Closed Base Wedge Osteotomy Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

 PREOPERATIVE DIAGNOSIS:  Painful bunion deformity of the left foot.

POSTOPERATIVE DIAGNOSIS:  Painful bunion deformity of the left foot.

OPERATION PERFORMED:
1.  Closed base wedge osteotomy of the first metatarsal of the left foot with screw fixation.
2.  Reverdin-Green osteotomy of the first metatarsal of the left foot with screw fixation.

SURGEON:  John Doe, DPM

ANESTHESIA:  General and local anesthesia.

HEMOSTASIS:  Pneumatic ankle tourniquet of the left ankle at 250 mmHg.

 ESTIMATED BLOOD LOSS:  Minimal, less than 50 mL.

INDICATION FOR OPERATION:  This is a (XX)-year-old male who presents with painful bunion deformity of the left foot of many years' duration.  The patient had bunion surgery done almost 18 years ago.  The patient has tried different shoe gear, orthotics, and different pain medications with minimal help.  The patient has opted for surgical correction.  All the benefits, risks, and complications of the procedure were discussed with the patient.  The patient agreed to proceed with surgery.  The consent was obtained and is included in the chart.

DESCRIPTION OF OPERATION:  The patient was brought into the operating room and placed on the operating table in the supine position.  Pneumatic ankle tourniquet was then placed around the patient's left ankle.  Following general anesthesia, local anesthesia was obtained around the patient's first three utilizing 20 mL of 1:1 mixture of 0.25% Marcaine plain and 1% lidocaine plain.  The foot was then scrubbed, prepped, and draped in the usual aseptic manner.  Left leg elevation was obtained for 2 minutes to exsanguinate the patient's left foot, and pneumatic ankle tourniquet was then inflated at 250 mmHg.

Attention was directed to the dorsal aspect of the first metatarsal head of the right foot where an 8 cm linear longitudinal skin incision was made medial and parallel to the tendon of the extensor hallucis longus.  The incision was deepened through the subcutaneous tissue using sharp and blunt dissection.  Care was taken to identify, retract all vital neurovascular structures.  All bleeders were ligated and cauterized as necessary.

Attention was then directed to the first interspace via the original skin incision where the tendon of the extensor hallucis brevis was initially identified and tenectomized.  The dissection was continued deep using a blunt dissection down to the level of the fibular sesamoid, which was freed of its attachments proximally, laterally, and distally.  The conjoined tendon of the abductor hallucis muscle was then identified and transected at its attachments to the base of the proximal phalanx of the hallux.

Then a Z-type tendon lengthening procedure was obtained to the extensor hallucis longus tendon.  At this time, the lateral contracture presented toward the hallux was noted to be reduced.  Next, a linear longitudinal capsulotomy was performed over the dorsal aspect of the first metatarsophalangeal joint.  The periosteal and capsular structures were then carefully dissected free of the osseous attachments, and they reflected medially and laterally thus exposing the head as well as the shaft of the first metatarsal at the operative site.

Attention was directed to the dorsal aspect of the base of the first metatarsal where a 0.045 inch K-wire was driven from dorsal to plantar aspect perpendicular to the weightbearing surface of the foot and at the medial cortex of the first metatarsal shaft about 1 cm distal to the first metatarsal cuneiform joint.  K-wire was used as a guide for the osteotomy cut.

Next, utilizing the surgical bone saw, two oblique osteotomy cuts were obtained, oriented from lateral, distal, to medial proximal, care was taken to keep the medial cortex intact.  Upon completion of the osteotomy cuts, a 3 mm bone wedge was removed and passed from the operating field.  At this time, the distal segment was shifted more laterally and to more corrected position.

Next, a bone clamp was utilized.  The K-wire was then removed and passed from the operating site.  Following the AO principles and technique, 2.5 x 24 mm cannulated self-tapping cortical bone screws were inserted across the C-arm site with excellent compression noted.

The first metatarsophalangeal joint range of motion was reevaluated and noticed to have laterally denuded articular surface.  A decision was taken to do the Reverdin-Green procedure to correct for the denuded articular cartilage.  Attention was then redirected to the medial aspect of the first metatarsal head where a through-and-through linear longitudinal plantar osteotomy was created in the metaphyseal region of this bone utilizing the sagittal bone saw in order to protect the sesamoid apparatus.

The second transverse osteotomy cut was obtained in the metaphyseal region of the first metatarsal head from medial to lateral and parallel to the articular surface with care being taken to keep the lateral cortex intact.  Then, a third transverse osteotomy cut was obtained in the metaphyseal region of the first metatarsal head from medial to lateral perpendicular to the longitudinal axis of the first metatarsal with care being taken to keep the lateral cortex intact.

Upon completion of all three osteotomy cuts, 3 mm bone wedge was excised and removed and passed from the operating field.  Then, the capital fragment was distracted and shifted into a more corrected position and then impacted a bone, the first metatarsal shaft.

At this time, 0.045 inch K-wire was driven from dorsal proximal aspects of the shaft to the distal plantar aspect of the first metatarsal head across the osteotomy site to act as temporary fixation as well as the guide for screw fixation.  Then, following the AO principles and technique, 2.5 x 20 mm cannulated self-tapping Vilex cortical bone screw was inserted across the osteotomy site with excellent compression noted.  K-wire was removed and passed from the operative field.  Attention was then directed to the remaining medial bone saw, which was resected utilizing the sagittal bone saw and passed from the operative site.  Correction of the deformity was assessed at this time and noted to be excellent.

The wound was then irrigated with copious amount of normal saline.  The capsular structures were reapproximated and coapted utilizing 2-0 Vicryl.  The extensor hallucis longus tendon was reapproximated utilizing 2-0 Vicryl.  The periosteal structure were reapproximated and coapted utilizing 3-0 Vicryl.  The subcutaneous tissue was then reapproximated and coapted utilizing 4-0 Vicryl.  The skin was then reapproximated and coapted utilizing 4-0 nylon in a continuous running interlocking suture technique.

