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.

Delivery Note - Normal Spontaneous Vaginal Delivery Sample

 DATE OF DELIVERY:  MM/DD/YYYY

 

PREDELIVERY DIAGNOSES:

1.  Gravida 1, para 0.

2.  Singleton intrauterine pregnancy at 41 and 2/7 weeks' gestation.

3.  Prolonged rupture of membranes.

4.  Meconium-stained amniotic fluid.

5.  Active labor.

 

POSTDELIVERY DIAGNOSIS:  Normal spontaneous vaginal delivery of a viable female in the left occipitoanterior position.

 

ANESTHESIA:  Epidural.

 

TYPE OF DELIVERY:  Normal spontaneous vaginal delivery of viable female in the LOA position.

 

COMPLICATIONS:  None.

 

ESTIMATED BLOOD LOSS:  350 mL.

 

FINDINGS:  Weight 7 pounds 12 ounces. Apgars 8, 9 and 9. Placenta delivered spontaneously intact with 3-vessel cord and meconium noticed. Second-degree perineal laceration repaired with 2-0 chromic under epidural and local anesthesia.

 

DELIVERY DETAILS:  The patient is a (XX)-year-old female, gravida 1, para 0, at 41 and 2/7 weeks' gestation by LMP, dated by 7-week ultrasound. Her dates are consistent with last menstrual period.

 

The patient presented to Labor and Delivery at 1630 with complaint of spontaneous rupture of membranes at 3 a.m. with regular contractions. Her vaginal exam at 1650 was 3, 100, -2. The patient desired natural childbirth. Due to prolonged rupture of membranes, penicillin prophylaxis was started at 1830. At 0130, she was 6, 100, -1. At 0450, bag was ruptured with meconium-stained amniotic fluid, and she was 8, 100, -1. At 0720, she was 8, 100, 0. At 0950, after epidural anesthesia, she was 10, 100, +1. She progressed to complete, 100 and +1 station at 1150 after resting for 4 hours after epidural anesthesia. Fetal heart tones in the second stage of labor were overall reassuring. She began pushing with direction. She pushed for 1 hour 20 minutes, delivered the head in the LOA position. Bulb suction of mouth and nose at the perineum. Shoulders delivered easily. Progressed to normal spontaneous vaginal delivery of viable female at 1310, delivered onto mom's abdomen. The cord was clamped x2 and cut. Baby was handed to the neonatologist with meconium-stained amniotic fluid. Apgars were 8, 9 and 9. Negative meconium below the cord. The weight was 7 pounds 12 ounces. Placenta delivered spontaneously intact with 3-vessel cord at 1315. Fundus massaged to firm.

 

Hemostasis achieved easily with an estimated blood loss of 350 mL after Pitocin 30 units IV piggyback given. A second-degree perineal laceration was noted and repaired with 2-0 chromic with local anesthesia. The mother and baby tolerated delivery well.

Brain MRI Medical Transcription Sample

HISTORY:  Asymmetric hearing loss.

MRI of the IACs was taken with and without contrast, thin sections, in coronal and axial images. Images through the whole head were also performed, both pre and postcontrast.

There is no evidence of an enhancing schwannoma or acoustic neuroma in the area of either internal auditory canal or the cerebellopontine angle. We do, however, see significant left mastoiditis and edema, which involves not only the mastoid air cells but the middle ear structures as well.

Today's examination also suggests two small white matter areas of demyelination on the FLAIR images in the gray-white matter junction of the right cerebral hemisphere involving the parietooccipital region, behind the posterior horn of the lateral ventricle and one in the superior aspect of the right parietal region. Both of these measure about 3 to 6 mm and do not enhance. These are most likely areas of demyelination and small vessel insult.

There is no abnormal enhancement noted, not only in the cerebellopontine angle and IAC regions but throughout the remainder of the head. Images through the whole head were also performed and do not show suspicious change.

