Transmetatarsal Amputation Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Nonhealing left first and second toe amputation with third toe gangrene.

POSTOPERATIVE DIAGNOSIS:  Nonhealing left first and second toe amputation with third toe gangrene.

OPERATION PERFORMED:  Completion left transmetatarsal amputation.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

INDICATIONS FOR OPERATION:  The patient is an (XX)-year-old lady who has had progressive gangrene of her left first and second digit. She developed foot infection and required emergent amputation of these. Prior to that time, she had undergone balloon angioplasty of her popliteal artery, which was severely stenotic. During this hospitalization, with dressing changes, the central portion of the wound improved and granulated. However, the peripheral tissue showed full-thickness slough, including the adjacent third toe. It was recommended that the patient be brought back to the operating room for debridement and possible transmetatarsal amputation to facilitate healing. The patient agreed understanding the risks, benefits, and other options.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed on the operating table in the supine position. After adequate induction of anesthesia, the left foot was prepped and draped in a sterile fashion. It was decided at this point, because of the extent of third toe gangrene, to proceed with a transmetatarsal amputation.

An incision was made around the base of the previously open wound and healthy tissue and continued out laterally on the dorsal surface of the foot just proximal to the web spaces and underneath the plantar aspect of the foot in a similar fashion. The incision was continued through the soft tissue down to the shafts of the metatarsal bones. Using an oscillating saw, the third, fourth, and fifth metatarsal shafts were divided. The amputation was completed to the plantar flap leaving a healthy flap intact. The specimen was passed off the field. There was noted to be no purulence. The tissue that was transected was extremely healthy with good pulsatile bleeding.

Hemostasis was obtained with limited electrocautery and several sutures of 3-0 Vicryl. The second, third, fourth, and fifth metatarsal shafts were mobilized further, and using an oscillating saw, they were debrided back approximately 1 to 2 cm further to facilitate closure of the plantar flap. After this had been done and hemostasis had been obtained, the plantar flap was brought in approximation with the dorsal incision using interrupted 3-0 nylons. Care was taken not to place the flap under severe tension in order not to jeopardize the vascular supply. At this point, the remaining shaft of the first metatarsal was debrided proximally using a rongeur back approximately 1 cm. The surrounding tissue was all very healthy. It was packed with a saline silk gauze. A clean, sterile, dry dressing was applied, and the patient was transferred to recovery in stable condition having tolerated the procedure well.

Ophthalmology SOAP Note Sample Report

SUBJECTIVE:  The patient was seen in followup today. She is a pleasant (XX)-year-old with a history of moderate dry macular degeneration. The patient reports some slight blurring of vision at near.

OBJECTIVE:  Visual acuity, uncorrected, is 20/30-2 OD, 20/50 pinhole, 20/40 OS. Intraocular pressure is 19 mmHg OU. Anterior segment examination shows 2+ NS, OD and a PCIOL OS. Dilated funduscopic examination reveals macular drusen, OU. There is a large drusenoid pigment epithelial detachment in the left eye. There is no evidence of any macular edema, hemorrhage or subretinal fluid.

ASSESSMENT AND PLAN:  Moderate dry macular degeneration, both eyes, with drusenoid pigment epithelial detachment, left eye. The patient appears stable from a retinal standpoint. We do not see any evidence of choroidal neovascularization, macular edema or hemorrhage. We did review signs and symptoms of these, and she does know to call immediately if she does have any distortion or vision changes. We have asked her to return in six months for a followup.

Ophthalmology SOAP Note Sample #2

SUBJECTIVE:  The patient is a pleasant (XX)-year-old who has experienced blurry vision in both eyes, left eye greater than the right eye, for the last several months. Her past ocular history is significant for dry macular degeneration and history of cataract surgeries in both eyes. The patient has also been treated for ocular hypertension.