Upon completion of the procedure, a total of 1 mL of Decadron was infiltrated around the incision site.  A postoperative block consisting 10 mL of 0.25% Marcaine plain was also injected.  The incision was dressed with Betadine-soaked Adaptic and covered with sterile compressive dressing consisting of 4 x 4s and Kling.  Pneumatic ankle tourniquet was then deflated and prompt hyperemic response was noted to all digits of the left foot.  A below-knee cast was then applied.

The patient tolerated the procedure and anesthesia very well.  The patient was transferred to the recovery room with vital signs stable and vascular status intact to all digits of the left foot.


Submuscular Ulnar Nerve Transposition Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Left ulnar neuropathy at the elbow.
2.  Left ulnar neuropathy at the wrist.

POSTOPERATIVE DIAGNOSES:
1.  Left ulnar neuropathy at the elbow.
2.  Left ulnar neuropathy at the wrist.

OPERATION PERFORMED:
1.  Left submuscular ulnar nerve transposition.
2.  Left ulnar tunnel release.

SURGEON:  John Doe, MD

ANESTHESIA:  Laryngeal mask airway.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

 COUNTS:  Instrument count was correct.

TOURNIQUET TIME:  Seventy minutes.

 DESCRIPTION OF OPERATION:  The patient was taken to the operating room and placed supine on the operating table.  After an adequate level of general laryngeal mask airway anesthetic had been obtained and a preoperative dose of 1 gram of Ancef had been given, the left upper extremity was sterilely prepped and draped in the usual fashion.  The extremity was elevated, exsanguinated, and the tourniquet insufflated to 275 mmHg.

The landmarks were palpated.  An approximately 10-12 cm incision was made just posterior to the medial condyle in an L-shaped fashion using a 15 blade.  The dissection was carried down through the subcutaneous tissues using pickups and tenotomy scissors.  Great care was taken in the dissection through the proximal forearm portion of the L-shaped incision while dissecting the soft tissues down to the level of the flexor forearm fascia to ensure that the medial antebrachial cutaneous nerve was not cut, and it was not.

Just proximal to the medial epicondyle, in the upper arm portion of the wound, the ulnar nerve was identified and dissected free from the medial epicondyle proximally for at least 8 cm using Army-Navy retractors to gain access to the upper arm.  The dissection of the ulnar nerve was then continued around the medial epicondyle by releasing the flexor forearm fascia that was over the nerve until it again dove down deep into the flexor muscles.  At this point, the nerve was completely identified and had been unroofed.

Attention was then directed toward the submuscular ulnar nerve transposition.  The skin and subcutaneous tissue was then released off the fascia overlying the medial epicondyle and folded anteriorly into a flap.  Proximally, the intermuscular septum was released and resected with minimal difficulty.  A step-cut was then made approximately a centimeter off of the medial epicondyle through the fascia of the flexor bundle.  This dissection proximally was carried down until the brachialis muscle could be identified.  The muscle was then completely released from the more superior aspect of the flexor attachment to the more inferior portion of the attachment near where the nerve was traversing.

Any bundles of fascia that might impinge on the nerve were completely released until there was a good submuscular tunnel that had been created for the nerve.  The nerve was then gently released from its bed preserving its vasculature, and it was transposed into the muscular bed that had been created by the submuscular dissection.  Once it was passed in this area, it was gently irrigated.  There were no tension points either proximally or distally on the nerve as it first entered and then exited the submuscular tunnel.  The flexor forearm mass was then reattached to its fascial insertion point using interrupted inverted #2 FiberWire sutures.  Once it had been completely repaired, the nerve was checked and found to not be compressed at any point along its course.

Attention was then directed towards the left ulnar volar wrist.  A Bruner-style incision was made over the ulnar portion of the flexor crease of the wrist.  The dissection was carried down to the subcutaneous tissue.  Proximal to the wrist flexor crease, the ulnar artery and ulnar nerve were identified with gentle dissection.  We then unroofed the fascia of Guyon's canal, extending into the palm of the hand, by releasing the fascia using tenotomy scissors for the entire length of the Guyon's canal.  After this had been done with the tenotomy scissors, the nerve was inspected and found to be intact, as was the ulnar artery.

At that point, all incisions were washed out and closed in layers with 5-0 nylon for the skin and the wrist and 2-0 Vicryl inverted interrupted sutures for the subcutaneous tissue of the elbow and 5-0 nylon for the skin.  All incisions were injected with 0.25% plain Marcaine.  A sterile dressing and posterior splint was applied.  The patient was extubated and taken to the recovery room in stable condition.  The patient will be discharged home on p.o. pain medicine and follow up in 10 days.


Management of Kidney Transplant Sample Report

DATE OF VISIT:  MM/DD/YYYY

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old lady who received a living-related kidney transplant four years ago in the setting of end-stage renal disease secondary to diabetic nephropathy.  She is coming in here for reevaluation and management.  She lives mainly overseas and she gets her blood work every three months there, and we see her here in the clinic every six months.  She is generally doing well.  The patient denies any urinary symptoms, shortness of breath, orthopnea or PND.  Blood pressures at home have been ranging in the 120s to the 140s and she noted some lower extremity swelling.

MEDICATIONS:  Norvasc 10 mg daily, aspirin 81 mg daily, insulin, Humulin N and Humulin R, metoprolol 100 mg p.o. b.i.d., CellCept 500 mg p.o. b.i.d., omeprazole 20 mg daily, prednisone 2.5 mg daily, tacrolimus 2 mg p.o. b.i.d., and Tylenol two tabs q. 6 hours p.r.n.

ALLERGIES:  Listed in the chart.

REVIEW OF SYSTEMS:  Per HPI.  All other systems reviewed and are negative.

PHYSICAL EXAMINATION:
GENERAL:  The patient does not appear in any distress.
VITAL SIGNS:  Blood pressure 170/86, repeat was 148/84; pulse rate 84; respiratory rate 18; temperature 98.2; and weight 184 pounds with a BMI of 27.5.
GENERAL:  The patient does not appear in any distress.
HEAD AND NECK:  Atraumatic and normocephalic.  No JVD.
CHEST:  Good air entry bilaterally.  No added sounds.
HEART:  Normal S1 and S2 and no murmurs.
ABDOMEN:  Soft and nontender.
LOWER EXTREMITIES:  Positive for +2 edema.  No clubbing or cyanosis.

