Inferior Turbinate Submucosal Reduction Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Inferior turbinate hypertrophy.
2.  Nasal obstruction.

POSTOPERATIVE DIAGNOSES:
1.  Inferior turbinate hypertrophy.
2.  Nasal obstruction.

OPERATION PERFORMED:  Bilateral inferior turbinate submucosal reduction.

SURGEON:  John Doe, MD

 ASSISTANT:  Jane Doe, MD

 ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  Less than 10 mL.

COMPLICATIONS:  None.

OPERATIVE FINDINGS:
1.  Severely enlarging inferior turbinates bilaterally abutting the nasal septum.
2.  Minimal response to nasal decongestion.
3.  At the conclusion of the procedure, the left nasal airway was significantly larger and the right nasal airway was somewhat more narrow but significantly improved and able to visualize posterior nasal cavity.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed on the table in the supine position. A suitable plane of anesthesia was obtained, and the patient was endotracheally intubated by anesthesia personnel. Next, Afrin-soaked pledgets were instilled into the nasal cavity. The pledgets were then removed. The anterior inferior turbinate was injected with 1% lidocaine with 1:100,000 epinephrine. Afrin-soaked pledgets were then reinstilled into the nasal cavity. The patient was prepped and draped in standard fashion. The Afrin-soaked pledgets were removed.

The 0-degree endoscope was used to visualize the left inferior turbinate. The Colorado-tipped Bovie was used to make a vertical incision in the anterior head of the turbinate. Bovie cautery was used to dissect down to the level of the inferior turbinate bone.

Next, the Cottle was used to free the periosteum and submucosal tissue from the bone. Once this was adequately removed from the bone, a 2.9 inferior turbinate shaver blade was inserted, and the submucosal tissue was removed, taking care not to make any rents in the mucosa. The tissue was removed anteriorly, superiorly, medially and inferiorly back the entire length of the inferior turbinate. The mucosa was also freed from the lateral aspect of the inferior turbinate bone and isolating the inferior turbinate bone. This tissue was also shaved.

Once the submucosal turbinate tissue was removed and the inferior turbinate bone was free from the mucosa, Takahashi forceps were used to grasp the bone and fracture the bone and remove it. A significant portion of the anterior-inferior turbinate bone was removed. At this point, mucosa was lateralized and large nasal airway was achieved on the left side.

The procedure was then repeated on the right side anterior-inferior turbinate. An anterior-inferior turbinate incision was made with Bovie cautery. This was carried down to the level of the bone. Submucosal tissue was removed with the shaver blade. The inferior turbinate bone was found to be far lateralized, and a plane was not able to be achieved between the inferior turbinate bone and the lateral nasal wall. Therefore, the inferior turbinate bone was not removed. Submucosal tissue was completely removed with the shaver blade.

Since there were some mucosal abrasions along the septum on the right side, a cut Doyle splint was placed and sutured to the right nasal septum with 4-0 Prolene with the knot placed in the right nasal cavity to separate the septal mucosa from the inferior turbinate mucosa. The inferior turbinate was lateralized, and the procedure was terminated. There was no significant bleeding at the conclusion of the case.

Breast Needle Localized Lumpectomy Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

 PREOPERATIVE DIAGNOSIS:  Right breast cancer.

 POSTOPERATIVE DIAGNOSIS:  Right breast cancer.

 OPERATION PERFORMED:
1.  Right breast needle-localized lumpectomy.
2.  Sentinel node biopsy.
3.  Axillary node dissection.

 SURGEON:  John Doe, MD

ANESTHESIA:  General.

COMPLICATIONS:  None.

 INDICATION FOR OPERATION:  This is a (XX)-year-old Hispanic female who underwent a needle biopsy, which showed right breast carcinoma.  After weighing options, the patient opted for right breast needle localization, lumpectomy, sentinel node biopsy, possible axillary node dissection.

The risks and benefits of the procedure were explained to the patient. Informed consent was obtained. The patient then underwent preoperative needle localization by the radiology department.

 DESCRIPTION OF OPERATION:  The patient was taken to the operating suite and placed in the supine position. General anesthesia was given by the anesthesiology department. The right breast and arm area were prepped and draped in the normal sterile fashion. Lymphazurin was injected in the right retroareolar area. Breast massage was then performed.

A small incision was made directly in the right axilla. Dissection was carried down through the subdermal layers using cutting. Once the clavipectoral fascia was incised, there was clearly a very large synovial cyst, suspicious for possible malignancy, noted.

At this point, a formal axillary node dissection was done due to intraoperative findings. Clips were used to ligate the small veins. At this point, the specimen was submitted for pathology. The wound was copiously irrigated. There was no active bleeding noted. A #10 JP drain was brought in through a separate stab incision. The drain was sutured to the skin using #2-0 nylon. The wound was closed with a 4-0 Vicryl in a running subcuticular manner. The wound was injected with lidocaine and Marcaine solution.

A whole new setup was then used for the lumpectomy. A small incision was made directly at the exit site of the needle.  Dissection was carried out through the subdermal layers using cutting. The needle was then brought into the wound, and a small skin flap was then created, and a wide circumferential dissection was performed all the way to the pectoralis muscle.

Subfascial dissection was then performed. Specimen was appropriately tagged and forwarded to Radiology. The radiologist confirmed the presence of the malignancy in the specimen with a greater than 1 cm margin all the way around.

The wound was copiously irrigated. No signs of bleeding noted. Clips were placed for future radiation therapy in the cavity. Skin was injected with Marcaine and lidocaine solution. Then 4-0 Vicryl was used to close the skin in a running subcuticular manner. Steri-Strips and sterile dressings were then applied. The patient was sent to recovery room in satisfactory condition.

INTRAOPERATIVE FINDINGS:
1.  Right breast needle-localized lumpectomy and axillary node dissection.
2.  All needle, sponge, and instrument counts were noted to be correct.

Closed Reduction of Vertebral Fracture Sample Report

DATE OF OPERATION:  MM/DD/YYYY

 PREOPERATIVE DIAGNOSES:
1.  C5-6 facet fracture. 
2.  Left C6 radiculitis. 

 POSTOPERATIVE DIAGNOSES:
1.  C5-6 facet fracture.
2.  Left C6 radiculitis.

 OPERATIONS PERFORMED:
1.  Attempted closed reduction of vertebral fracture and subluxation with traction. 
2.  Subsequent open reduction and treatment of vertebral fracture and subluxation. 
3.  C5-6 anterior cervical diskectomy and fusion. 
4.  Anterior cervical instrumentation C5-6. 
5.  Left anterior iliac crest structural bone graft harvest. 
6.  Use of operating microscope. 
7.  Application and removal of cranial tongs. 

 SURGEON:  Jane Doe, MD

 ASSISTANT:  John Doe, MD

 ANESTHESIA:  Local followed by general endotracheal.

 ESTIMATED BLOOD LOSS:  Approximately 100 mL.

 IMPLANTS:  DePuy Eagle plate with four screws. 

 COMPLICATIONS:  None.

 DESCRIPTION OF OPERATION:  The patient was taken to the operating room, and using 1% lidocaine and antibiotic ointment, Gardner-Wells tongs were placed in line with the external auditory meatus approximately a centimeter above the ear. The anesthesiologist provided some conscious sedation. The patient tolerated the placement of tongs very well.

 Ten pounds of traction were then added and a lateral C-arm image obtained, which showed persistent subluxation. Manual traction was then applied and maneuvers attempted with rotation as well as flexion and extension in an attempt to reduce the fracture. However, persistent subluxation was noted, and the decision was made to proceed with open reduction.

 The patient was then administered general anesthetic with use of in-line traction. SSEP and EMG monitoring leads were placed. A Foley catheter was in place. Preoperative antibiotics were administered. SCDs were applied. The patient's arms were tucked to the side. The cervical spine and the left anterior iliac crests were prepped and draped in the standard sterile fashion.

 A transverse incision was made overlying the C5-6 interspace. The platysma was divided in line with the incision. The anterior fold between the strap muscles, trachea and esophagus medially and the sternocleidomastoid and carotid sheath laterally was developed bluntly. The prevertebral fascia was incised and the subluxed level identified, both clinically as well as with a lateral C-arm image by placing a spinal needle within the disk space. The longus coli was elevated off of the C5-6 interspace bilaterally and self-retaining retractors placed below the longus coli muscles bilaterally.

