual aseptic fashion. A time-out was called, and the patient's identity as well as the procedure planned, site, and side confirmed before we proceeded. Local anesthetic was used to raise a wheal of local within the dermis under the clavicle on the right side at a distance of approximately two-thirds between that of the sternal notch and the shoulder. Once this wheal was raised, local anesthetic was then extended from that site to the clavicle. Cannulation needle was then inserted under the clavicle, but because of the broadness of his clavicle, we were unable to pass the needle under the clavicle, and therefore, this mode of access was abandoned. We then turned our attention to the performance of cannulation of his internal jugular vein on the right side. A small wheal of local anesthetic was raised at the superior apex of the triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle on the right side. With the patient's head turned slightly to the left, once the wheal was raised, a locator needle consisting of a 25-gauge needle on a syringe was carefully inserted while aiming at a 30-degree angle for the ipsilateral nipple. Having accessed venous blood, the cannulation on a syringe was then inserted adjacent to the locator needle. This was inserted and the internal jugular vein accessed, evidenced by aspiration of venous blood. The locator needle was removed and passed off the field. Guidewire was then passed with the cannulation needle, and under fluoroscopic control, advanced until it was in the proximal superior vena cava. The cannulation needle was then removed and our attention was turned to the formation of a pocket for the port. A transverse incision was drawn on the skin, planned with a sterile skin marker. This was for a length of approximately 3 cm below the clavicle, between the shoulder and the chest, in the midclavicular line, approximately 3-4 cm below the clavicle. Once drawn on the skin, local anesthetic was used to infiltrate the underlying dermis and subcutaneous tissue. The incision was made and extended through the remainder of the dermis using electrocautery, maintaining hemostasis as we progressed. Local anesthetic was then used to infiltrate the underlying subcutaneous tissues deep and inferior to this for the purpose of development of the Port-A-Cath pocket. A skin flap was then raised inferiorly deep to the investing adipose of the skin for the port itself. Once the pocket was of adequate size to accept the port, local anesthetic was then used to infiltrate subcutaneously the path between the Port-A-Cath pocket and the guidewire insertion site. A #11 blade scalpel was used to slightly enlarge the skin nick in the neck at the site of the guidewire insertion. Once this was performed, a mosquito clamp was then carefully used to dilate the subcutaneous tissues immediately deep to the skin. The catheter itself, which had been previously irrigated with heparinized saline, was connected distally to a syringe of heparinized saline and proximally to a tunneler. The tunneler was then used to tunnel the catheter from the Port-A-Cath pocket site to the guidewire insertion site. Once this was done, the tunneler was removed and again catheter flushed with heparinized saline. The dilator and introducer were placed over the guidewire and introduced into the internal jugular and over the guidewire and into the superior vena cava. This was done under fluoroscopic control and confirmed. The guidewire and the dilator were then removed, the catheter inserted into the introducer, advancing the catheter tip until it was in the proximal superior vena cava. The peel-away introducer was then carefully removed and discarded. The additional length of the catheter at the guidewire insertion site was then pulled back at the Port-A-Cath site to bring the catheter completely subcutaneous. A rubber-shod clamp was then placed over the catheter within the Port-A-Cath pocket site, and the catheter cut approximately 1 cm beyond that distally. The catheter cut site was then attached to the port and the rubber-shod catheter released. The catheter was then more fully advanced over that port catheter connector site and the locking mechanism, as provided by the company, was advanced over the connector site, locking this in place. The port was then placed within the pocket and secured to either side of the port catheter connector site, to the posterior adipose and fascia, using sutures of 2-0 Prolene. The Port-A-Cath pocket was then irrigated with sterile saline and inspected again for hemostasis. Having obtained excellent hemostasis, the port was then accessed using a Huber needle and heparinized saline. The port could be easily aspirated and flushed. Fluoroscopy was then used to ensure that there were no kinks along the catheter path and that the catheter tip was within the proximal superior vena cava. There was no evidence at that time for a hemothorax or pneumothorax. The skin of the port pocket site was then closed in 2 layers. The deep dermis was approximated using a running simple suture of 3-0 Vicryl, and the skin closed with a running subcuticular suture of 4-0 Monocryl. The guidewire insertion site was also closed with a single inverted suture of 4-0 Monocryl. Both sites were then cleansed, dried, and dressed with Steri-Strips before placement of gauze and Tegaderm dressings. The patient tolerated the procedure well. Sponge, needle, and instrument counts were all correct at the end of the procedure. The patient was then brought to the same day surgery area at the end of the procedure, awake, and in good condition. Postoperative chest x-ray failed to demonstrate any pneumothorax or hemothorax, and the catheter was in good position with no evidence for kinks.

Subscribe to: Posts (Atom)