LABORATORY DATA:  Blood work from three days ago showed a white cell count of 5.8, hemoglobin 14.6, hematocrit 45.8, and platelet count 292,000.  Sodium 138, potassium 4.2, chloride 106, bicarbonate 26, glucose 84, BUN 18, creatinine 0.84, phosphorus 4, calcium 9.6, magnesium 1.8, AST 18, ALT 18, total bilirubin 0.5, HDL is 42, LDL 98.  Tacrolimus level 5.2 with a glycated hemoglobin of 7.8.

ASSESSMENT AND PLAN:  This is a (XX)-year-old lady who is a recipient of a living-related kidney transplant, coming in for management.
1.  Kidney transplant, living-related.  She has been maintaining a stable graft function with a creatinine around 0.84.  Her current immunosuppression seems to be adequate.  We will continue her current immunosuppression.  Her last tacrolimus level was 5.2 and is at target.
2.  Hypertension.  Blood pressure seems to be above target along with lower extremity edema.  She will be a good candidate for a diuretic.  We will add a hydrochlorothiazide of 12.5 mg p.o. daily.  The other blood pressure medications that she is on include metoprolol and amlodipine with her history of diabetes along with a subnephrotic range of proteinuria detected last year.  She will be a good candidate for an angiotensin-receptor blocker and we should consider the addition of a losartan and the weaning down off amlodipine in the coming next visit.
3.  Subnephrotic range proteinuria.  So far, she is not on any anti-proteinuric agents.  We will send off for repeat spot urine, protein-creatinine ratio along with the UA today.
4.  Diabetes.  Her hemoglobin has improved from almost 12 to 7.8.  She follows up regularly with Dr. John Doe.  She does not seem to have any hypoglycemic unawareness.

Living Related Kidney Transplant Sample Report  Urology Operative Sample Reports

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Prostate Adenocarcinoma Consult Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

 REASON FOR CONSULTATION:  Prostate adenocarcinoma.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old who underwent prostate biopsies for a rising PSA.  Biopsies were negative for malignancy.  His PSA was followed and ultimately rose to 7.6 last year.  This prompted a second round of prostate biopsies showing one core positive for adenocarcinoma, Gleason score 4+3 equals 7.  Treatment options have been reviewed by Dr. John Doe.  A Radiation Oncology consultation is kindly requested.  The patient's AUA symptom score is 7.  He denies recent osseous discomforts.

PAST MEDICAL HISTORY:  Hypertension; spinal stenosis, lumbar spine, treated in the past with physical therapy and epidural steroid injection; significant hearing loss requiring hearing aids; glaucoma; elevated cholesterol; and history of GERD.

PAST SURGICAL HISTORY:  Cholecystectomy, removal of schwannoma from rib, and bilateral hip replacements.

MEDICATIONS:  Sular, Diovan, Lipitor, and Travatan ophthalmic drops.

 ALLERGIES:  None.

 FAMILY HISTORY:  Maternal cousin had breast cancer in her 30s.  Two maternal cousins had pancreatic cancer in their 40s.  A half-sister had breast cancer in her 50s.

 SOCIAL HISTORY:  The patient has three children and two stepchildren.  The patient denies tobacco use and drinks alcoholic beverages socially.

REVIEW OF SYSTEMS:  A 12-point review of systems is reviewed and placed on chart.

PHYSICAL EXAMINATION:
GENERAL:  The patient is in no acute distress.
VITAL SIGNS:  Temperature 98.2, pulse 68, respirations 18, blood pressure 156/82, and weight 182 pounds.  Pain 0 on a scale of 0 to 10.  ECOG performance status 0.
HEENT:  PERRLA, EOMI, sclerae nonicteric.  No suspicious lesions of the oral cavity.  No palpable neck adenopathy.
LUNGS:  Clear to auscultation.
HEART:  Regular rate and rhythm.
ABDOMEN:  Without tenderness, organomegaly or masses.  No inguinal adenopathy.
RECTAL:  Good sphincter tone.  There is a 0.5 cm nodule at the left prostate apex.  Prostate otherwise mildly enlarged diffusely.  No rectal masses present.
EXTREMITIES:  No clubbing, cyanosis or edema of the extremities.

LABORATORY DATA:  PSA profile as follows; 3.66, 3.76, 5.32, 4.8, 5.6, 6.36, 6.3, and 7.6.

RADIOLOGIC DATA:  By report, bone scan and chest x-ray showed no evidence of metastatic disease.

PATHOLOGY DATA:  Prostate biopsies from last year:  Adenocarcinoma, Gleason score 4+3 equals 7, involving 69% of a core taken from the left apex.  No perineural invasion seen.  High-grade prostatic intraepithelial neoplasia seen in biopsies taken from the left apex, left base, and right lateral apex.  Eight additional prostate biopsies negative for malignancy.

ASSESSMENT:  Stage T2aNxM0 prostate adenocarcinoma, Gleason score 4+3 equals 7, PSA 7.6.

RECOMMENDATIONS:  We have discussed radiotherapy treatment options with the patient.  At the outset, the patient stated that he had done significant research and was leaning more toward external beam radiation than an implant or resection, and therefore, while we briefly discussed a radioactive permanent prostate seed implant, the majority of our discussion was focused on external beam treatment.

The risks, benefits, and details of this were outlined in detail.  The patient is very interested in the different types of technology available for delivering external beam radiation.  He had questions regarding use of the TrueBeam linear accelerator, the Trilogy linear accelerator, and protons.  We discussed these as well as use of TomoTherapy and the BrainLAB Novalis system.

Overall, we do not believe there is a significant difference in the above.  However, the patient is leaning toward the TrueBeam linear accelerator.  One question which arises is whether his bilateral hip replacements will interfere with the image-guided portion of his treatment.  We will discuss this further to see if this is an issue.  If it is, an alternative would be use of TomoTherapy, which could provide image guidance for the radiation, despite the hip implants.