 The operating microscope was then brought in for the decompression and preparation of the anterior space. The diskectomy was performed with a series of curettes and rongeurs. The PLL was torn off of the posterior aspect of the C5 body; however, it was in continuity and there was no tear within its substance. The fracture was reduced via application of Caspar distractor and applying posterior translational force to the C5 body. AP, lateral and oblique C-arm images were obtained and showed perhaps a millimeter of residual subluxation related to rotational instability. This reduced with posteriorly directed force and rotation to the left, and it was felt that it could be held with the plate applied in this position. The disk space was measured with a trial and an 8 mm graft fit well.

 An incision was made over the iliac crest over two fingerbreadths away from the ASIS. The fascia overlying the iliac crest was incised and the inner and outer tables exposed a couple of centimeters deep. Two Cobb elevators were placed within the wound to protect the soft tissues and an 8 mm by approximately 12 mm graft was harvested with an oscillating saw and osteotome. This was then placed within the C5-6 interspace and a single level Eagle plate applied with four screws, each of which had excellent purchase while holding the spine in a reduced position. The repeat C-arm images showed satisfactory alignment and placement of the instrumentation and graft.

 The wound was thoroughly irrigated with antibiotic irrigation. A Penrose drain was placed and the platysma closed with interrupted figure-of-eight 3-0 Vicryl stitches. The skin was then closed with 4-0 running Monocryl stitch. The iliac crest wound was closed with 0 Vicryl interrupted figure-of-eight stitches within the fascia followed by 2-0 Vicryl interrupted buried stitches in the skin and a 4-0 running Monocryl. Steri-Strips and sterile dressings were applied to both wounds. A new Philadelphia collar was applied, and the patient's tongs were removed. The patient was awakened without difficulty and was able to move bilateral upper and lower extremities to command. The patient was then taken to the recovery room in stable condition. There were no intraoperative complications.

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Posterior Tibial Tendon Repair Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

 PREOPERATIVE DIAGNOSIS:  Left foot and ankle posterior tibial tendon tear with arch collapse and calcaneal valgus.

 POSTOPERATIVE DIAGNOSIS:  Left foot and ankle posterior tibial tendon tear with arch collapse and calcaneal valgus.

 OPERATION PERFORMED:
1.  Left foot posterior tibial tendon repair and advancement with flexor digitorum longus tendon transfer.
2.  Left calcaneal medial slide osteotomy.
3.  Left midfoot arthrodesis at the first metatarsal cuneiform joint.

 SURGEON:  John Doe, DPM

 ANESTHESIA:  General with local of 20 mL of 0.5% Marcaine with epinephrine.

 HEMOSTASIS:  Left thigh tourniquet at 300 mmHg for 120 minutes.

 COMPLICATIONS:  None.

 ESTIMATED BLOOD LOSS:  Minimal.

 SPONGE AND NEEDLE COUNT:  Correct.

 DESCRIPTION OF OPERATION:  Under mild sedation, the patient was brought in and placed on the operating table in the supine position. Following general anesthesia and 600 mg of clindamycin, approximately 20 mL of 0.5% Marcaine with epinephrine was injected about the left ankle. The foot was then scrubbed, prepped and draped in the usual aseptic manner. The left leg was then elevated and exsanguinated. The left thigh tourniquet was inflated to 300 mmHg. Attention was then directed to the medial aspect of the left ankle where a 5 cm incision was made along the posterior tibial tendon. The incision was then deepened down to the tendon. The tendon sheath was incised. There was moderate synovial fluid expressed as well as synovitis. There was a 1.5 cm linear tear of the posterior tibial tendon by the medial malleolus with moderate to severe attenuation of the tendon. The tendon was debrided and repaired at the linear partial tear with #5 nylon. It was then released from the base of the navicular. There was also a small accessory navicular bone that was removed from the tendon. The plantar medial aspect of the navicular was then resected utilizing the oscillating bone saw. The tendon sheath was developed for the flexor digitorum longus tendon. It was also noted that besides the posterior tibial tendon being severely attenuated, also the spring ligament had a partial tear and attenuation of the spring ligament at the talonavicular joint. The flexor digitorum longus tendon was identified and then followed back as far proximal as possible to the medial malleolus and then was released distally proximal to the master knot of Henry of the flexor hallucis longus tendon. A drill hole and tapping was done for the 5.5 Bio-Corkscrew screw, and the incision was then packed temporarily.

 Attention was then directed to the first metatarsal cuneiform joint. It was noted to have severe laxity and hypermobility of the first ray. A 3 cm incision was made over the dorsomedial aspect of the first metatarsal cuneiform joint. The incision was then deepened down to the level of the joint. The articular cartilage and subcondylar bone was then resected utilizing oscillating bone saw and bone curettes. The bone was then fenestrated with 0.062 inch K wire and then irrigated. Attention was then directed to the lateral heel where a 4 cm linear incision was made just posterior to the peroneal tendons. Incision was then deepened down to the subcutaneous tissue. The sural nerve and lesser saphenous vein were identified and retracted anteriorly. A linear incision was made at the periosteum and then a linear osteotomy performed of the calcaneus. The ostium was then shifted medially approximately 8 mm and then fixated with two Acutrak Plus screws, 60 mm and 45 mm in length. Good alignment and good compression was noted clinically and radiographically. The incision was irrigated with copious amounts of normal saline and gentamicin. The rough edges of the osteotomy were then smoothed, and the incision was closed with 4-0 Vicryl and 4-0 nylon. Attention was then directed to the first metatarsal cuneiform joint arthrodesis and temporarily fixated with a 0.062 inch K wire and then a 4 hole Lapidus plate and Arthrex set, two locking screws proximally, one distally, and a cancellous screw in the central portion, and also the temporary guide was removed and then a 4.0 cancellous screw was then placed from the first metatarsal into the medial cuneiform from dorsal distal to plantar proximal. Good alignment and fixation noted clinically and radiographically with good stability of the arch and decreased hallux valgus and bunion. The incision was then flushed and closed with 4-0 Vicryl and 4-0 nylon. Attention was then directed to the posterior tibial tendon where a 5.5 Bio-Corkscrew anchor was then placed in the plantar medial aspect of the navicular. The posterior tibial tendon and flexor digitorum longus tendon were then advanced and attached to the anchor and then reinforced with a modified Krackow stitch. The distal ends of the tendon were also reinforced with #2 FiberWire. The spring ligament had to also be repaired with #2 FiberWire.

 The incision was then flushed and closed with 3-0 Vicryl for the tendon sheath and 4-0 Vicryl and 4-0 nylon for the skin. The foot was then injected with an additional 10 mL of 0.5% Marcaine with epinephrine and bandaged with Betadine-soaked Adaptic, Betadine-soaked 4 x 4's, fluffs, Kling, cast padding, and short leg 3-way splint. The left thigh tourniquet was deflated at approximately 120 minutes with prompt hyperemic response to all digits of the left foot. The patient left the OR for the PACU with vital signs stable. The patient is to remain toe-touch weightbearing and follow up in one week and was placed in a short leg cast.

Acute Renal Failure Consultation Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

 REFERRING PHYSICIAN:  John Doe, MD

 REASON FOR CONSULTATION:  Acute renal failure.

 HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old with history of hepatitis C and cirrhosis of the liver.  He was sent to the emergency room from the nursing home with a history of painful lower extremities, decreased urine output, and petechial lesions over his extremities.  The patient himself is a very poor historian.  He also appears to be disoriented to time, and therefore, reliable history could not be obtained from the patient.  The nursing home note also suggests that the patient had been confused.  Also noted was increased severity of his skin lesions, and the patient had not voided for about 8 hours prior to his transfer to the emergency room.

 PAST MEDICAL HISTORY:  Significant for cirrhosis of the liver, history of hepatitis C, history of type 2 diabetes, coronary artery disease, hypertension, spinal stenosis, herniated disk, history of osteoarthritis, and benign prostatic hyperplasia.