There is a mild and diffuse amount of atrophy noted on the exam. Some mild enlargement of the ventricles is also seen, but it is quite minimal. The craniocervical junction on the lateral sagittal images is intact and does not present with a Chiari malformation.

IMPRESSION:
1. There is no evidence of a tumor, which enhances or nonenhancing in the internal auditory canal or cerebellopontine angle bilaterally.
2. No abnormal enhancement is noted throughout the exam.
3. There is abnormal presumed mucosal inflammation and edema suggested in the left mastoid air cells and including the left middle ear cavity suggestive of significant inflammation.
4. Two small areas of demyelination suggested in the right gray-white matter junction region of the superior parietal and then the parietooccipital region. These are most likely very small vessel insults. Again, they do not enhance.

Neuropsychological Evaluation Medical Transcription Sample

 Neuropsychological Evaluation Medical Transcription Sample

REASON FOR REFERRAL: The patient is a (XX)-year-old male who returns at this time for yearly neuropsychological evaluation. He has been diagnosed with mild cognitive impairment and evaluation at this time was recommended to determine the presence of any improvement following implementation of CPAP for sleep apnea.

TESTS PERFORMED: Selected Wechsler Adult Intelligence Scale-III subtests and the Wechsler Memory Scale-III, California Verbal Learning Test, Clock Drawing, Trail Making Test, Semantic and Phonemic Verbal Fluency Tests, Boston Naming Test, Rey-Osterreith complex Figure with recall and recognition trials, Grooved Pegboard, Geriatric Depression Scale, and interview.

INTERIM HISTORY: The patient stated that his wife thinks that his memory has gotten worse over the last year. He gave the example of thinking about something with his eyes closed and forgetting what it was when he opens his eyes. He also finds that he forgets what he is thinking about when interrupted by any kind of activity or distraction. When asked about any changes in his temperament, as noted in past evaluations, he agreed that he does sometimes get impatient with his wife. He said that his wife has told him that his speech is not as loud as it used to be and that he mumbles. He continues to be independent with all of his activities of daily living, including driving and bill paying. He remembers to take his medications, and if on occasion he forgets, his wife will remind him. He was in the habit of golfing four days a week until he fell about a week ago and bruised his elbow. He said that he does not sleep that well. He only gets about 3 hours of sleep at night and will often take a nap in the afternoon. A few months back, he underwent left carotid endarterectomy with no apparent complications. He stopped using his CPAP machine at that time and has not resumed its use. He questions whether his apnea is that significant. He is not sure if the CPAP actually helped him.

BEHAVIORAL OBSERVATIONS: The patient was alert and fully cooperative. He presented as a neatly dressed and groomed man, appearing slightly younger than his age. He answered questions with an appropriate degree of elaboration. His affect was normal in range and intensity and his overall mood was good. In fact, he seemed to be in better mood at this evaluation than last year. He joked and laughed several times throughout the interview and formal testing. He was able to comprehend all the instructions, but occasionally they had to be repeated because of difficulty hearing. He does have a hearing aid in his left ear. His level of effort was felt to be good. He was able to establish rapport with the examiner. He understood the nature and the purpose of the examination.

RESULTS OF EXAMINATION: The patient demonstrated a mild decline on measures of attention and concentration, but improvement on measures of visual motor processing speed. Measures of verbal learning and memory are essentially unchanged for both paragraph length material and unrelated words. These scores fall into the average to below average range for his age. Immediate memory for a complex figure declined somewhat from the average to the below average range and delayed recall fell into the mildly impaired range. In contrast, his immediate and delayed recall of pictures of a family were essentially unchanged and in the normal range. Language functions declined somewhat from the previous visit, though not universally. His semantic verbal fluency declined from average to below average, whereas his phonemic verbal fluency actually improved slightly from impaired to below average. Confrontational naming still from superior to average. His visual-spatial functions were essentially unchanged. Fine motor speed and dexterity remained unchanged from last year, but declined slightly on the nondominant side. His clock drawing was unchanged, showing intact spatial planning and conceptualization. With respect to his mood, he endorsed about the same number of symptoms of depression as he did last year, with a score of 9 on the Geriatric Depression Scale as oppose to 8. This is in some contrast to his presentation, which was clearly more cheerful than last year.