OBJECTIVE:  On examination, the patient's vision is 20/40 in the right eye and 20/30 in the left eye. Anterior segment examination reveals posterior chamber intraocular lenses in both eyes. Intraocular pressures are 20 in each eye. Fundus examination of the right eye shows the retina to be attached 360 degrees without any tears or holes. There are drusen in the macula. There is a small pocket of subretinal fluid temporal to the optic disc, not involving the fovea. There is no cystoid macular edema present. There is no retinal hemorrhage or lipid exudation present. Fundus examination of the left eye shows the retina to be attached 360 degrees without any tears or holes. There is a flat choroidal nevus inferotemporally. There are RPE changes and drusen in the macula and temporal to the optic disc. There are two distinct pockets of subretinal fluid, one involving the inferior macula and the other one in a juxtapapillary position involving the superonasal portion of the macula. There is no retinal hemorrhage present. There is no cystoid macular edema or lipid exudation present. Fluorescein angiography reveals focal areas of leakage in both eyes consistent with central serous retinopathy. ICG videoangiography shows enlarged and hyperpermeable choroidal vessels in both eyes consistent with central serous retinopathy. There is no tuft of neovascularization noted per ICG angiography.

ASSESSMENT AND PLAN:  The patient has pockets of subretinal fluid with pinpoint areas of leakage in both eyes and ICG angiographic pattern consistent with central serous retinopathy. The patient informed us that she is taking Advair for her asthma. Steroid products have been associated with CSR. We asked her to follow up with her primary care physician in order to see whether she could be on a nonsteroidal medicine. We plan to see her back in one month for reevaluation.

Ophthalmology SOAP Note Sample #3

SUBJECTIVE:  The patient is a pleasant (XX)-year-old who was noted to have choroidal nevus in her right eye and is here today for further evaluation. She has not experienced loss of vision or distortion.

OBJECTIVE:  On examination, her vision is 20/20 in both eyes. Pressures are 15 in each eye. Fundus examination of the right eye reveals an approximately 1 mm flat choroidal nevus temporal to the optic disc. There is no orange pigment or subretinal fluid present. Fundus examination of the left eye shows the retina to be attached 360 degrees without any tears or holes.

ASSESSMENT AND PLAN:  The patient has a flat choroidal nevus in her right eye. We reassured her that we do not see any high-risk features. At this point, we recommend annual monitoring. Baseline fundus photographs were obtained today.

Ophthalmology SOAP Note Sample #4

SUBJECTIVE:  The patient was seen for followup examination. We have been following this patient for epiretinal membrane in his left eye and retinal microaneurysms and hemorrhages in both eyes. We initiated systemic workup, including hemoglobin A1c. The patient's hemoglobin A1c level came back borderline high. The patient states that his vision has been stable.

OBJECTIVE:  On examination, the patient's vision is 20/60 in the right eye and 20/40 in the left eye. Anterior segment examination reveals posterior chamber intraocular lenses in both eyes. The intraocular pressures are 16 in each eye. Fundus examination showed scattered microaneurysms and intraretinal hemorrhages. There is a stable epiretinal membrane in the left eye. OCT examination showed epiretinal membrane with mild macular edema in the left eye.

ASSESSMENT AND PLAN:
1.  Retinal microaneurysms and hemorrhages: The patient's hemoglobin A1c was borderline high. We asked him to follow up with his primary care physician to be evaluated further for diabetes. We plan to see him back in three months for reevaluation.
2.  Epiretinal membranes in the left eye: This appears to be stable. We asked him to continue Acular eye drops three times a day in that eye.

Ophthalmology SOAP Note Sample #5

SUBJECTIVE:  The patient was seen for followup examination. The patient has been followed for proliferative diabetic retinopathy and epiretinal membrane. The patient states that her blood sugar is under good control, and she has not noted any loss of vision.