 PAST SURGICAL HISTORY:  Includes cholecystectomy, appendectomy, and hernia repair.

 MEDICATIONS:  In the nursing home included Aldactone 25 mg b.i.d., sliding scale insulin, folic acid, Lortab, Glucotrol XL 10 mg daily, Ativan 1 mg q 6 hours p.r.n., multivitamin, vitamin C, Benadryl, Protonix, Inderal 10 mg daily, and Lasix 20 mg b.i.d.  The patient also was on ProMod milkshake.

 It also appears that he was admitted just recently, earlier this month.  He was discharged with a PICC line for unclear reasons.  It appears that the PICC line was removed two weeks ago.  He also had a large-volume paracentesis last month.

 SOCIAL HISTORY:  Unobtainable from the patient.  Previous H and P suggests that he has no history of tobacco but is a recovering alcoholic, who has been sober for the past five years.

 FAMILY HISTORY:  Significant for coronary artery disease.

 PHYSICAL EXAMINATION:
GENERAL:  The patient is lethargic and confused.  He is oriented to place and person but does not remember sequence of events that made him get hospitalized.
VITAL SIGNS:  His blood pressure is ranging between 116 and 128 systolic, diastolic between 70 and 84.  Pulse is in the 80s.  Intake/output recorded as 500 mL in and 120 mL out.
HEENT:  Pupils are round and reactive to light.
NECK:  Supple.  No jugular venous distention noted.
LUNGS:  Clear.
HEART:  Regular rate.
ABDOMEN:  Distended with ascites.
EXTREMITIES:  He had 1+ thigh edema.

 LABORATORY DATA:  Yesterday, his BUN was 54, creatinine was 2.6, sodium 130, potassium 5.5, chloride 102, CO2 of 24, AST 46, alkaline phosphatase 362.  Albumin was low at 2.  Total protein 5.6, calcium 7.8. ALT was 54, amylase was 18, and lipase was normal at 156.  CBC, white count of 11.6, hemoglobin of 11.8, and platelets of 306.  His BNP was 150.  His previous labs were reviewed.  It appears that he has had recently an extensive workup for his petechial lesions, most of that was negative.  Significantly, he did have positive hepatitis C antibody.  His hepatitis B surface antigen was nonreactive.  His urinalysis today reveals 1+ protein, 3+ blood, 1+ leukocyte esterase, 10-15 hyaline casts, 20-40 wbc's, 20-40 rbc's, and 2+ bacteria.

ASSESSMENT:
1.  Acute on chronic renal failure.  The etiology could be prerenal azotemia, could be due to urosepsis and resulting acute tubular necrosis.  We will also have to consider hepatorenal syndrome.  Another possibility is cryoglobulinemic glomerulonephritis as the patient is positive for hepatitis C and also has some skin lesions.
2.  Cirrhosis of the liver.
3.  Hyperkalemia is due to renal failure and Aldactone use.
4.  Diffuse petechial lesions, more prominent on his lower extremities, the etiology is uncertain.  Some of them appear like target lesions seen in erythema multiforme, but the patient reports that they have been present since he was a child, but it is unclear if this is reliable history.  Another consideration is cryoglobulinemia causing skin lesions, even though the appearance is not a typical purpuric lesion that we find in cryoglobulinemia.
5.  History of diabetes.
6.  Possible urinary tract infection.

 PLAN:  At this time, we will administer IV fluids as well as albumin and observe his response.  We will obtain urine electrolytes, C3 and C4 complement levels, and cryoglobulin level.  Obtain abdominal ultrasound.  We will temporarily stop his Aldactone due to the presence of hyperkalemia.

 We will continue to follow the patient with you.  Thank you, Dr. Doe, for allowing us to participate in the care of this patient.

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Vision Loss Ophthalmology Consult Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

 REASON FOR CONSULTATION:  Loss of vision in left eye.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old Hispanic woman who was transferred from an outside hospital where she was admitted with blurry vision.  The patient stated that she was at work, and over a few hours, she lost vision in her left eye.  She could not drive.  She had difficulty walking.  Prior to that, she was having some itching in her eyes for the last one week.  She was taking Flonase.  The patient's friend took her to the hospital where she had to help her walk.  The patient was transferred here for further evaluation.  The patient complained of generalized body ache since yesterday.  She denied any fever.  The patient denied any weakness, numbness in her arms and legs.  She never had these symptoms ever before.  There is no family history of multiple sclerosis.  The patient denied any rash.  She is under stress as her mother is in the hospital with cancer of the lungs.  The patient is able to take care of herself.

PAST MEDICAL HISTORY:  Gastric ulcer.

PAST SURGICAL HISTORY:  None.

SOCIAL HISTORY:  The patient lives with a roommate.  She denied any smoking and alcohol use.

MEDICATION:  Afrin and Percocet.

 FAMILY HISTORY:  Cancer.

PHYSICAL EXAMINATION:
GENERAL:  The patient is lying in bed, crying in pain.
HEENT:  Normal.
NECK:  Supple.
LUNGS:  Clear.
HEART:  S1 and S2 normal.
NEUROLOGIC:  Alert and oriented x2.  Speech was normal.  Affect: The patient was constantly crying.  Cranial nerve examination:  The patient had 2 mm dilated pupils, slowly reactive.  Extraocular movements are intact.  She could not count fingers from her left eye.  She had light perception.  She could not recognize the color, and on the right side, she could count fingers.  Rest of the cranial nerve examination was normal.  Motor examination was very difficult to do, as the patient was in extreme pain.  She was extremely tender to touch all over.  Reflexes, 2+ knees, 1+ ankle reflexes, downgoing toes.  Sensory examination was grossly intact.  Coordination:  Gait was not checked due to severe pain.

ASSESSMENT:  This is a (XX)-year-old Hispanic woman who was admitted to the hospital with loss of vision in the left eye.  The patient's neurological examination revealed loss of vision in her left eye to light perception only.  Differential diagnosis includes optic neuritis, but we cannot explain the patient's generalized pain.  We would also keep local eye disease like central retinal artery occlusion in our differential even though we do not think that is the case in her.  Generalized pain is of unclear etiology.  She is under stress.  An MRI of the brain and orbit was normal.  Sedimentation rate is 20.

PLAN:
1.  Visual evoked potentials.  If the patient has evidence of optic neuritis, we will start her on IV steroids.
2.  Pain control.
3.  Ophthalmology consultation.
4.  Motrin.

Thank you, Dr. Doe, for giving us the opportunity to evaluate this pleasant patient.

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Carotid Artery Stenosis Evaluation Consult Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Evaluation and treatment of carotid artery stenosis.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old Hispanic male referred for evaluation of carotid artery stenosis.  During routine workup, a stress test was performed as well as a sonogram of the carotids.  The sonogram of the carotids showed a significant stenosis in the right internal carotid artery.  With these results, an MRA was requested showing arteriosclerosis and narrowing of the proximal right internal carotid artery with a focal high-grade stenosis approximately 1 cm distal to the bifurcation, estimated approximately 90%.  Normal appearance of the left internal carotid artery with bilateral normal vertebral arteries and basilar artery.  The patient is complaining of intermittent dyspnea, no other symptoms.  No symptoms of amaurosis fugax or focalized sensory or motor deficits.

PAST MEDICAL HISTORY:  Positive for hypertension, hyperlipidemia, peptic ulcer disease, gastroesophageal reflux disease, coronary artery disease, and status post myocardial revascularization.  There is no history of diabetes, stroke or cancer.

PAST SURGICAL HISTORY:  Positive for coronary artery bypass graft x3, status post bilateral inguinal hernia repair, status post laparoscopic cholecystectomy, and status post PTCA to coronary arteries.

MEDICATIONS ON ADMISSION:  Zocor, Toprol XL, Norvasc, aspirin, and hydrochlorothiazide.

FAMILY HISTORY:  Positive for coronary artery disease.

SOCIAL HISTORY:  The patient lives by himself and has one daughter.  The patient smoked intermittently, but quit several years ago.