We also briefly discussed active surveillance, but this was not recommended in view of the Gleason 4+3 tumor seen on biopsy.  We have promised to get back to the patient after discussing things further.


Bunionectomy with Osteotomy Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Hallux abductovalgus deformity on the right lower extremity.

 POSTOPERATIVE DIAGNOSIS:  Hallux abductovalgus deformity on the right lower extremity.

 OPERATION PERFORMED:  Bunionectomy with osteotomy and internal fixation of the right foot.

SURGEON:  John Doe, MD

ANESTHESIA:  Local with IV sedation.

ESTIMATED BLOOD LOSS:  Less than 10 mL.

 SPECIMENS:  No pathologic samples were retained.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old female who presented several months ago complaining of pain associated with a bunion on the right foot.

She had undergone conservative treatment consisting of alteration in her shoe gear, orthotic devices, padding, etc., which had been ineffective in reducing symptoms, and due to the level of discomfort and limitations associated with it, the patient has opted for surgical correction.

The patient has been advised as to all possible risks and benefits of such procedure and agrees to it at this time by signing an informed consent.

DESCRIPTION OF OPERATION:  The patient was brought to the OR and placed on the operating table in the supine position.  After proper IV sedation was initiated by the anesthesiologist, local anesthesia was accomplished using approximately 8 mL of 0.5% Marcaine in the form of a modified forefoot block to the right lower extremity.  The patient was then aseptically prepped and draped in the usual fashion and a pneumatic cuff placed around her right ankle for hemostasis purposes.

After checking anesthesia, the patient was noted to be insensate, and the foot and ankle were then exsanguinated using an Esmarch bandage and the pneumatic cuff elevated to a level of approximately 250 mmHg.  After again checking anesthesia, attention was addressed to the dorsomedial aspect of the patient's right foot where a dorsal curvilinear incision was placed overlying the first metatarsophalangeal joint, approximately 6 cm long.

This was placed and deepened using sharp and dull dissection, taking care to cauterize all appropriate small vessels and preserve any neurovascular structures as indicated to the level of capsular tissue and periosteum, which was incised similar to the operative incision.  All appropriate soft tissues were then freed from the distal aspect of the first metatarsal and the base of the proximal phalanx revealing a small dorsomedial prominence, which was resected using power equipment.

The patient then had a sequential lateral release performed in the usual fashion, including the lateral capsular ligaments and the adductor tendon.  The digit assumed a much more rectus position after that procedure was performed and the sesamoid complex relocated.  The patient then had an osteotomy performed in the usual fashion using a chevron technique and fixated using a 22 mm long 2.7 absorbable screw.

The patient then had the first metatarsophalangeal joint placed through vigorous range of motion, and it was noted to be stable.  The patient then had the remainder of the first metatarsal head remodeled so as to remove any sharp edges or excess bone.  The patient then had the wound copiously irrigated using normal saline solution.  The deep soft tissue structures were reapproximated using 3-0 and 4-0 Vicryl suture and final skin closure attained using 4-0 polypropylene suture in a running interlocking technique.

The patient then had the wound cleansed and dressed using iodine-soaked Adaptic gauze, Kling and Coban.  The pneumatic cuff was then deflated.  The patient tolerated the anesthesia and the procedure well, left the OR for recovery with all vital signs stable and vascularity intact in the entire right lower extremity.

The patient was instructed as to postoperative care for bandaging as well as weightbearing status, which is full weightbearing with the use of postoperative shoe.  The patient was also educated as to all signs and symptoms of infection and asked to contact the clinic if any of those signs or symptoms should manifest.  The patient will return to the clinic in five days for first wound check.


Tibial Sesamoid Excision Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

 PREOPERATIVE DIAGNOSIS:  Chronic sesamoiditis of the left foot with elongated first metatarsal and contracted left hallux.

POSTOPERATIVE DIAGNOSIS:  Chronic sesamoiditis of the left foot with elongated first metatarsal and contracted left hallux with degenerative changes of the sesamoid apparatus of the left foot.

OPERATION PERFORMED:
1.  Excision of the tibial sesamoid and excision of the fibular sesamoid of the left foot.
2.  Fusion of the left hallux interphalangeal joint.

ANESTHESIA:  MAC, preoperative block consisted of 10 mL of 0.5% Marcaine with epinephrine.

COMPLICATIONS:  None.

TOTAL TOURNIQUET TIME:  50 minutes.

 OPERATIVE FINDINGS:  Intraoperatively, the patient did have hypertrophy of the synovium on the plantar aspect of the first metatarsophalangeal joint with the inflammatory changes and erosions of the articular surface of the tibial and fibular sesamoids.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed in the supine position on the operating table.  Anesthesiologist administered intravenous sedative agents.  A local field block was performed.  The foot and leg were prepped and draped in normal sterile technique.  Esmarch bandage used to exsanguinate the foot, and ankle tourniquet was inflated to 250 mmHg.

A plantar medial longitudinal incision was made and centered over the first metatarsophalangeal joint of the left foot.  Dissection was carefully carried down through superficial and deep fascial layer.  At this time, the capsule was identified and divided longitudinally.  The tibial sesamoid was identified and resected in toto.

There was thinning of the articular surface with chronic inflammatory changes of the surrounding soft tissues.  The flexor hallucis longus tendon was identified and gently retracted plantarly exposing the fibular sesamoid, which was also excised in toto.

The fibular sesamoid was a bipartite sesamoid with irregularities and degenerative changes.  Copious lavage was performed.  The capsular layer was closed with 3-0 Vicryl, the subcutaneous deep fascial layer was closed with 4-0 Vicryl, and the skin edges were approximated with 4-0 Prolene using a running subcuticular stitch.  Steri-Strips were applied.

A longitudinal incision was then made and centered over the interphalangeal joint of the left hallux.  Dissection was carefully carried down through superficial and deep fascial layer.  The extensor tendon was transected transversely at the level of the interphalangeal joint.  Distal articular surface of the first proximal phalanx was resected as well as the base of the distal phalanx.  The cut edges were flush.  Copious lavage was performed.