OBJECTIVE:  On examination, the patient's vision was 20/25 in the right eye and 20/30 in the left eye. Intraocular pressures were 16 in the right and 17 in the left. There was no neovascularization of iris. Fundus examination showed PRP laser in both eyes. There was no clinically significant macular edema present. There was epiretinal membrane present in both eyes. OCT examination of the right eye showed no macular edema. OCT examination of the left eye showed less macular edema.

ASSESSMENT AND PLAN:  We reassured the patient that she is stable from a retinal standpoint. We asked her to stop Acular eye drops in her right eye and continue Acular in her left eye once a day. We also asked her to continue good control of her blood sugar levels.

Ophthalmology SOAP Note Sample #6

SUBJECTIVE:  The patient was seen for followup examination. We have been following him for nonproliferative diabetic retinopathy. He states that his blood sugar is under good control and has not experienced loss of vision.

OBJECTIVE:  On examination, the patient's vision is 20/20 in both eyes. Anterior segment examination is unremarkable. Fundus examination shows scattered dot-blot hemorrhages and microaneurysms in both eyes. There is no clinically significant macular edema in both eyes. There is no neovascularization process present in either eye. OCT examination confirms a lack of macular edema in both eyes. Fluorescein angiography shows microaneurysms with minimal leakage without any neovascularization process in either eye.

ASSESSMENT AND PLAN:  The patient has mild to moderate nonproliferative diabetic retinopathy. We asked him to continue good control of his blood sugar and pressure levels. We will continue regular monitoring.

Ophthalmology SOAP Note Sample #7

SUBJECTIVE:  The patient was seen for followup examination. We have been following her for epiretinal membrane in her right eye and extramacular drusen in both eyes. She states that her vision has been stable.

OBJECTIVE:  On examination, the patient's vision is 20/25 in the right eye and 20/20 in the left eye. Anterior segment examination shows age-appropriate nuclear sclerotic changes in both eyes. Intraocular pressures are 16 in each eye. Fundus examination shows the retina to be attached 360 degrees without any tears or holes. There are peripheral and extramacular drusen in both eyes. There is no subretinal fluid or hemorrhage present. There is a mild and a stable epiretinal membrane in the right eye. OCT examination shows no subretinal fluid or macular edema in both eyes. There is a stable epiretinal membrane in the right eye.

ASSESSMENT AND PLAN:  The patient is very stable from a retinal standpoint. We reassured her of these findings. At this point, we recommend annual monitoring.

Dilation and Curettage D&C Operative Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Incomplete spontaneous abortion with vaginal bleeding.

POSTOPERATIVE DIAGNOSIS:  Incomplete spontaneous abortion with vaginal bleeding.

OPERATION PERFORMED:  Dilation and curettage.

SURGEON:  John Doe, MD

ASSISTANTS:  None.

ANESTHESIA:  General endotracheal anesthesia.

ANESTHESIOLOGIST:  Jane Doe, MD

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old gravida 3, para 2 at 6 weeks pregnancy who presented today with heavy vaginal bleeding and cramping. The patient was seen in the emergency room where she was found to have dilated cervix and passing clots. There was no evidence of products of conception or passage of products of conception from the vagina. Transvaginal ultrasound performed in the emergency room showed no gestational sac in the uterus and a large amount of blood and tissue within the uterus near the internal os. The ultrasound in the emergency room also showed no fluid in the cul-de-sac and both adnexa were well visualized and within normal limits. The patient was counseled at that time for expectant management and dilation and curettage to evacuate the uterus and the patient choose to have the D&C.

OPERATIVE FINDINGS:  Pertinent findings at the time of procedure are products of conception at the internal os. Specimens removed were contents of uterus. Estimated blood loss 50 mL. No complications.

DESCRIPTION OF PROCEDURE:  The patient was taken from the preoperative holding area to the operating room. Prior to the procedure, the patient was fully counseled as to the risks, benefits, indications, and options for the procedure, to which the patient agreed. The patient was placed supine on the operating room table. General endotracheal anesthesia was administered, and once adequate anesthesia was demonstrated, the patient's legs were then placed in candy cane stirrups. The patient was then prepped and draped in the standard surgical fashion for D&C.