REVIEW OF SYSTEMS:  The patient has had no weight loss or weight gain in the recent past.  No fever in the recent past.  The patient complained of fatigue and occasional dizziness.  The patient wears glasses for reading.  No history of pain, double vision, glaucoma or cataracts.  History of ringing in ears.  No history of vertigo, hoarseness or frequent nosebleed.  No pain urinating, no burning.  The patient describes prostatism with increased frequency and urination at nighttime.  No hematuria.  No history of shortness of breath, no coughing, no wheezing, no persistent cough, and no frequent infections.  No abdominal pain.  No nausea, no vomiting, no heartburn.  No upper or lower GI bleeds.  The patient complains of intermittent constipation.  Positive for chest pain and palpitations.  No abnormal bleeding or hypercoagulable state.  The patient is complaining of stiffness and muscle pain in the upper and lower extremity.  No seizures or memory loss.  No CVAs.  No loss of consciousness.  No rashes or sores.  No itching, no burning of the skin.

PHYSICAL EXAMINATION:
VITAL SIGNS:  The patient is afebrile, pulse 66, respirations 18, and blood pressure 154/82.
GENERAL APPEARANCE:  The patient is awake, alert, oriented, in no acute distress.  Well nourished and well developed.
HEENT:  Head is normocephalic and atraumatic.  No sinus or mastoid tenderness.  Pupils are equal and reactive to light and accommodation.  Extraocular muscle movements are intact.  The oropharynx is clear.  Oral mucosa is pink and moist.
NECK:  Supple and symmetrical.  No jugular vein distention.  No thyromegaly, no lymphadenopathy.  The patient has a right carotid bruit.
CHEST:  Symmetrical with a surgical scar from the previous bypass surgery.
LUNGS:  Decreased breath sounds on both bases, but the lungs are clear.  No wheezes, rales or crackles.
HEART:  Shows a regular rate and rhythm.  S1 and S2.  No murmurs, rubs, or gallops.
ABDOMEN:  Soft, nontender.  Bowel sounds are present.  No visceromegaly, no palpable masses, no detectable bruits, no guarding or peritoneal signs.  Surgical scar from a previous procedure.
EXTREMITIES:  No edema, cyanosis, clubbing or joint swelling.  No calf pain.
VASCULAR:  Peripheral pulses are present in all extremities with good capillary refill.
NEUROLOGICAL:  No gross motor or sensory deficits.  The patient is awake, alert, and oriented x3.

DIAGNOSTIC TESTS:  MRA, as previously described in the history of present illness.  EKG shows a normal sinus rhythm with left atrial enlargement.  Anterolateral T-wave abnormalities.

LABORATORY TESTS:  White blood count 5.6, hemoglobin 15.6, hematocrit 45.4, and platelets 154,000.  PT 13.4, PTT 29.8.  Sodium 140, potassium 3.5, chloride 98, CO2 of 26, glucose 92, BUN 16, and creatinine 1.1.  Total protein 8.6, albumin 4.8, magnesium 1.8.  Urinalysis within normal limits.

IMPRESSION:
1.  Severe right internal carotid artery stenosis.
2.  Arterial disease.
3.  Status post coronary artery bypass graft surgery.
4.  Hypertension.
5.  Dyslipidemia.
6.  Gastroesophageal reflux disease.

PLAN:  With the previous information, the patient has an asymptomatic severe right carotid artery stenosis; its treatment option is carotid endarterectomy.  Risks and possible complications were explained to the patient as well as treatment options.  The patient agrees with the procedure and will proceed with a right carotid endarterectomy.  We will do intraoperative EEG evaluation as well as a cerebral oximetry during the operative procedure.  The patient agrees.

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Congestive Heart Failure Consult Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old Hispanic male, who was transferred for hypotension. Medical history is from review of the medical record and nursing home records, as the patient is unable to provide a significant amount of information. The patient was transferred from the nursing home for several days of generalized weakness and was noted to be hypotensive in the nursing home. The nursing home records reflect that the patient has had a new cough with green sputum, though he, over the past few days, has had decreased breath sounds and crackles, right more than left, with a few expiratory wheezes as well. He has not had a documented fever in the nursing home. He was treated in the nursing home for bronchitis with Biaxin, mucolytics, Robitussin, and was started on Bumex for venostasis disease. The patient was admitted today with hypotension. In the ambulance, his systolic blood pressure was approximately 80 while in the emergency department his systolic blood pressures in both arms were in the 60s. He was given approximately 2 liters of fluid during his time in the ER and atropine and was started on a dopamine drip. His initial EKG demonstrated sinus rhythm with a ventricular rate of approximately 44 beats per minute with a prolonged PR interval though no evidence of acute ischemic events. No ST segment abnormalities.

PAST MEDICAL HISTORY:  COPD, for which the patient takes prednisone on every-other-day basis, diabetes mellitus, hypertension, benign prostatic hypertrophy, chronic renal insufficiency, and sick sinus syndrome.

MEDICATION ALLERGIES:  NKDA.

 SOCIAL HISTORY:  Unknown whether or not the patient is a smoker or a drinker, and it is unknown what the patient's prior occupation was.

FAMILY HISTORY:  Noncontributory.

CURRENT MEDICATIONS:  In the nursing home include Mucinex, Bumex, Tylenol as needed, Biaxin, Colace, glyburide 10 mg twice daily, fluticasone nasal spray, GlycoLax, metformin 500 mg twice daily, multivitamins, lisinopril 2.5 mg daily, Flomax, Lasix, loratadine, Aldactone 25 mg daily, Toprol-XL 50 mg daily, Zocor 20 mg daily, NovoLog, prednisone 10 mg 3 times a week on Monday, Wednesday, and Friday.

REVIEW OF SYSTEMS:  From the medical record indicates no constitutional symptoms, no fever, no chills, although he does report weakness. He denies shortness of breath or recent chest pain or pleuritic chest pain. He denies recent syncope. The patient had a recent echocardiogram, which demonstrated an ejection fraction of 65% with an increased LV size, mitral valve leaflets with normal motion, but mild left atrial dilatation, RA and RV with normal size and unremarkable IVC, though he had mild TR and an estimated right ventricular systolic pressure of 53 mmHg and was interpreted as mild diastolic dysfunction with mild-to-moderate pulmonary hypertension.

PHYSICAL EXAMINATION:
VITAL SIGNS:  The patient's vital signs upon arrival to the intensive care unit are blood pressure of 120/56, heart rate ranging from 50 to 68 with sinus rhythm, respiratory rate approximately 22 times per minute, and a temperature of 95.6 degrees.
GENERAL:  The patient is sleepy and lethargic, though is arousable and does answer questions for a brief period when prompted to do so. He does follow commands until he falls asleep.
HEART:  The patient has a regular rate and rhythm. S1 and S2 are appreciated.
LUNGS:  There are diffuse bilateral crackles in the posterior lung fields. Also heard are bilateral expiratory wheezes with a few scattered inspiratory squeaks.
ABDOMEN:  Soft and nontender.
EXTREMITIES:  Display significant symmetric lower extremity edema, 3+ bilaterally, as well as erythematous, warm lesions to both anterior legs consistent with cellulitis.

LABORATORY AND DIAGNOSTIC DATA:  Demonstrates blood gas with pH of 7.34, pCO2 of 50.6, and pO2 of 57.8. Chemistry with a sodium of 135, potassium 4.2, chloride 100, CO2 of 30, BUN 54, creatinine 2.0, and glucose of 62. Albumin is 2.5. Total bilirubin is 0.4. Magnesium is 2.6. Troponin is less than 0.4, and BNP is 106. INR is 0.92. White count is 10.8, hemoglobin is 12.4, hematocrit is 38.6, and platelets are 184. Urinalysis, urine cultures, and blood cultures are pending at this time. A chest x-ray was done in the emergency department demonstrating pulmonary vascular congestion and a widened mediastinum on this portable view. He had a CAT scan done in the past demonstrating wide mediastinum due to mediastinal lipomatosis, though he had a prominent ascending thoracic arch at that time, which measured 4.2 cm as well.

ASSESSMENT:  This gentleman has a congestive heart failure and chronic obstructive pulmonary disease exacerbation in the setting of an infection, possibly cellulitis, possibly urinary tract infection complicated by excessive beta blockade.