A guidepin for the 4.0 cannulated screw was then inserted through the distal aspect of the hallux and then retrograde back through the proximal phalanx.  The position was verified on fluoroscopy.  A 48 mm cannulated partially threaded screw was then inserted, and excellent compression was achieved.  The hallux now lay in a rectus position.  Copious lavage was performed.

The extensor tendon was repaired with 3-0 Vicryl, the subcutaneous layer was closed with 4-0 Vicryl, and the skin edges were approximated with 4-0 Prolene using a running subcuticular stitch.  Steri-Strips were applied.  A postoperative block was performed using 8 mL of 9:1 mixture of 0.5% Marcaine plain and dexamethasone phosphate.  Betadine-soaked Owens gauze and a bulky dry sterile dressing were applied holding the hallux in a rectus position.

The patient tolerated the procedure and anesthesia well and left the operating room for the recovery room weightbearing as tolerated with the Cam walker, and follow up with us next week for a wound check.


Cardiomyopathy Discharge Summary Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

 DATE OF DISCHARGE:  MM/DD/YYYY

FINAL DIAGNOSES:
1.  Cardiomyopathy.
2.  Atrial fibrillation, new onset, with rapid ventricular response.
3.  Congestive heart failure.

PROCEDURES PERFORMED:
1.  Left heart catheterization.
2.  Coronary angiography.
3.  Left ventriculogram.

 CONSULTANT:  John Doe, MD

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who has been in good health until two weeks prior to admission when she presented with cold symptoms, cough and congestion but no fever or chills.  She was treated with antibiotics and expectorants for acute bronchitis with mild improvement.

On the morning of admission, she became short of breath with pressure-type substernal chest pain.  She was seen at the emergency room due to worsening symptoms and was found to be in atrial fibrillation with rapid ventricular response.  Cardiac enzymes were normal.  CAT scan of the chest was negative for pulmonary embolism.  She was admitted after she was started on Cardizem drip.

PHYSICAL EXAMINATION:
GENERAL:  Revealed well-developed, well-nourished, oriented Hispanic female who was complaining of shortness of breath.
VITAL SIGNS:  Blood pressure 114/56, respirations 18, pulse 78, and temperature 98.4.
HEENT:  Normal.
HEART:  Regular rate and rhythm.
LUNGS:  Clear to auscultation.
ABDOMEN:  Benign.
EXTREMITIES:  No edema, clubbing or cyanosis.

LABORATORY DATA:  Revealed a normal CBC:  Hemoglobin 14.2, hematocrit 42.4.  Blood sugar 122, BUN 17, creatinine 1.18.  CK 86, troponin 0.06.  BNP 554.  Thyroid function test was normal.  D-dimer 1.22.

 TRANSTHORACIC ECHOCARDIOGRAM:  Left ventricle was markedly dilated.  Overall, left ventricular systolic function was moderately to markedly decreased.  Left ventricular ejection fraction was 35%.  There was severe diffuse left ventricular hypokinesis.  Left ventricular wall thickness was normal.  Left atrium was moderately dilated.  There was mild mitral annular calcification.  There was moderate mitral valvular regurgitation.  The right ventricle was moderately to markedly dilated.  Right ventricular systolic function was moderately reduced.  There was moderate tricuspid valvular regurgitation.  Right atrium was moderately dilated.

EKG:  Atrial fibrillation with rapid ventricular response at the rate of 148 beats per minute with nonspecific ST-T wave abnormality.

HOSPITAL COURSE:  The patient was admitted to telemetry bed and continued on Cardizem drip with anticoagulation with heparin.  She underwent echocardiogram with the above findings.  She was seen by Dr. John Doe in consultation.  She later developed congestive heart failure requiring diuretic treatment with ACE inhibitor.  Beta blocker was also given.

The patient underwent cardiac catheterization showing 20% stenosis of the left main coronary artery with calcification.  There was 50% proximal stenosis of the left anterior descending artery with focal 40% stenosis in the mid segment and 50% stenosis on the mid to distal segment.  At the bifurcation of the small diagonal artery, there was 50-70% ostial stenosis and 50% mid stenosis of the left circumflex artery, 50% proximal stenosis of the second obtuse marginal artery and 50-70% small focal stenosis of the mid right coronary artery being dominant artery.

Left ventriculogram showing left ventricle dilatation and globally hypokinetic with ejection fraction of 20-25%.  Left ventricular end-diastolic pressure was 33 mmHg.  Dr. Jane Doe's recommendation was to treat the patient medically with beta blocker, ACE inhibitor, and digoxin for rate control of her atrial fibrillation in addition to aspirin and lipid-lowering therapy.  Electrophysiology consultation was also obtained.  The patient remained stable throughout her hospital stay.  She was later transferred to outside hospital for further evaluation and treatment.

Cardiology Consult Sample Report  Cardiovascular Terms for Medical Transcriptionists

Shoulder Arthroscopic Decompression Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Right shoulder impingement syndrome.
2.  Right shoulder acromioclavicular joint arthritis.
3.  Right shoulder rotator cuff tear.

POSTOPERATIVE DIAGNOSES:
1.  Right shoulder impingement syndrome.
2.  Right shoulder acromioclavicular joint arthritis.
3.  Right shoulder rotator cuff tear.

OPERATION PERFORMED:
1.  Right shoulder arthroscopic decompression.
2.  Right shoulder arthroscopic distal clavicle excision.
3.  Right shoulder arthroscopic rotator cuff repair.

SURGEON:  John Doe, MD

 ASSISTANT:  None.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old female with long-standing pain in her right shoulder with an MRI proving a full-thickness tear of the rotator cuff. She is very symptomatic and presents today for arthroscopic surgery to improve her pain.

DESCRIPTION OF OPERATION:  Informed consent was obtained. She was taken to the operating room and was given interscalene as well as general anesthesia. We placed her into the lateral position with her right shoulder up. Her fingers were placed in finger traps and attached to the lateral arm holder. We prepped and draped the shoulder in routine fashion.