CONCLUSIONS: Neuropsychological reevaluation shows some inconsistent results. There is an increase in processing speed, but a slight decrease on measures of attention and concentration and some aspects of language function. Also, his performance on a visual memory test decreased slightly. Overall, there is not enough evidence in the results to indicate a significant decline. I continue to feel that he has mild cognitive impairment that could be due to sleep apnea. Given the relatively stable performance over the last several years, the likelihood of early dementia of the Alzheimer's type is slim.

DIAGNOSTIC IMPRESSION: Mild cognitive impairment.

RECOMMENDATIONS:
1. Encouraged the patient to continue using the CPAP.
2. Will discuss the results of the evaluation with him in a feedback session next week.
3. Unless he begins to experience significantly increased cognitive problems or his wife observes significant changes in his cognitive or behavioral functioning, there is no need for further neuropsychological followup. Should either of these occur, I would be happy to see him for further evaluation and consultation.

Laparoscopic Low Anterior Resection Operative Sample Report

 PREOPERATIVE DIAGNOSIS: Rectal cancer.

POSTOPERATIVE DIAGNOSES:
1. Rectal cancer.
2. Umbilical hernia.

OPERATIONS PERFORMED:
1. Laparoscopic low anterior resection.
2. Laparoscopic mobilization of splenic flexure.
3. Umbilical hernia repair.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: General endotracheal.

OPERATIVE FINDINGS:
1. Rectal cancer.
2. Umbilical hernia.
3. Obesity.

SPECIMENS: Sigmoid colon and rectum, proximal and distal margins.

ESTIMATED BLOOD LOSS: 250 mL.

IV FLUIDS: 4000 mL.

ANTIBIOTICS: Ancef and Flagyl.

DRAINS: None.

COMPLICATIONS: None.

POSTOPERATIVE CONDITION: Stable.

INDICATIONS FOR SURGERY: The patient is a very pleasant (XX)-year-old male referred to me for rectal cancer. Recently, the patient developed bright red blood per rectum on the toilet paper and in the stools over the last few months. He underwent colonoscopy, which demonstrated rectal cancer. Biopsies demonstrated invasive colonic adenocarcinoma, moderately differentiated. The patient was then referred to me for further surgical management. The risks, benefits, and alternatives of the procedure were discussed extensively with the patient and family. All of their questions were answered. They agreed to proceed.

DESCRIPTION OF OPERATION: After obtaining informed consent, the patient was taken to the operating room. He was given perioperative IV antibiotics. He was then placed on the operating table in a supine position. Subcutaneous heparin was administered. Compression boots were applied. The patient then underwent general endotracheal anesthesia. A Foley catheter was then placed. The patient was then placed in the lithotomy position. The beanbag was then desufflated. He was then secured to the table. His abdomen was prepped and draped in the usual sterile manner. The umbilicus was opened with a #11 blade. Dissection revealed an umbilical hernia. The subcutaneous tissue was taken off the skin and the contents of the hernia were then placed back into the abdomen. Access to the abdomen was gained with blunt dissection. A single U-shaped 0 Vicryl suture was then placed into the fascia. A 12 mm trocar was then placed into the abdomen and gas insufflation was obtained.