The patient was placed in 10 degrees of Trendelenburg. The patient was given 100 mg of doxycycline prior to the start of the case. The bladder was then decompressed and approximately 50 mL of urine was produced. A weighted speculum was placed in the posterior vagina and cervix was grasped with single tooth tenaculum. Uterus sounded to 8 cm. The cervix was then serially dilated with Hanks dilator. An 8 cm straight suction curette was then introduced and a suction curettage was performed. Once all products of conception were evacuated, a sharp curettage was performed until a gritty surface was appreciated on all four quadrants of the uterus. No further bleeding was noted. Products of conception were then examined on the back table, which was grossly consistent with products of conception.

The patient tolerated the procedure and anesthesia well, was awakened from anesthesia without complications and was transported to the recovery room in stable condition.

Cesarean Section Dictation Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Intrauterine pregnancy at 40 weeks.
2.  Frank breech position.

POSTOPERATIVE DIAGNOSES:
1.  Intrauterine pregnancy at 40 weeks.
2.  Frank breech position.

OPERATION PERFORMED:  Primary low transverse cesarean section with two-layer closure.

SURGEON:  John Doe, MD

ANESTHESIA:  Spinal anesthesia.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  500 mL.

URINE OUTPUT:  200 mL.

IV FLUIDS:  1300 mL crystalloid. Ancef 1 gram at cord clamp IV.

OPERATIVE FINDINGS:  Normal male infant with Apgars of 8 and 9 at one and five minutes with weight of 6 pounds 8 ounces.

DESCRIPTION OF OPERATION:  After informed consent, risks and benefits of the procedure was discussed with the patient. The patient was taken to the operating room where she was placed in the dorsal lithotomy position with leftward tilt. After placement of spinal anesthesia, which was found to be adequate, she was then prepped and draped in the usual sterile fashion.

A Pfannenstiel skin incision was made with a scalpel and carried through to the underlying layer of fascia. The fascia was then nicked in the midline, extending bilaterally and sparing the inferior aspects. The fascia was dissected off the rectus muscles bluntly. The rectus muscles were separated in the midline, and peritoneum was identified, entered with hemostat, and extended superiorly and inferiorly with good visualization of the bladder.

The bladder blade was then inserted. The vesicouterine peritoneum was identified and entered sharply with Metzenbaum scissors and extended bilaterally and then the bladder flap was created digitally. The uterine incision was then made with the scalpel and extended with bilateral index fingers in a crescent-shaped fashion. The fetal buttocks were then grasped and bilateral legs were delivered, and the infant was delivered in the usual fashion of a beech delivery, atraumatically. The cord was clamped and cut. The infant was then handed off to the awaiting pediatric staff. The placenta was then delivered spontaneously, intact.

The cervix was then dilated with ring forceps. The uterus was then exteriorized and cleared of all clots and debris. The uterine incision was then closed with 1-0 chromic in a running locked fashion. A second layer of the same suture was used in an imbricating fashion for hemostasis. The uterus was then returned to the abdomen. Bilateral gutters were cleared off all clots and debris. The uterine incision was noted to be hemostatic.

The subfascial layer was noted to be hemostatic, and the fascia was closed with 1-0 Vicryl in a running fashion. The subcutaneous layer was then closed with 3-0 Vicryl in a subcutaneous fashion. The skin was closed with 4-0 Vicryl in a subcuticular fashion. Steri-Strips, Telfa, and Tegaderm dressing were applied. All instruments, needle, and lap counts were correct x2. The patient was taken to the recovery room in stable condition.

Bronchoscopy with Bronchoalveolar Lavage Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Respiratory failure.
2.  Possible pneumonia.

PROCEDURE PERFORMED:  Bronchoscopy with bronchoalveolar lavage.

SURGEON:  John Doe, MD

ANESTHESIA:  IV sedation.