We made a small posterior incision and placed the arthroscope into the glenohumeral joint. She had a full-thickness tear of the supraspinatus with a lot of granulation tissue present within the tear. This tear was somewhat more medial and not really insertional. She had a lot of synovitis in her joint. We placed a shaver in the joint to perform a synovectomy and debridement of some frayed portions of her labrum. Her articular surfaces were healthy, and her biceps was intact.

We then placed the arthroscope into the subacromial space. She had a thickened bursa. We made a lateral portal and performed a complete bursectomy. The CA ligament was very thickened and calcified. We released the ligament portion to reveal a large anterior spur, and we used a motorized shaver on high speed to resect this spur. The AC joint was also very tight and arthritic. We made a direct anterior portal and used a shaver to resect the distal clavicle. This relieved the impingement.

The rotator cuff tear was in the supraspinatus, and it was a more medial side-to-side type tear. We placed a disposable cannula and performed this in a side-to-side fashion; first piercing the more lateral edge of the tendon and then grasping that suture and passing it through the more medial leaf of the tendon using a Scorpion suture Passer. We passed two sutures. These were #2 FiberWire sutures with arthroscopic knots tied more laterally, giving secure repair of tendon-to-tendon. There was no gapping and no motion at the repair site.

We then removed the instruments and closed the portals. We applied sterile dressings and a sling, and she was awakened and taken to the recovery room in good condition.


Scalp Injury ER Medical Transcription Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

 CHIEF COMPLAINT:  Scalp injury.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male who apparently was at a party tonight when he slipped on something on the floor, fell down, hit the back of his head, noted some blood, and came in complaining of some mild sharp scalp pain since.

The patient denies any loss of consciousness. The patient denies any neck pain and denies any chest pain or trouble breathing.

PAST MEDICAL HISTORY:  History of hernia repair.

ALLERGIES:  None.

MEDICATIONS:  None.

SOCIAL HISTORY:  The patient reports drinking one to two beers daily. The patient denies tobacco or illicit drug use.

 REVIEW OF SYSTEMS:  As above in HPI. The patient denies any other recent illness. All other systems are negative.

PHYSICAL EXAMINATION:
GENERAL:  The patient is a pleasant, well-nourished young male. The patient does not appear to be in any distress.
VITAL SIGNS:  Blood pressure 120/76, pulse 72, respirations 18, temperature 98, and O2 sat is 97% on room air.
HEENT:  Head is normocephalic. He is noted to have a small posterior scalp laceration that is approximately 1 cm. This is a relatively superficial scalp laceration. Pupils are equal and reactive. Extraocular muscles are intact. Oropharynx is clear.
NECK:  Supple.
LUNGS:  Clear to auscultation.
HEART:  Regular rhythm.
ABDOMEN:  Soft, nontender.
EXTREMITIES:  There is no edema.
NEUROLOGIC:  The patient is awake, alert, and oriented x4. Gait is within normal limits. Exam is nonfocal.

EMERGENCY DEPARTMENT COURSE AND MEDICAL DECISION MAKING:  The patient was seen and examined as above. His wound was copiously irrigated. We used three staples to reapproximate the wound after using some lidocaine for topical anesthesia. The patient tolerated the procedure well. He was given a tetanus shot here today.

The patient will be discharged home with instructions to have his staples removed in 7 to 10 days and otherwise return as needed.

DISCHARGE DIAGNOSIS:  Scalp laceration.

PLAN:  The patient is discharged home with instructions as above.

DISPOSITION:  To home.

DISCHARGE CONDITION:  Good.

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Pancreatic Cancer Consultation Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Pancreatic cancer.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old lady whom we have been following for metastatic pancreatic cancer. We saw the patient last in the office in August, and we felt that her clinical condition was deteriorating and she was not strong enough for chemotherapy. We ordered a restaging CT of the chest and abdomen and the plan was to follow up with us after the scans to make a decision about whether to continue with further systemic therapy or to be enrolled in hospice.

Over the course of the two weeks since we saw her, she went to see Dr. Jane Doe where she was placed on the macrobiotic diet and was started back on gemcitabine. She immediately developed the same skin blotchiness that she had developed previously and had progressive upper abdominal back pain and came back to the hospital for evaluation.

PAST MEDICAL HISTORY:  Positive for hypertension and positive for depression.

MEDICATIONS:  As an outpatient are Lipitor, Zetia, Fosamax, lisinopril, Zoloft, Xanax, vitamin B12, Os-Cal, vitamin C, Neurontin, and since she has been in the hospital, she has been started on a morphine infusion at 3 mg an hour and continues on the Duragesic patch at 75 mcg an hour that she had been on.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  Tobacco:  She does not smoke. Ethanol:  She does not drink.

FAMILY HISTORY:  Positive for cancer. Her sister has gastric cancer.

REVIEW OF SYSTEMS:  GENERAL:  The patient's activity level has been declining. Her Karnofsky performance status is still only 40 and precludes her from doing anything outside the house. PULMONARY:  No shortness of breath, no cough. CARDIOVASCULAR:  The patient has the midline pain that she attributes to gastroesophageal reflux disease. GASTROINTESTINAL:  The patient has no constipation or diarrhea. See history of present illness for remainder. RHEUMATOLOGIC:  No bone pain or arthritis. DERMATOLOGIC:  Skin rash, see history of present illness. NEUROLOGIC:  No headaches, no focal neurologic symptoms.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure is 118/66, pulse 76, respirations 16, and temperature 97.6.
GENERAL:  The patient is a well-developed, well-nourished female who is in moderate discomfort from lower abdominal pain, which she now describes as having gone from her epigastrium down to the lower abdomen and is bilateral.
LUNGS:  Clear to auscultation and percussion.
HEART:  Regular rhythm and rate without murmur, gallop or rub.
ABDOMEN:  Mildly tender. She does have hepatomegaly. There is no splenomegaly.
EXTREMITIES:  No clubbing, cyanosis or edema.
LYMPH NODES:  Negative for cervical, supraclavicular or infraclavicular lymphadenopathy.