Initial inspection of his abdomen revealed no abnormalities. His liver was examined and there was no evidence of metastatic disease. It was clear that this case was going to be difficult at this point in time as the patient was extremely obese in his abdomen. We then placed him in the Trendelenburg position and mobilized his small bowel out of the pelvis. We then began a dissection over the sacral perimeter beneath the IMA pedicle. This dissection was difficult as his mesentery was extremely thick and the small bowel would not stay out of the pelvis despite multiple maneuvers. I then felt that it was easier to perform a lateral dissection first. His sigmoid colon was then taken off the left pelvic sidewall carefully to preserve the underlying vascular structures as well as the ureter. This dissection was carried along the edge of the retroperitoneum as it attached to the colon, colon mesentery, and the sigmoid colon. This was then taken all the way up to the level of the splenic flexure. We then began our dissection over the distal transverse colon. The gastrocolic ligament was divided and access to the lesser sac was gained. The Harmonic scalpel was used to transect the omentum distally overlying the colon.

We then carried this dissection up to the splenic flexure. We then fanned the splenic flexure out and mobilized carefully beyond this over the area of Gerota's fascia overlying the left kidney. This was mobilized all the way up to the level of the inferior border of the pancreas, where the inferior mesenteric vein was identified. We then carried this dissection back down towards the left pelvic sidewall. We identified the left gonadal vessels. Identification of the ureter was difficult because of his fatty tissues. We did eventually identify this and this was preserved and mobilized laterally away from the colon mesentery. We then performed dissection back from the medial side underneath the IMA pedicle leading across where the dissection had been performed laterally. The ureter was kept inferior. The proximal IMA was identified. A window above this was opened with Bovie electrocautery. The overlying peritoneum of the IMA was then opened with a combination of coagulation and Harmonic scalpel. We then transected the IMA carefully with the ligature device. Hemostasis was adequate at that time.

We then performed additional dissection medially up under the mesentery of the sigmoid colon again leading across Gerota's fascia and retroperitoneal structures, which had been mobilized inferiorly from the lateral aspect.  Once I felt that the splenic flexure was completely mobilized and that the mobility on the transverse colon, splenic flexure, and descending colon was adequate, we made a small lower midline incision. This was performed with Bovie electrocautery. The fascia was then divided, the midline was identified, and the perineum was then opened. The bladder was carefully mobilized laterally to avoid injury. A medium sized protractor drape was then placed into the abdomen.

The colon was then removed from the abdomen. An area between the descending colon and sigmoid colon was identified and chosen as the area to be transected. The mesentery here was divided. The marginal vessels were identified and divided. The marginal vessel had good pulsatile bleeding. These were then clamped and secured with 0 Vicryl sutures. The bowel was then cleaned off and then transected with an automated purse-string device. The ILS-29 anvil was then placed into the descending colon and secured with the previously placed suture. This was then packed away as was the small bowel up into the abdomen, and the pelvic portion of our procedure was then performed.

We had already dissected over the sacral promontory in the presacral plane and this was continued distally with Bovie electrocautery. Care was taken to preserve the fascia appropriate to the rectum. The prerectosacral fascia was then divided to gain access below the level of the tumor. This tumor was palpable. We then performed the lateral dissection along the right and left pelvic sidewalls. Care again was taken to not injure either ureter or vascular structures, but provide adequate margin for our tumor. We then performed this dissection anteriorly as our lateral dissection met. The bladder and anterior structures were then mobilized away from the edge of the colon. Care was taken to preserve those anterior structures.

I do not believe we reached the level of the seminal vesicles and they were thus preserved. Dr. Doe then performed proctoscopy to ensure we were well distal to our tumor and we were. The mesentery had thinned in this region and was taken along with the rectum with a single fire of the TX-60 stapling device. The specimen was then removed, opened, and examined along with pathology. The distal margin was approximately 2.6 cm. There was some fibrosis within the mesentery and there was some palpable lymphadenopathy. The abdomen was then irrigated copiously with saline solution. Hemostasis was adequate. We then performed the ILS-29 stapled colorectal anastomosis. There was absolutely no tension on the anastomosis. Hemostasis was adequate. The doughnuts were then examined and found to be complete. The anastomosis was then leak tested under water and there was no leakage. We had to remove the packing from the abdomen. We also removed the protractor drape.