ESTIMATED BLOOD LOSS:  Zero.

SPECIMENS:  Left and right bronchoalveolar lavage for microbiology.

COMPLICATIONS:  None.

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old gentleman who has been admitted to the neurosurgical ICU with myasthenia gravis. Despite plasmapheresis and ongoing ICU care, he has continued with respiratory failure and his NIFs have remained low. The patient thus presents for tracheostomy. He has also been diagnosed with a possible pneumonia by the neurosurgical ICU team with the presence of left lower lobe infiltrate. Thus, he also presents for bronchoalveolar lavage at the same time.

DESCRIPTION OF PROCEDURE:  On the date of the procedure, the patient remained in the neurosurgical intensive care unit. He underwent bronchoscopic-assisted percutaneous tracheostomy. Once this procedure had been successfully completed, the bronchoscope was inserted through the patient's newly placed #8 Shiley tracheostomy tube. This was advanced to the carina. We surveyed the left side first. Then, the bronchoscope was advanced into the left lower lobe and was wedged in the left lower lobe segmental orifices, segment 9. An alveolar lavage specimen was taken. It was suctioned and collected in a Lukens trap and was then passed off the table and sent to Microbiology. We then advanced the bronchoscope into the right lower lobe segmental bronchi. The bronchoscope was wedged, and an additional alveolar lavage was taken. The specimen was suctioned and was collected in a Lukens trap and was passed off the table to send to Microbiology. We then surveyed the bronchi. There was a small amount of blood that was remaining from the tracheostomy. This was suctioned free and removed. It did not reaccumulate. We surveyed the right upper lobe, right middle lobe, and right lower lobe segmental orifices, and each of these was seen to be free of mucous plugs. We then surveyed the left upper lobe, left lower lobe, and lingula. There was a moderate amount of secretions present in the left lower lobe. These were suctioned free and removed. These did not recur. There was no significant mucous plugging seen in the left lower lobe. There was general, what appeared to be, edema of the airways, but there did not appear to be severe tracheobronchitis. We did not see any endobronchial lesions. The bronchoscope was then removed, and the procedure was terminated. The patient tolerated the procedure well and remained in critical condition in the neurosurgical intensive care unit at the termination of the case.

Above Knee Amputation Operative Sample Report

 DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Severe ischemia, left lower extremity.

POSTOPERATIVE DIAGNOSIS:  Severe ischemia, left lower extremity.

OPERATION PERFORMED:  Left above knee amputation.

SURGEON:  John Doe, MD

ANESTHESIA:  General anesthesia.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and was placed in the supine position. General endotracheal anesthesia was induced. The left lower extremity was prepped and draped in the usual sterile manner. Then, curved incisions were made just above the knee, both anteriorly and posteriorly. These had meeting at the medial and lateral edges. Subcutaneous tissues and fascia were incised again using cautery extensively. Then, quadriceps muscle was transected using cautery again. Femoral vessels were identified and were dissected and separated. Femoral artery and femoral veins were individually clamped, transected, and proximal ends were suture ligated with 2-0 silk stitches. There was thrombus from popliteal vein graft, which was also transected and ligated with 2-0 silk stitches. Then, all the muscles were transected, and the sciatic nerve was transected and tied with the 2-0 Vicryl tie and allowed to retract. The femur itself was cleaned. Using an electric saw, we transected the femur. Then, bone wax was applied to prevent bleeding from the marrow. Then, muscles were closed in front of the femur with interrupted 2-0 Vicryl sutures. Subcutaneous tissues were closed with two layers of interrupted 2-0 Vicryl sutures. Then, the skin was closed with staples. Sterile dressings were applied, and the patient was transferred out of the operating room in stable condition.

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Ischemic gangrene and rest pain, right foot.

POSTOPERATIVE DIAGNOSIS:  Ischemic gangrene and rest pain, right foot.