PLAN:  We will treat his CHF exacerbation with intermittent doses of loop diuretics and with CPAP 6 cm of water pressure. We will treat his underlying infection, which likely include cellulitis and possibly an urinary tract infection, with cefepime which he has already received in the emergency department and vancomycin to cover resistant gram positive, which may be responsible for his cellulitis. We will obtain a CAT scan of his chest to evaluate the mediastinal widening in the presence of a known ascending thoracic arch prominence on a prior CAT scan and low blood pressure. We will hold metformin and oral diabetes medications and instead place him on an insulin sliding scale. We will treat his COPD exacerbation with albuterol and Atrovent nebulizers and increase his steroids to Solu-Medrol 40 mg q. 8 hours IV. The patient is currently not bradycardic, though if bradycardia persists despite dobutamine, we will initiate therapy with glucagon to reverse beta blockade. The patient likely suffers from obstructive sleep apnea, as he is noted to have a thick neck and is obese and was noted to be snoring. We will prescribe empiric CPAP therapy for the presumed diagnosis of sleep apnea, as well as for a CHF exacerbation.

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Pediatric SOAP Note Dictation Sample Report

CHIEF COMPLAINT:  Sore throat.

SUBJECTIVE:  The patient is a (XX)-year-old female who presents to the clinic with father due to concerns for sore throat.  The patient states that over the past three days, she has had difficulty with sore throat, runny nose, cough and nasal congestion.  Yesterday, she also had a fever of 101.  Her appetite has been decreased.  She is still maintaining good fluid intake.  No vomiting or diarrhea.  No sick contacts at home; however, she does attend school. Medications included Tylenol during this illness. No known drug allergies.

OBJECTIVE:
VITAL SIGNS:  Temperature 98.2 and weight 51 kg.
GENERAL:  Alert, in no acute distress.
HEENT:  Normocephalic and atraumatic.  Pupils are equal, round, and reactive to light.  Conjunctivae are clear.  Tympanic membranes are clear bilaterally.  Nares are patent, free of discharge.  Oropharynx has slight erythema.  No tonsillar exudates.
NECK:  Supple with shotty anterior cervical lymphadenopathy.
LUNGS:  Clear to auscultation bilaterally.
HEART:  Regular rate and rhythm without murmur.
ABDOMEN:  Benign.
SKIN:  Free of rashes.

LABORATORY DATA:  Rapid strep screen was negative.

ASSESSMENT:  A (XX)-year-old female with viral nasopharyngitis.

PLAN:  A rapid strep screen was performed in the clinic today, which was negative.  We will send this for culture and contact the family with appropriate medical management if it returns positive.  Otherwise, discussed likely viral etiology of illness.  Supportive care measures were reviewed.  The patient and her father were advised about warning signs and to return to clinic if any noted. Otherwise, follow up as needed.

Sample #2

CHIEF COMPLAINT:  Possible eye infection.

SUBJECTIVE:  The patient is an (XX)-year-old female who presents to the clinic with mother due to concerns for possible pinkeye.  Mother states that over the past three to four, her eyes have been watering a lot, and there was a little bit of green discharge.  They also appear slightly red.  Over the past few days, she has also had runny nose and nasal congestion.  The patient denies any fever or coughing.  Overnight, she began complaining of ear pain.  She is still maintaining good oral intake.  No vomiting or diarrhea.  No sick contacts. No routine medications.  No known drug allergies.

OBJECTIVE:
VITAL SIGNS:  Temperature 98.2.  Weight 15.8 kg, height 94 cm.
GENERAL:  Alert, in no acute distress.
HEENT:  Normocephalic and atraumatic.  Pupils are equal, round, and reactive to light.  Conjunctivae are clear.  She does have some watering of the eyes noted.  Tympanic membrane on the right is erythematous and bulging, left is clear.  Nares are patent, clear rhinorrhea.  Oropharynx is pink and moist.
NECK:  Supple.
LUNGS:  Clear to auscultation bilaterally.
HEART:  Regular rate and rhythm without murmur.
ABDOMEN:  Benign.
SKIN:  Free of rashes.

ASSESSMENT:
1.  Right otitis media.
2.  Mild conjunctivitis.
3.  Viral upper respiratory infection.

PLAN:  Recommended beginning the patient on a 10-day course of amoxicillin, 80 mg/kg/day, to treat for her otitis media.  Her conjunctivitis is mild, and we do not believe she will require any topical antibiotics at this time since she will already be on an oral antibiotic.  Discussed continuing supportive care measures and to return to clinic as needed.

Sample #3

CHIEF COMPLAINT:  Fever, congestion.

SUBJECTIVE:  The patient is an (XX)-month-old female who presents to the clinic with a one-day history of fever up to 103 degrees, decreased appetite and increased fussiness.  Mother states that she has had chronic runny nose, nasal congestion and intermittent wet cough for the past four weeks.  The patient does attend daycare, and there have been multiple sick exposures at school.  Mother states that there have been confirmed cases of RSV.  The patient, however, has not had any wheezing, increased work of breathing, vomiting or diarrhea.  The patient is drinking fluids well and maintaining good number of wet diapers.  Medications include Tylenol every 4 to 6 hours as needed and Advil every 6 to 8 hours as needed.  No known drug allergies.

OBJECTIVE:
VITAL SIGNS:  Temperature 98.2, pulse 100, respiratory rate 22, weight 8.3 kg, length 66 cm, oxygen saturation 100% on room air.
GENERAL:  Awake, alert, active infant in no acute distress.
HEENT:  Normocephalic and atraumatic.  Pupils are equal, round, and reactive to light.  Conjunctivae are clear.  Left TM is erythematous and bulging.  Right TM is slightly erythematous, dull.  Positive nasal congestion.  Throat is nonerythematous.  Mucous membranes are moist.
HEART:  Regular rate and rhythm.
LUNGS:  Clear to auscultation bilaterally with no wheezes.  Good air movement throughout.
ABDOMEN:  Soft, nontender, and nondistended.  Active bowel sounds.
GENITOURINARY:  Erythematous confluent areas with satellite lesions.
EXTREMITIES:  Warm and well perfused.

ASSESSMENT:
1.  Bilateral otitis media.
2.  Prolonged viral upper respiratory infection.
3.  Monilial diaper dermatitis.

PLAN:
1.  For otitis media, we will treat with a 10-day course of cefdinir 125 mg/5 mL half teaspoon by mouth twice a day.
2.  For viral symptoms, recommended continued supportive measures, clearing nasal secretions as needed, encouraging fluid intake, advancing diet slowly as tolerated and Tylenol or ibuprofen as needed for fever or pain.
3.  For monilial dermatitis, prescription was provided for nystatin ointment to apply to affected area three times a day until clear. Recommended airing the patient out of diaper, limiting moisture in this area and using diaper creams in between as needed.
4.  Warning signs were discussed with the mother. Mother is to return with the patient if the patient develops persistent fever, worsening symptoms, respiratory difficulty, poor feeding or for any other concerns.

Central Slip Repair Operative MT Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Left index finger central slip avulsion with early boutonniere deformity.
2.  Left long finger proximal interphalangeal joint posttraumatic arthritis, severe.

OPERATION PERFORMED:
1.  Left index finger central slip repair.
2.  Left long finger proximal interphalangeal joint fusion.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  General.

COMPLICATIONS:  None.

TOURNIQUET TIME:  Approximately 115 minutes.

 ESTIMATED BLOOD LOSS:  Minimal.

DESCRIPTION OF OPERATION:  After informed consent was obtained from the patient, he was taken to the operating room, transferred from the gurney to the operating table, and placed in supine position. General anesthesia was administered, and he was intubated without complication or difficulty. The patient received Ancef 1 gram IV preoperatively for infection prophylaxis. The left upper extremity had a well-padded tourniquet placed in proximal of the left arm. The left arm was then sterilely prepped and draped in the usual fashion.