At this point in time, all counts were correct. The fascia was then closed with running 1 PDS suture. The wound was then irrigated copiously with saline solution. The wound was then staple closed. The fascia at the umbilicus was closed with a single 0 Vicryl suture that had been previously placed. All the other trocar sites were then closed with single 4-0 Vicryl or 4-0 Monocryl suture. All the wounds were cleaned and dried and secured with Tegaderm and a sterile gauze dressing. The patient was then awakened, extubated, and taken to recovery room in good condition.

Subarachnoid Hemorrhage Medical Transcription Sample Report

 DIAGNOSIS:  Subarachnoid hemorrhage.

CHIEF COMPLAINT: Headache.

HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old woman in her usual state of health until yesterday when she apparently fell. She was lying on the couch when someone knocked at her door and she arose quickly to answer the door and apparently lost her balance and became lightheaded. The next thing she remembers, she had fallen to the ground and was being helped up.

Her memory events around the accident are limited to what I have described, so she did experience amnesia to the event if not an actual loss of consciousness. Currently, she complains of a dull headache that is mild in nature and is worse with certain movements, generally relieved with laying still. She had no numbness or weakness of her extremities, no neck pain, no nausea or vomiting. No seizures.

PAST MEDICAL HISTORY, PAST SURGICAL HISTORY, MEDICATIONS, ALLERGIES, FAMILY HISTORY, SOCIAL HISTORY, REVIEW OF SYSTEMS: All well documented on her inpatient chart.

PHYSICAL EXAMINATION: On examination today, the patient appears her stated age. She is a pleasant woman, cooperative and in no apparent distress. Temperature is 98.2, pulse 92, respirations 19, BP of 114/54. She is awake, alert and oriented x3. Her language is free of evidence of dysphasia. Fund of knowledge is appropriate. Attention span and concentration is normal. The memory is intact to recent, remote and immediate recall. Pupils are 3 mm and briskly reactive. Her extraocular movements are full. The face is symmetrical. Facial sensation is intact. Hearing is intact bilaterally. Her tongue protrudes in midline. Her uvula elevates in midline, and her shoulder shrug is symmetric. She has normal muscle tone and strength in both upper and lower extremities without a pronator drift and no problems with dysmetria or finger-to-nose testing. Deep tendon reflexes are 2+ throughout. No Hoffmann's. I did not assess her gait and station.

REVIEW OF TESTING: CT scan of the head shows scattered subarachnoid hemorrhage over the convexity as well as some small amount of blood in the basilar cisterns. There is a large subgaleal hematoma in the left occipital region, all consistent with her history of a recent fall. There is no evidence of an aneurysm or subarachnoid hemorrhage. I have read the radiology report, agree with the findings.

Her platelet count is slightly depressed but it is greater than 100,000. Her INR and PTT are normal.

IMPRESSION:

1. Traumatic subarachnoid hemorrhage after a fall.
2. This patient's GCS is 15.

RECOMMENDATIONS: Recommend repeating her CT scan today as well as checking cervical spine x-rays.

Ulcers of Leg SOAP Note Medical Transcription Sample Report

SUBJECTIVE:  This is a (XX)-year-old Hispanic female with a past medical history as mentioned in the previous visit, who came for a followup for the ulcers in the left leg.  Apparently, the left ulcer has still not completely healed but with erythema and less induration. There is some purulent discharge noted.  The leg edema is markedly improved with diuretics.  The patient still has some engorged varicose veins but without any new ulcerations.

OBJECTIVE:

GENERAL APPEARANCE:  The patient is a morbidly obese, fairly-developed female. The patient is alert and oriented x3, not in any acute distress. The patient is ambulatory.

VITAL SIGNS:  Temperature 98.4 with a blood pressure of 132/80, pulse of 88, respirations of 20, and weight of 221 pounds, which is decreased from the previous weight of 228.

LUNGS:  Clear to auscultation.