OPERATION PERFORMED:  Right above knee amputation.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed on the operating table in the supine position. After adequate induction of anesthesia, the right leg was prepped and draped in sterile fashion. The intended incisions were marked out on the skin just above the patella with an anterior and posterior flap configuration. An incision was then made along these marked lines and continued through the subcutaneous tissue into the fascia circumferentially around the leg. The muscles in the anterior compartment were then divided down to the femur. The femur was mobilized using a periosteal elevator and divided using an oscillating saw. The muscles of the posterior and medial compartment were then divided using an amputation knife to complete the amputation. Specimen was passed off the field. The superficial femoral vein and artery were clamped individually and oversewn with 3-0 Prolene. The sciatic nerve was identified and mobilized. It was suture ligated with 3-0 chromic for vascular control. Multiple other pulsatile bleeding sites were controlled with electrocautery and 3-0 chromic sutures. Hemostasis was obtained with gentle pressure. The bone was beveled anteriorly and smoothed. The marrow was packed with bone wax. The anterior and posterior fascias were then reapproximated to each other using interrupted 2-0 Vicryl sutures. The skin was closed using staples. A clean, sterile, dry compression dressing was placed. The patient was transferred to the recovery room in stable condition having tolerated the procedure well.

Marsupialization of Bartholin Gland Abscess Sample Report

 DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left Bartholin gland abscess.

POSTOPERATIVE DIAGNOSIS:  Left Bartholin gland abscess.

OPERATION PERFORMED:  Marsupialization of left Bartholin gland abscess.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  Negligible.

COMPLICATIONS:  None.

INDICATIONS FOR OPERATION AND OPERATIVE FINDINGS:  The patient was seen in the office one day prior to admission, at which time a large Bartholin gland cyst was appreciated and extended the cyst approximately 4 cm. Due to the largeness of the Bartholin gland, it was decided that office intervention was not indicated. Thus, the patient was admitted for incision and drainage and marsupialization. Examination under anesthesia again noted a left Bartholin gland abscess, approximately 4 cm. Once the abscess opened, a purulent type material was appreciated, and cultures and sensitivities were forwarded to microbiology.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room in stable condition and placed on the operating room table in the dorsal supine position. The patient was then administered general anesthesia without difficulty. The patient was then repositioned in the dorsal lithotomy position. Exam under anesthesia was performed. The findings on examination are delineated above. The patient was then perineally prepped and draped.

With the use of an 11 blade, an incision was made in the mucocutaneous junction, approximately 1 cm. This allowed the purulent material to exit the cavity. Cultures were taken of this material. The Bartholin gland cavity was then copiously irrigated with sterile saline. Once this was performed, then marsupialization was accomplished with a 3-0 Vicryl continuous stitch. This stitch was continuous and of an interlocking fashion.

At the conclusion of the marsupialization, the site was hemostatic. The patient was then repositioned to the dorsal supine position and awakened from general anesthesia. The patient was transferred to the stretcher and taken to the postanesthesia recovery unit in good condition. There were no complications associated with this procedure.

Laparoscopic Salpingectomy Sample Report

LAPAROSCOPIC SALPINGECTOMY PROCEDURE SAMPLE REPORT

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Left ectopic pregnancy and cerclage in place.

POSTOPERATIVE DIAGNOSIS: Left ectopic pregnancy and cerclage in place.

OPERATION PERFORMED: Laparoscopic left salpingectomy and cervical exam under anesthesia.

SURGEON: John Doe, MD

ASSISTANT: None.

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: 600 mL with 550 mL of hemoperitoneum.

SPECIMENS: Left tube.

COMPLICATIONS: None apparent.

CONDITION: Stable to recovery room.

OPERATIVE FINDINGS:
1. Actively bleeding left ectopic pregnancy with 550 mL of hemoperitoneum in the abdomen
2. Surgical absence of the right tube.
3. Normal-appearing ovaries bilaterally.
4. Uterus adhesed to the bladder in the anterior abdominal wall.
5. Omental adhesions to the anterior abdominal wall.
6. Normal-appearing appendix and gallbladder.
7. Multiple cervical divots indicative of prior cerclage placement but no visible cerclage due to cervical mucosa.