LABORATORY DATA:  CBC: White blood count 6.4, hemoglobin 10.6, platelets of 188,000. Sodium 138, glucose 114, creatinine 0.8, albumin 3.2, globulin 2.9, calcium 8.4, bilirubin 0.5, AST is 40, alkaline phosphatase is 268.

IMPRESSION:
1.  Pancreatic cancer.
2.  Liver metastases.
3.  Hypertension.
4.  Abdominal pain secondary to pancreatic cancer, liver metastasis, and constipation.
5.  Constipation.

PLAN:
1.  PCA pump. Increase the infusion rate to 4 mg an hour and allow the patient to give herself up to 5 mg an hour.
2.  If this is not effective after 24 hours, will have Anesthesia assess the patient for possible epidural pump for narcotic infusion.

Femur Fracture Intramedullary Nailing Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Right femur fracture.
2.  Right patella fracture.
3.  Left base of fifth metacarpal fracture.

POSTOPERATIVE DIAGNOSES:
1.  Right femur fracture.
2.  Right patella fracture.
3.  Left base of fifth metacarpal fracture.

OPERATIONS PERFORMED:
1.  Intramedullary nailing, right femur fracture.
2.  Open reduction internal fixation, right patellar fracture, with cerclage wiring.
3.  Closed treatment of left fifth metacarpal fracture.

 SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal.

COMPLICATIONS:  None.

SPECIMENS REMOVED:  None.

ESTIMATED BLOOD LOSS:  350 mL.

TOURNIQUET TIME:  Not used.

INDICATION FOR OPERATION:  The patient is a (XX)-year-old female involved in a motor vehicle accident, who was seen and evaluated the day before surgery and noted to have the above new orthopedic injuries. Informed consent was obtained for surgery, and she was brought to the operating room at the earliest convenience for fixation of these fractures.

DESCRIPTION OF OPERATION:  The patient was brought back to the operating room and placed supine on the operating table. The right hip was bumped up. Anesthesia was induced by the anesthesia team. Informed consent was obtained prior to the procedure. A time-out was performed, and the patient's name, medical record number, operative site and operation to be performed were verified by the entire operative team. The patient was then prepped with ChloraPrep and draped in the usual standard sterile fashion. Preoperative antibiotics in the form of one gram of Ancef was given prior to the procedure being performed.

An incision was carried down in the midline, over the knee, from the tibial tubercle, approximately 12 cm long. The incision was carried down sharply through skin and subcutaneous tissues until the fascia above the patella and prepatellar bursa was identified. It was noted to be markedly hemorrhagic.

A median parapatellar arthrotomy was then performed from the level of the tibial tubercle up proximal to the pole of the patella. The patella was then brought laterally and inspected and noted to have a nondisplaced fracture through the mid part of the patellar articular surface, and alignment was noted to be excellent.

Attention was turned to the femur fracture. A guidewire was placed under direct visualization and fluoroscopic guidance up through the notch. Using biplane fluoroscopy, there was noted to be bone in both views. The starting reamer was then utilized to penetrate the subchondral bone. The long guidewire and ball-tipped guidewire were threaded up through the canal. The fracture was reduced and the guidewire was passed without complication. It was checked under biplanar fluoroscopy as well, and the alignment was noted to be acceptable.

Reaming was begun starting at 8, then 9, 10, 10.5, 11, 11.5 and 12. A 11 x 380 retrograde intramedullary Stryker nail was placed without complication and threaded up through the fracture up to proximally. Once this was done, the distal locking guide was placed and the distal locking screws were placed without complication.

The fracture rotation was then checked, and it was noted to be acceptable with adequate rotation and angulation. The proximal locking screws were then placed, one dynamically and one statically, without complication. The wounds were irrigated and attention was turned to the patella.

A 16 gauge wire was utilized to make a cerclage around the patella through the subcutaneous cuff. This was revised several times until x-rays and visual inspection noted it to be in excellent position without any wire in the joint or displacement of the fracture. This was tightened down and wounds irrigated copiously.

X-rays were obtained, biplane fluoroscopy, noting that patellar alignment was excellent and all screw lengths were adequate. The wounds were sutured closed. The median parapatellar arthrotomy was closed with interrupted 0 Vicryl sutures and the skin closed with 2-0 Vicryl sutures and staples.

The locking screw holes were covered with 2-0 Vicryl sutures and staples. The patient's leg was washed and dried. Bacitracin, Adaptic gauze and dry gauze dressings were placed. Drapes were removed and x-rays were taken while the patient was still asleep. A well-padded splint was placed for the patient's ankle and calcaneus fractures.

Attention was turned to the left hand and x-ray showed the base of the fifth metacarpal fracture was minimally placed. It was checked under fluoroscopy and noted to be adequate. The splint was replaced. The patient was awakened from anesthesia and taken to the PACU in stable condition.

PLAN:  The patient will convalesce in the hospital and will likely return to the operating room for definitive operative fixation of the calcaneus and lateral malleolus fractures once the soft tissues have improved.


Arthroscopic Subacromial Decompression Sample Report

DATE OF OPERATION:  MM/DD/YYYY

 PREOPERATIVE DIAGNOSIS:  Right rotator cuff tear.

 POSTOPERATIVE DIAGNOSES:
1.  Right rotator cuff tear, subscapularis and supraspinatus.
2.  Right labral tear.

OPERATION PERFORMED:
1.  Right arthroscopic subacromial decompression.
2.  Right arthroscopic extensive debridement to include the labrum, subscapularis and supraspinatus tendons.

 SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  Scalene.

TOURNIQUET TIME:  None.

ESTIMATED BLOOD LOSS:  Less than 5 mL.

COMPLICATIONS:  None.