An Esmarch bandage was used to exsanguinate the left upper extremity, and the tourniquet was inflated to 250 mmHg prior to incision. Using a #15 scalpel blade, a longitudinal incision was first made overlying the PIP joint in dorsal aspect of the left long finger. The radial and ulnar collateral ligaments were taken down, and the PIP joint was evaluated. There were severe osteoarthritic changes with large osteophyte and significant cystic erosion of the joint, both distally and proximally. With a rongeur as well as a bone saw, the bony prominences were taken down and the surfaces refashioned. The surfaces were made to allow fusion at approximately 30- to 35-degree angle of the joint in flexion. An attempt to use Acutrak standard compression cannulated screw to pierce the joint was made. Upon trying to place the screw, after a guidewire was placed, the dorsal cortex of the distal portion of the proximal phalanx cracked and the fixation with the screw was not continued. The screw was removed. We decided to do a K-wire tension banding of the PIP joint. This was performed, and adequate apposition of the joint surfaces and stability was noted. C-arm images confirmed the fixation and alignment of the PIP joint in left long finger in AP and lateral planes in acceptable position. The bony prominences, both radially and ulnarly, were significantly improved. Next, the wound was irrigated with copious amount of sterile normal saline. The extensor tendon mechanism was repaired over the PIP joint and covered with 4-0 Vicryl suture in running and interrupted fashion. The skin edges were reapproximated with 4-0 nylon suture in interrupted horizontal mattress fashion.

Next, attention was directed to the left index finger. A longitudinal incision overlying the PIP joint was made approximately 3 cm in length. Blunt dissection was carried down to subcutaneous tissues developing a skin flap both radially and ulnarly. Small superficial vessels were cauterized with bipolar cautery to derive hemostasis. The extensor mechanism was evaluated in dorsal aspect of the PIP joint. There was evidence of an avulsed fracture at the attachment of the central slip and migration of this fracture approximately 5-6 mm. There was early scar formation and attempted healing in the bed of the fracture site. Using a #15 scalpel blade, a longitudinal incision was made between the lateral bands and the central slip, and the central slip was mobilized to be advanced distally. The fracture bed was debrided back to healthy-appearing bone and the avulsed fracture fragment was also cleaned of any early callus healing. A mini Mitek suture anchor was then placed into the proximal portion of middle phalanx at the fracture site. Using a 0.035 K-wire, two holes were made in the fragment and the sutures from the Mitek suture anchor were passed across the fragment. A Bunnell type of stitch was then placed in the dorsal and proximal portion of the central slip to reinforce the repair. The joint did have a 0.062 K-wire placed across the joint holding in full extension prior to the repair of the central slip avulsion. C-arm images confirmed the alignment of the joint and the re-establishment of the avulsed fragment in its bed in appropriate position in AP and lateral projections. The wound was then irrigated with copious amount of sterile normal saline.

The central slip was then sutured to the lateral bands in its advanced position with 4-0 Vicryl suture in interrupted figure-of-eight fashion, both radially and ulnarly. The skin edges were reapproximated with 4-0 nylon suture in interrupted horizontal mattress fashion. Digital block was performed to both the left index and long fingers with total of 15 mL of half-half mixture of 1% Xylocaine and 0.5% Marcaine without epinephrine to provide postoperative analgesia. Xeroform dressing was placed over the wounds, and sterile 4 x 4 and sterile cast were used to protect the wounds. A well-padded volar splint extending to the tips of the fingers was placed on the left upper extremity incorporating the index and long finger to provide immobilization for early postoperative recovery. It was held in position with light Ace wrap.  General anesthesia was reversed at the conclusion of the case. The patient was extubated and returned to the recovery room in stable condition. Of note, the tourniquet was deflated at approximately 115 minutes of use with adequate perfusion in the left hand after tourniquet deflation with less than 2 seconds capillary refill felt in all digits.

DISPOSITION:  Following observation in the recovery room, the patient will be discharged to home if comfortable and stable. The patient will be instructed for elevation of left upper extremity often at home, avoiding any use of the left hand. The patient is to keep his dressings clean, dry, and intact until his followup in 7 to 10 days. The patient was given Percocet for postoperative pain relief.


Lip Laceration ER Medical Transcription Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

 CHIEF COMPLAINT:  Lip laceration and abdominal pain.

 HISTORY OF PRESENT ILLNESS:  This patient is a (XX)-year-old Hispanic female with two complaints. Her first complaint is a lip laceration. She says she was assaulted by her husband two days ago and at that time sustained a lip laceration. She did not seek medical care at that time. She says she has been starting to have increasing pain as well as drainage from that wound. She denies any other injuries from the assault. The second complaint is of abdominal pain. She says she has been having abdominal pain and burning with urination for the last several days and is concerned she may have a STD. She denies any vomiting and denies any diarrhea. She says she is sexually active and does not use protection.

PAST MEDICAL AND SURGICAL HISTORY:  History of schizophrenia.

CURRENT MEDICATIONS:  Cogentin and Prolixin.

ALLERGIES:  She has no known drug allergies.

FAMILY HISTORY:  Unremarkable.

SOCIAL HISTORY:  The patient does admit to smoking two packs of cigarettes a day. Admits to daily ETOH use. Denies any illicit drug use.

REVIEW OF SYSTEMS:
CONSTITUTIONAL:  The patient denies fever, chills, dizziness, weakness.
CARDIOVASCULAR:  The patient denies chest pain or palpitations.
RESPIRATORY:  The patient denies shortness of breath or cough.
All other review of systems negative.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 128/88, pulse 102, respiratory rate 16, temperature 100.4, and O2 sat 100% on room air.
GENERAL:  Well-developed, well-nourished Hispanic female, in no acute distress, appears comfortable lying in bed.
HEENT:  Head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles are intact. No nystagmus. No scleral icterus. Oral mucosa is moist and pink without erythema or exudate. On the right angle of her upper and lower lips, she has a laceration starting at the vermilion border extending back into the anterior aspect of the oral mucosa that is relatively large. There is purulent drainage present. There is also erythema and induration present, but no fluctuance present. The teeth are normally aligned.
NECK:  Supple with no JVD, no cervical lymphadenopathy noted, no midline C-spine tenderness or step-offs.
RESPIRATORY:  Lungs are clear bilaterally with equal breath sounds.
CARDIAC:  Regular rate and rhythm. Normal S1 and S2. No murmurs, rubs or gallops.
ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.
EXTREMITIES:  No clubbing, cyanosis or edema noted.
GENITOURINARY:  Normal female external genitalia. The patient does have a mild yellowish discharge present from the cervix. The uterus is normal size. There are no adnexal masses or tenderness. There is no cervical motion tenderness.
NEUROLOGIC:  The patient is GCS 15. Cranial nerves II through XII intact. No focal neurological deficits.

EMERGENCY DEPARTMENT COURSE:  The case was discussed with the face surgeons on call, who agreed to follow up with the patient in five days in order to better evaluate the lip. The patient was given 500 mg of Cipro, a gram of azithromycin, and 2 grams of Flagyl while in the emergency department. She was also given two Percocets for her pain, and her tetanus was updated.

MEDICAL DECISION MAKING:  The patient is a middle-aged woman with two complaints. The first complaint is of a lip laceration. She has a rather large lip laceration that would have been primarily repaired if she had come in when she had the initial injury, but at this point, the laceration is large and appears to be infected, so we do not want to close it so that an abscess does not develop. Therefore, at this point, the patient will be covered with antibiotics and will follow up the ENT Clinic on Friday, which is five days from now. As for the patient's second complaint of lower abdominal pain, she does have what appears to be a cervicitis. Her urine also appears to be infected, so we will treat her for a urinary tract infection as well as cervicitis. Her beta hCG was negative.

DIAGNOSES:
1.  Lip laceration with infection.
2.  Urinary tract infection.
3.  Cervicitis.

PLAN:
1.  The patient was given a prescription for Cipro 500 mg p.o. b.i.d. x 6 days.
2.  The patient was given a prescription for clindamycin 300 mg p.o. q.i.d. x 10 days.
3.  The patient was given a prescription for Peridex mouthwash 10 mL swish and spit after meals and before bed.
4.  The patient was given a prescription for Percocet one p.o. q 4 hours p.r.n., total #20.
5.  The patient was instructed to follow up with her primary care physician and follow up with ENT Clinic on Friday.

DISPOSITION:  The patient was discharged home in good condition.