DESCRIPTION OF OPERATION: After informed consent, the patient was brought to the operating room and placed supine on the operating table for laparoscopic left salpingectomy and cervical exam under anesthesia. General endotracheal anesthesia was then administered by the anesthesiologist. The patient was then placed in the dorsal lithotomy position and prepped and draped in the usual sterile fashion for an abdominal and vaginal procedure. A Foley catheter was placed into the bladder.

A Graves speculum was placed into the vagina and the cervix was carefully examined and manipulated around. There could be seen several divots in the cervix, indicative of where the cervix had been pierced during cerclage placement. However, even though the patient reported a pulling or pinching sensation, especially during intercourse, no visible portion of the cerclage could be seen protruding through the cervical mucosa. A small portion of what was possibly eroded Mersilene tape was grasped with ring forceps and removed, but the entire cerclage by no means was able to be retrieved.

A HUMI uterine manipulator was then placed into the uterus and this passed through easily and attention was returned to the abdomen. The umbilicus was infiltrated with 0.25% Marcaine and a stab incision was made through it. A 5 mm trocar containing a 5 mm 0-degree scope was placed into the abdomen under direct visualization. Pneumoperitoneum was then created with CO2 gas. Two other ports were then placed under direct visualization, a 10 mm in the left lower quadrant and a 5 mm in the right lower quadrant.

Systematic examination of the pelvis revealed the above findings. The omentum was adhesed to the anterior abdominal wall in the midline. This was taken down with the Harmonic scalpel. The right ovary appeared normal in configuration; although, it was somewhat adherent to the right pelvic sidewall. The left ovary and tube were encased in clot. The 10 mm suction was used to evacuate all clots; this amounted to 550 mL. The left tube contained an unruptured ectopic; although, the ectopic was actively bleeding bright red blood from the tubal end.

The tube was stabilized using a grasper and a Harmonic scalpel was used to dissect the tube away from the mesosalpinx and the ovary and also used to come across the tubal insertion into the uterus. The operative site was examined and found to be hemostatic.

A 10 mm EndoCatch was then placed into the abdomen and the left tube was placed in the EndoCatch and it was removed with a 10 mm port. The pelvis was then copiously irrigated and suctioned. The patient was taken out of Trendelenburg, and all the blood from the upper abdomen was allowed to run down into the pelvis and this was suctioned away as well. The pressure was dropped to 6 and all operative sites were examined and found to be hemostatic. The procedure was then terminated.

A Carter-Thomason CloseSure device was used to close the 10 mm fascial port with 0 Vicryl. All instruments were then removed from the patient's abdomen and the gas was suctioned out of her abdomen. Her skin incisions were closed with 4-0 Vicryl in a buried fashion and Dermabond was applied to the incisions.

All sponge and instrument counts were correct x2 at the end of the procedure. The Foley catheter and HUMI uterine manipulator were also removed, and the patient was returned to the supine position and awoken from anesthesia. The patient did tolerate the procedure well. She was transferred to the recovery room with vital signs stable.

Below Knee Amputation Operative Sample Report

 DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Ischemic left foot.

POSTOPERATIVE DIAGNOSIS:  Ischemic left foot.

OPERATION PERFORMED:  Left below-the-knee amputation.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General, orotracheal intubation plus epidural.