CARDIOVASCULAR SYSTEM:  Normal rate.  Regular rhythm.  There is no gallop

EXTREMITIES:  The extremities are still with about 1+ to +2 pitting leg edema and there is still an open leg ulcer on the left shin area, the mid section, but without any purulent discharge.  No visible induration noted.  Mild erythema.  There is no active bleeding noted and nontender.  The patient also has good pedal pulses.

NEUROLOGIC EXAMINATION:  Intact.

ASSESSMENT AND PLAN:

1.  Nonhealing ulcers of the left leg.  Plan is to retreat with Cipro 500 mg p.o. b.i.d. for 10 days with clindamycin 300 mg p.o. 3 times a day for 10 days.  Would get an x-ray of the left leg and also refer the patient to Infectious Disease for further evaluation and management as well as outpatient wound care center.  The patient will be followed up in about a month.

2.  Hypertension, well controlled.  Will continue with the diuretic with Lasix 20 mg b.i.d. with potassium supplement.

3.  Leg edema most likely secondary to venous insufficiency.  Continue with the same treatment as #2.

4.  The patient will be advised to follow up in about a month.

Ingrown Toenail Progress Note Transcription Sample Report

HISTORY OF PRESENT ILLNESS:  The patient comes in with 2 concerns. Primarily, he has noted an infection on his right great toe. For about 2 days, he noticed it was a little bit sore and red and it increased over the past 2 days and it woke him up throbbing last night.

He has not had any fevers or chills. He has been cleaning it with alcohol and peroxide and squeezing small amounts of pus from it. He does not have a history of ingrown toenail.

He also would like his throat checked. He said he has had cold about 3 weeks ago and initially had a temperature of 100.6 that lasted a couple of days followed by a runny nose and a sore throat. Most of his symptoms have resolved except for a little residual right sore throat. He has had no trouble swallowing. No more fevers or chills. No chest congestion or shortness of breath or wheezing.

The patient also mentions that his blood pressure always seems to be borderline high with a diastolic in the 90s and he would like that checked as well. He does not have a family history of premature heart disease. He exercises regularly and is very active. Does not smoke. Occasional alcohol.

PAST MEDICAL HISTORY:  Thalassemia trait, Guillain-Barre syndrome, IDA, perforated eardrum, history of right carpal tunnel syndrome, tenosynovitis, impaired fasting glucose, history of chronic low back pain.

MEDICATIONS:  No regular medicines.

ALLERGIES:  No known drug allergies.

PHYSICAL EXAMINATION:  Vital Signs:  Blood pressure by the nursing assistant 148/90, by myself was 140/90, pulse of 66, temperature 97.8, oxygen saturation 98%. The patient is pleasant, in no apparent distress and looks well. His skin is warm and dry. Ears:  Some mild erythema and old scarring. Posterior pharynx without erythema or exudate. Sinuses are nontender. Nodes are negative. Neck is supple. Lungs are clear without rales, rhonchi, or wheezes. Negative egophony. Good inspiratory effort. Cardiac: S1, S2 regular rate and rhythm. Right great toe is erythematous around the nail on both sides, a little bit of scab on the medial corner of the nail. There is no joint line tenderness. Good range of motion. There is no streaking.

ASSESSMENT AND PLAN:

1. Ingrown toenail on the right. We will treat with warm soaks at least 4 times a day in either warm soapy water or peroxide and water. We will treat with Keflex 500 mg one p.o. q.i.d. for 7-10 days. He is to keep this covered while at work.
2. Resolving upper respiratory infection without sign of bacterial infection at this time.
3. Blood pressure at 140/90, borderline high. He would like to discuss this with Dr. John Doe. We will set up an appointment for him to return in about a month. In the meantime, we will have him check his blood pressures at home, about 3 times a week, and bring a record of his blood pressure readings and his cuff so we can check that when he comes in. He will call for any new or worsening symptoms.

Colorectal Surgery SOAP Note Transcription Sample Report

DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient is here for a long office visit. He was recently discharged from an outside clinic where he had been admitted after he had a bowel obstruction. He had recurrent strictures of ileum from Crohn's disease.