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PEG Tube Placement Transcription Sample Report

DATE OF PROCEDURE:   MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Inability to eat.

POSTOPERATIVE DIAGNOSIS:  Inability to eat.

PROCEDURE PERFORMED:  Percutaneous endoscopic gastrostomy tube placement.

SURGEON:  John Doe, MD

ANESTHESIA:  IV sedation.

ESTIMATED BLOOD LOSS:  Zero.

TUBES:  20-French Ponsky PEG tube to gravity drainage.

COMPLICATIONS:  None.

 INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old female who was recently hospitalized after sustaining a cerebrovascular accident secondary to dysfunction from this. She has been unable to take adequate nutrition by mouth. After a discussion between the family and the neurology service, it was felt that a G-tube would be appropriate to aid in her recovery and to maintain enteral access. She now presents for this procedure. Prior to beginning the procedure, we met with the family and discussed the procedure, complications, risks, benefits, and alternatives.

DESCRIPTION OF PROCEDURE:   On the day of the procedure, the patient was taken to the endoscopy suite. She was placed in 30 degrees head-up position. A time-out was held, and the patient and the planned procedure were confirmed with all those present. She was placed on pulse oximetry and a monitor as well as nasal cannula oxygen. She was sedated with divided doses of fentanyl and Versed. She received a total of 100 mcg of fentanyl and 3 mg of Versed throughout the procedure, which allowed for excellent sedation.

Once an adequate level of sedation was reached, a bite block was placed, and her esophagus was intubated. We then passed the GE junction and entered the stomach. We continued the endoscopy out to the first portion of the duodenum. There were no ulcers present. A retroflexed view of the GE junction revealed a small hiatal hernia. The light from the endoscope was readily visible through the patient's anterior abdominal wall, 2 cm inferior to the left costal margin. This transilluminated quite easily. A single finger impulse was seen briskly through the gastroscope as well. The patient's epigastrium was then prepped with Betadine and draped in a standard sterile fashion. We used a local needle to infiltrate the skin over the proposed PEG site first. This was infiltrated with a wheal of lidocaine. The local needle was then used to enter the stomach. Suction was held on this as it was used to enter the stomach, and we saw no air or succus or stool prior to entering the gastric lumen. Local was then infiltrated as we withdrew the needle along the path of this.

A small stab incision was then made, and the introducer needle was then placed while aspirating into the gastric lumen. Again, no air, succus or stool was noted prior to visualizing the tip of the needle in the gastric lumen. The guidewire was then placed through the introducer needle. This was grasped and was withdrawn through the patient's mouth. This was then attached to a #20 Ponsky PEG tube, which was then pulled in an antegrade manner into the stomach and out the anterior abdominal wall. The esophagus was reentered better with the gastroscope, and this was advanced into the stomach. The tube at 2.5 cm was noted to be not too tight or not too loose but to appear just right without any blanching of the gastric mucosa. It appeared it spun easily as well. It was secured at this depth, then cut to size, and placed to gravity drainage.

The stomach was then desufflated, and the endoscope was then withdrawn along the length of the esophagus. The patient tolerated the procedure well, and with supplemental oxygen, remained with saturations greater than 95% throughout the procedure. There were no complications. The patient was then taken to the recovery room in stable condition.

Sphenopalatine Artery Ligation Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

 PREOPERATIVE DIAGNOSIS:  Recurrent right-sided epistaxis.

POSTOPERATIVE DIAGNOSIS:  Recurrent right-sided epistaxis.

OPERATIONS PERFORMED:
1.  Right sphenopalatine artery ligation.
2.  Right anterior ethmoidectomy.
3.  Left sinus exploration.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  Approximately 150 mL.

SPECIMENS:  None.

OPERATIVE FINDINGS:  There were no remarkable findings in the nasal cavity. The patient did have synechia of the left middle turbinate to the septum. This was most likely due to her previous multiple packings of the sinus cavities.

 INDICATION FOR OPERATION:  The patient is a (XX)-year-old female who has had a history of recurrent right-sided epistaxis requiring multiple packings. The decision was made to take the patient to the operating room for an elective right sphenopalatine artery ligation and anterior ethmoidectomy. The risks and benefits of the procedure were explained to the patient, and the decision was made to proceed.

 DESCRIPTION OF OPERATION:  The patient was taken to the operating room and was placed in the supine position on the operating room table. General face-mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty. The table was then turned. Afrin-soaked pledgets were placed in the areas bilaterally allowing for decongestion. After approximately 5 minutes, the nasal pledgets were removed, and 4 mL of 1% lidocaine with 1:100,000 epinephrine was injected in the left and right nasal cavities. Injection sites included the septum, middle turbinate, and the superior uncinate. The Afrin-soaked nasal pledgets were placed back into the nares for approximately another five minutes. The patient was then draped. The nasal pledgets were removed. Left nasal cavity exploration was performed. Of note, there was synechia of the septum to the middle turbinate. No other lesions or masses were noted in the inferior, middle, and superior meatus. There was no evidence of superficial vasculature, which may be responsible for bleeding. The septum appeared clean of any local trauma. The nasopharynx was clear, and the left eustachian tube was open.

Attention was then turned towards the right nasal cavity. A 0-degree endoscope was used to visualize the right nasal cavity. Again, there was some mild scarring of the middle turbinate to the lateral nasal wall. A Straightshot microdebrider was used to resect the inferior half of the middle turbinate to allow access to the uncinate, maxillary sinus, the grand lamella and the sphenopalatine artery canal. The uncinate was removed with backbiting forceps. The Straightshot microdebrider was used to complete the uncinectomy.

A large maxillary antrostomy was then performed with the microdebrider. This was begun at the natural os of the maxillary sinus and carried posteriorly to the posterior antral wall. The opening of the antrostomy went to the superior border of the inferior turbinate. The superior border went to the lamina papyracea. A caudal elevator was then used to elevate the mucosa over the region of the sphenopalatine artery. The artery was then identified. A 2 mm Kerrison rongeur was then used to open up the canal of the sphenopalatine artery. This was carried laterally to the posterior antral wall. The bony encasing of the artery was opened to allow a 270-degree view around the artery. The branch point of the posterior nasal artery was identified. A Freer was then used to loosen the superior and inferior tissues from around the artery to allow placement of hemoclips. Approximately three hemoclips were then placed laterally to the branch point of the sphenopalatine artery. The clips were well secured to the artery. Suction Bovie cautery was then used medially to the clips for local cauterization.

Attention was then turned towards the anterior ethmoidectomy. The ethmoid bulla was removed with the microdebrider. The microdebrider was carried superiorly into the anterior ethmoids. The nasofrontal recess was identified. The skull base was identified. There was no evidence of injury to the skull base. There was an area of thin bone. The anterior ethmoid artery was not directly identified, and thus, there was no cautery performed at this location.

The nose was then thoroughly irrigated with copious amounts of warm normal saline. Approximately 5 mL of FloSeal was then injected into the maxillary sinus and the anterior ethmoids for hemostasis and healing. One Doyle splint was used on the right nasal cavity to prevent further synechia. This was sewn in place with #3 Prolene. The nasal cavities were again thoroughly irrigated with warm normal saline and suctioned. There was no evidence of bleeding at the end of the case. The patient was then awoken from general anesthesia, extubated, and sent to the postanesthesia care unit in stable condition.

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Implantable Cardioverter Defibrillator Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PROCEDURES PERFORMED:
1.  Implantation of implantable cardioverter defibrillator.
2.  Intraoperative testing of ICD function.
3.  Unsuccessful attempt at placement of left ventricular pacing lead.

INDICATIONS FOR PROCEDURE:
1.  Congestive heart failure, NYHA class II.
2.  Dilated nonischemic cardiomyopathy.
3.  Left bundle branch block.

INDICATION FOR PROCEDURE:  This is a (XX)-year-old woman with a history of nonischemic dilated cardiomyopathy. The patient has class II congestive heart failure, on medical therapy, with persistent left ventricular dysfunction, most recently 30% by echocardiography. She was enrolled in the REVERSE trial, which involved placement of a biventricular ICD and then randomization to either back VVI pacing or active cardiac resynchronization pacing. She presented today for anticipated placement of a biventricular ICD.