DESCRIPTION OF OPERATION:  The patient was placed supine. The left lower extremity was prepped and draped in the usual aseptic fashion. The intended incision site was marked. We incorporated the medial fasciotomy incision. The anterior aspect of the incision was made four fingerbreadths distal to the tibial tuberosity. The incision was continued through the fascia. The anterior compartment muscles were divided using electrosurgical dissection. The tibia and fibula were cleared. Periosteal elevator was used to clear the periosteum from the tibia. The tibia was transected with a power reciprocating saw. The fibula was transected 1 cm proximal to the tibial transection site using the bone cutters. The amputation was then completed with an amputation knife. The flap was debulked using scissors. The nerve was placed on traction, ligated and divided sharply and allowed to retract. The wound was then closed using 2-0 and 3-0 Vicryl sutures. 3-0 nylon vertical mattress stitches were placed in the skin. The large medial fasciotomy incision complicated the closure. The wound could not be closed completely secondary to the fasciotomy incisions. The open areas were packed with gauze. The stump was then wrapped with Kerlix and an Ace wrap. The patient tolerated the procedure well. There were no apparent complications.

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left diabetic foot infection.

POSTOPERATIVE DIAGNOSIS:  Left diabetic foot infection.

OPERATION PERFORMED:  Left open below-the-knee amputation.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General, orotracheal intubation.

DRAINS:  None.

SPECIMENS:  Left foot to pathology for permanent section.

DESCRIPTION OF OPERATION:  The patient was placed supine. A tourniquet was positioned in the left proximal leg but not inflated. The area was prepped and draped in the usual aseptic fashion. A circumferential incision was made proximal to the malleoli after the tourniquet was inflated. The incision was continued to bone. The bone was transected with the power reciprocating saw. The specimen was removed. The tourniquet was deflated. The vessels were identified and suture ligated. Other bleeding points were treated with electrosurgical cautery. The area was irrigated and examined for hemostasis. Xeroform, Kerlix, and an Ace were applied. The patient tolerated the procedure well. There were no apparent complications.

Loop Electrosurgical Excision Procedure Sample Report

 DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Moderate cervical dysplasia.

POSTOPERATIVE DIAGNOSIS: Moderate cervical dysplasia.

OPERATION PERFORMED: Loop electrosurgical excision procedure conization of the cervix.

SURGEON: John Doe, MD

ANESTHESIA: General by LMA.

ANESTHESIOLOGIST: Jane Doe, MD

COUNTS: Sponge and needle counts were announced as correct x2.

ESTIMATED BLOOD LOSS: 10 mL.

INDICATIONS FOR OPERATION: The patient is a (XX)-year-old gravida 2, para 2 woman, who had an atypical Pap smear that returned as ASCUS-H. Colposcopic examination revealed CIN 2 at the 12 o'clock position. The patient was therefore consented for a conization procedure.

DESCRIPTION OF OPERATION: After excellent general anesthesia, the patient was prepped and draped in a sterile fashion in the dorsal lithotomy position. No vaginal prep was done. A bivalve speculum was placed into the vaginal vault, and the cervix was bathed liberally with a 5% acetic acid solution. Acetowhite epithelium was noted to emanate. This was an adequate colposcopic examination. Dilute Lugol's was then placed on the cervix with further delineation of the acetowhite epithelial areas.

Pitressin, 20 units in 40 mL of normal saline, was infiltrated locally into the cervix in a circumferential fashion for a total of 10 mL. The cervix was noted to blanch nicely. Using 100 watts of pure cut, the anterior lip of the ectocervix was removed in one pass. The posterior lip was then removed in one pass. A suture was placed at the 12 o'clock position. The endocervical specimen was then taken on one pass using 100 watts of pure cut. This was placed in a separate jar. Endocervical curettings were then done, and these were also placed in a third jar. The large ball electrode was then placed, and using 60 watts of pure coag, hemostasis was achieved in the cervical bed. Monsel's solution was then placed on the cervical bed. There was good hemostasis. All instruments were removed.

Sponge and needle counts were correct x2. The patient awoke easily in the operating room and was taken to the recovery room in stable condition. The specimens were sent to pathology as follows: Jar #1 contained the ectocervical specimens with a suture at the 12 o'clock position. The anterior portion also was the larger piece. Therefore, the medium sized portion in the jar is the posterior lip, second endocervix, third endocervical curetting.