DRAINS:  None.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old Hispanic male who injured his right shoulder when doing therapy for his cervical spine. The patient felt a pulling sensation and pain down the lateral side of his arm. He has continued to have pain complaints and was sent to our office where, after a detailed history, physical examination and review of plain film radiographs, including an MRI scan, concerns of a rotator cuff tear was entertained. Because of continued pain complaints, the patient presents now for the above-mentioned operation.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room, and after scalene block was administered by the anesthesia team, the patient was positioned on the operating room table in a sitting position. Of note, preoperative antibiotics were given. The right shoulder was prescrubbed with Betadine. The right upper extremity, including the right base of the neck and shoulder, was prepped and draped in the usual sterile fashion.

After bony palpation, a posterior portal was created with a 15 scalpel blade, and this was used for the arthroscope. Next, a true anterolateral portal was created in a similar fashion, and this was used for outflow and instrumentation. The superior labrum demonstrated significant fraying, which involved the biceps anchor, which started at the 11 o'clock position and extended to about the 1 o'clock position. A radiofrequency device was utilized to debride this area. With lifting, it was noted that there was some detachment, but the degenerative nature demonstrated that no formal repair would be required. The anteroinferior, inferior and rest of the posterior labrum were within normal limits. There was a negative drive-through sign, and the axillary pouch showed no loose bodies. The humeral head and glenoid fossa showed no significant degenerative changes. There was significant fraying representative of a partial tear of the subscapularis, and this was debrided with a 5.5 full radius shaver.

Further probing demonstrated some mild delamination, but it was not felt to be repairable in nature. The rotator interval showed no defects. The superior glenohumeral ligament, middle glenohumeral ligament, and the anterior band of the inferior glenohumeral ligament showed no tearing. The biceps was medialized. There was no fraying. The supraspinatus was visualized, and there was some mild delamination at the articular surface representative of a PASTA lesion. This was debrided with a radiofrequency device, and this only represented 5%, and therefore, it was felt that no formal repair would be needed. The posterior cuff and the rest of the supraspinatus were visualized, and there was no tearing. The arthroscope was then placed into the subacromial region. Significant amounts of neovascularization with a hypertrophic, thickened subacromial bursa was identified.

Under direct visualization, a direct lateral portal was created in a similar fashion, and this was used for instrumentation. A formal bursectomy was performed. A moderately thickened coracoacromial ligament was seen, and this was incised and released. A moderate-sized enthesiophyte was identified. A formal acromioplasty was performed with a 5.5 full radius shaver. Approximately 6 mm of bone was resected. Resection was carried to a smooth, flat surface. The arthroscope was placed in the direct lateral portal, and visualization demonstrated a flat smooth acromion. Inspection of the bursal side of the rotator cuff demonstrated no partial tears. It was felt by the operative team that an adequate subacromial decompression as well as extensive debridement of the labrum, supraspinatus and subscapularis had been performed.

The instruments were removed, and the portal sites were closed with 4-0 nylon in a simple interrupted fashion. All sponge and instrument counts proved to be correct, and estimated blood loss was less than 5 mL. The wounds were then cleaned and dressed under the sterile field. A Polar Care ice machine and a shoulder immobilizer were placed to the right upper extremity. The patient was then escorted to the recovery room in stable condition. Examination in the recovery room revealed that the radial pulse was 4/4; however, due to scalene block, neurologic examination could not be completely assessed.


Knee Arthrotomy Transcribed Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Gunshot wound to right knee.
2.  Right patellar fracture.
3.  Right femoral lateral condyle fracture.

POSTOPERATIVE DIAGNOSES:
1.  Gunshot wound to right knee.
2.  Comminuted fracture of lateral facet of patella.
3.  Fracture of lateral condyle, femur.
4.  Retained bullet fragments in knee joint.

OPERATION PERFORMED:
1.  Right knee arthrotomy.
2.  Removal of retained bullet fragments.
3.  Open reduction and internal fixation, right lateral femoral condyle fracture.
4.  Partial patellectomy.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  200 mL.

COMPLICATIONS:  None.

INDICATION FOR OPERATION:  The patient is a (XX)-year-old gentleman who sustained a gunshot wound to his right knee. Radiographs and CT scans showed the above fractures. Informed consent was obtained for operative fixation and irrigation and debridement of his knee joint.

DESCRIPTION OF OPERATION:  The patient was brought to the OR and laid supine on the OR table. General anesthesia was induced. A tourniquet was placed high up on his right thigh, and the right lower extremity was prepped and draped in the usual sterile fashion. An Esmarch bandage was used to exsanguinate the right lower extremity, and the tourniquet was inflated to 350 mmHg.

An anterior approach to the knee joint was performed. A lateral parapatellar arthrotomy was performed. The patellar fracture was examined, and there was noted to be a highly comminuted fracture of the lateral facet of the patella. Approximately 10-15% of the patellar articular surface was comminuted, and these bone fragments were not reconstructable. Therefore, a rongeur was used to remove these loose bone fragments. The fractured patella was smoothed out using a rongeur.

Next, attention was directed toward removing the two large bullet fragments in the knee joint. These were removed without difficulty. Attention was directed to the lateral femoral condyle. Approximately 30% of the articular surface of the lateral femoral condyle was comminuted and destroyed. There was a sagittal fracture line, as was also noted preoperatively on CT scans.

Three 3.5 mm cortical screws were used to stabilize the lateral femoral condyle fracture from lateral to medial. These screws were placed in standard AO fashion holding this fracture reduced. Again, approximately 30% of the articular surface of the lateral femoral condyle was involved and was not reconstructable.

The wound was thoroughly irrigated with 9 liters of normal saline, the middle 3 liters of which contained 100,000 units of bacitracin. C-arm fluoroscopy was used to examine the knee joint. Two more small pieces of bullet fragments were found, and these were removed under C-arm visualization.

The parapatellar arthrotomy was closed using #1 Ethibond suture in figure-of-eight fashion. The subcutaneous layer was closed with 2-0 Vicryl suture followed by staples for the skin. The bullet entrance wound was also thoroughly debrided and irrigated out. This wound was closed with a simple 2-0 nylon suture.

Of note, the tourniquet was deflated prior to closure, and hemostasis was obtained. Sterile dressings were applied. The patient was placed into a knee immobilizer. He was awakened from anesthesia and transferred to a stretcher and taken to the PACU for recovery.


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