DESCRIPTION OF PROCEDURE:  The patient was brought to the electrophysiology laboratory in the fasting state after signing informed consent. The left subclavian area was prepped and draped in the usual sterile fashion. Local anesthesia was achieved along the left deltopectoral groove using a combination of 1% lidocaine and 0.5% Marcaine. An incision was extended along the groove, and using a combination of blunt and Bovie dissection, the incision was extended to the level of the prepectoral fascia. Pulse generator pocket was fashioned inferomedial to the incision using blunt dissection in the prepectoral space. A left axillary vein was visualized with a Site-Rite II ultrasound device, and under direct ultrasonic visualization, the vein was punctured with a Cook needle, and a guidewire was placed. Using similar ultrasound guided technique, two additional guidewires were placed in the left axillary vein using separate needle sticks. Over one guidewire, a 9 French introducer sheath was advanced, and through the sheath, an active fixation ICD lead was advanced with the aid of straight and curved stylets. The lead was initially positioned in the distal right ventricular apex where sensing characteristics were less than optimal. The lead was drawn back slightly to a more proximal location of the right ventricular apex where acceptable sensing and pacing characteristics were found, and the lead was actively fixed in the location of this site. The lead was securely sutured to underlying pectoral muscles. Final lead measurements were favorable, and there was no diaphragmatic stimulation at high output pacing.

Over the second guidewire, a 7 French introducer sheath was advanced, and through this sheath, an active fixation pacing lead was advanced into the right atrium. The lead was initially fixed in an anterior location but dislodged during attempted cannulation of the coronary sinus and ultimately was positioned in a posterior position in the right atrium where sensing and pacing characteristics were favorable. The lead was securely sutured to the underlying pectoral muscle. Final lead measurements were favorable, and there was no diaphragmatic stimulation at high output pacing.

Over the third guidewire, a Medtronic extended hook coronary sinus guiding sheath was advanced, and attempts were then made to cannulate the coronary sinus. The coronary sinus proved to be extremely difficult to cannulate due to a very large right atrium and the position of the coronary sinus well off the floor of the atrium. In addition, there was a proximal valve impeding progress of any of our larger and stiffer catheters. It was possible with some effort to cannulate the coronary sinus with a guidewire and MPA-2 catheter, but insufficient support was afforded by the right atrium to allow passage of the sheath, which would dislodge the catheter and guidewire from the vessel.

Other attempts to place a stiffer catheter, including two different steerable EP catheters and a Medtronic Prevail Steerable catheter, were unsuccessful as we could not cannulate beyond the proximal portion of the coronary sinus and thereby also not allow sufficient support to advance the sheath. Extensive efforts were expended in the effort to place the sheath within the coronary sinus, including empiric efforts to cannulate via the middle cardiac vein or a posterolateral vein with guidewire sheath. When it was unable to advance beyond the coronary sinus ostium, ultimately elected to abandon efforts at placement of a left ventricular lead and thereby exit the patient from the research trial.

The guidewire and sheath were removed, and good hemostasis was obtained with digital pressure. The pulse generator pocket was thoroughly irrigated with antibiotic solution. The right atrium and right ventricular leads were attached to a dual chamber ICD, which was placed into the preformed pocket. The patient was sedated with intravenous Brevital, and ventricular fibrillation was induced with a synchronous countershock. The device properly detected arrhythmia and delivered a 15 joule countershock, which resulted in conversion to sinus rhythm. After 5 minutes, the patient remained sedated, and ventricular fibrillation again was induced in a similar fashion. On this occasion, a 10 joule countershock resulted in conversion to sinus rhythm. The patient emerged from anesthesia without difficulty and remained hemodynamically stable throughout the procedure during defibrillator testing.

 The wound was closed using two layers of deep Vicryl suture. The skin was closed using running 4-0 Monocryl suture. The wound was dressed with Steri-Strips and sterile gauze. The patient left the electrophysiology laboratory in stable condition with proper device function observed on monitor.


Austin Bunionectomy Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Hallux abductovalgus, left foot.
2.  Hallux interphalangeus, left foot.
3.  Contracted extensor hallucis longus tendon, left foot.
4.  Contracted adductor hallucis tendon, left foot.
5.  Hammer digit, third toe, left foot.

POSTOPERATIVE DIAGNOSES:
1.  Hallux abductovalgus, left foot.
2.  Hallux interphalangeus, left foot.
3.  Contracted extensor hallucis longus tendon, left foot.
4.  Contracted adductor hallucis tendon, left foot.
5.  Hammer digit, third toe, left foot.

OPERATIONS PERFORMED:
1.  Modified Austin bunionectomy with AO fixation.
2.  Proximal phalangeal osteotomy with monofilament wire fixation, left hallux.
3.  Adductor hallucis tendon release, left foot.
4.  Extensor hallucis longus tendon lengthening, left foot.
5.  PIPJ arthroplasty with K-wire fixation, third digit, left foot.

SURGEON:  John Doe, DPM

DESCRIPTION OF OPERATION:  The patient was brought to the OR and placed on the operating table in the supine position. IV was intact for IV sedation. Ancef 1 g was delivered IVPB preoperatively. The patient discontinued 81 mg ASA three days preoperatively. Local anesthesia was obtained using 2% Carbocaine. The left foot was prepped and draped in the usual aseptic manner. Hemostasis was obtained using Esmarch tourniquet to the left ankle.

Attention was directed over the dorsal aspect of the first MPJ where an 8 cm curvilinear incision was made medial to the extensor hallucis longus tendon. A medial converging semi-elliptical incision was made, and encompassed section of skin was excised. The incision was deepened using sharp and blunt dissection technique and vital structures retracted medially and laterally. Superficial vessels were cauterized.

Inverted L capsulotomy was performed, and extension of the proximal phalanx and the capsule and periosteum were freed from the head and neck of the first metatarsal and base of the proximal phalanx. The lateral adductor hallucis tendon release was performed. Fibular sesamoid was further freed proximally, laterally and distally. Medial eminence on the first metatarsal head was excised and flushed. Osteotomy was then performed from medial to lateral with the apex pointing distally and the base proximally in a chevron fashion with a longer dorsal hinge. The head was then transposed into a more rectus position laterally and then fixed using two 2.7 mm cortical screws using AO lag technique. The first metatarsal was further remodeled using power saw, rongeur and rasp.

Attention was then directed towards the base of the proximal phalanx where an osteotomy was performed from dorsal to plantar with the apex pointing laterally and the base medially, and the encompassed section of bone was excised. The osteotomy was reduced and fixed using 20 gauge monofilament wire fixation in figure-of-eight fashion. At this time, the contracted extensor hallucis tendon was lengthened using V sliding tendon lengthening procedure that was stabilized using 4-0 Vicryl mattress suture. The site was copiously flushed. A medial capsulorraphy was performed. Deep closure was obtained using 2-0 Vicryl simple interrupted sutures, subcutaneous closure with 4-0 Vicryl mattress suture and skin closure with 4-0 Monocryl subcuticular running suture, tincture of benzoin and Steri-Strips.

Attention was then directed towards the third digit of the left foot where two converging semi-elliptical incisions were made over the PIPJ of the third toe of the left foot. The encompassed section of skin was excised. Transverse incision was made over the extensor apparatus and capsule over the PIPJ, and the head of the proximal phalanx was delivered dorsally and excised in total. The site was copiously flushed. K-wire was delivered in retrograde fashion to middle and distal phalanx and back to the proximal phalanx and third metatarsal.

Deep closure was obtained using 4-0 Vicryl simple interrupted suture in such a fashion that the distal end of the proximal portion, the extensor apparatus and capsule were tucked in void created by the excision of the head of the proximal phalanx. Subcutaneous closure made with 4-0 Vicryl mattress suture and skin closure with 4-0 nylon simple interrupted suture. Postoperatively, 0.5% Marcaine and dexamethasone were administered. The site was dressed with Adaptic, Polysporin, sterile gauze, sterile Kling, Kerlix, and Coban compression dressing applied. Upon releasing the tourniquet, normal color returned to all digits of the left foot. The patient tolerated the procedure well.

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