He is followed by Dr. John Doe. He finally underwent a resection by Dr. Jane Doe, 2-3 feet of terminal ileum, which was reattached to the colon.

He had some diarrhea treated with Imodium tablets 4 times a day. Otherwise, he has had no nausea or vomiting. His appetite is improved. He has followup with the Colorectal Surgery in about a week.

PAST MEDICAL HISTORY:  Other histories include labile blood pressure, hyperlipidemia, reflux esophagitis.

OBJECTIVE:  On examination, his vital signs include blood pressure of 122/84, pulse 82, respirations 18, weight is 240. HEENT:  Sclerae anicteric. Neck was supple. Lungs:  Clear. Heart:  Regular rhythm. No gallop or ectopy. Carotids had no bruits. Abdomen:  Soft, distended. He had a healing midline scar going from the entire midline. He had some mild eschars coming off without signs of infection or drainage. Extremities:  No edema, cyanosis or clubbing. Pedal pulses were intact. Neurologically, he was nonfocal.

ASSESSMENT AND PLAN:  The patient is recovering from extensive colorectal surgery with the lower terminal ileum. He is having some postoperative diarrhea, which is to be expected at this time. We can check to see if his CBC, liver profile, albumin are recovered.

His list of medications are aspirin 81 mg a day, he takes B12 1000 mcg monthly intramuscularly. He is going to be restarting his Humira after he has healed from his surgery. He is taking loperamide, which is Imodium 2 tablet 4 times a day for diarrhea. Takes a multivitamin daily, Protonix 40 mg daily. He had been on Welchol, but this has been held and he is now on Metamucil 2 tablets once daily.

We will see him back in 2-3 months. He will call sooner if any problems.

Bloody Diarrhea Transcription Consultation Sample Report

REASON FOR CONSULTATION:  Bloody diarrhea for about 10 days.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who presented to the emergency room with 10 days of bloody diarrhea.  She had been given Augmentin 875 mg for a total of 10-day course for presumed infection of her foot and pain about 2-1/2 weeks ago.

She had no problems with GI symptoms until 7 days later, when she began to have bloody diarrhea, not having severe abdominal cramping prior to the passage of small volume or frankly bloody stools about 8-10 times per day.

She denies fever, but she has chills and nausea.  No vomiting but decreased appetite, minimal weight loss, diffuse abdominal tenderness throughout the day with left residual weakness and dry mouth which has gotten better as the days go on with IV dehydration.

No neck pain, rash, anal lesion or heartburn.  She does complain of rectal soreness.  The patient had recent C. diff that was negative.

PAST MEDICAL HISTORY:  Ulcerative proctosigmoiditis.  She had a flare in January after being given Avelox.  The patient had a colonoscopy at that time that showed evidence for pseudomembrane.  Type 2 diabetes, hypertension and increased cholesterol.

Her first episode of ulcerative proctitis was 11 years ago.  Colonoscopy was performed.  Most recent colonoscopy was done by myself 9 months ago that showed colitis in the anal verge at 20 cm with loss of vascularity, increased erythema, exudate and friability.  For 20 to 30 cm, the mucosa was normal, for 30 cm into the right colon there was evidence of colitis and multiple pseudomembranes.  The plan was to perform a colonoscopy when she was not having a flare, so as to document the extent of her ulcerative colitis to determine the frequency of colonic evaluations in the future.

She canceled that because she had just started a new job 3 weeks prior.

PAST SURGICAL HISTORY:  Cholecystectomy and carpal tunnel surgery.

SOCIAL HISTORY:  Cigarette smoking.  Alcohol:  None.

FAMILY HISTORY:  Cousin has Crohn's disease.

MEDICATIONS:  Prior to coming to the hospital; Crestor, lisinopril and Glucophage.

ALLERGIES:  NONSTEROIDAL, CODEINE, QUINOLONES.

MEDICATIONS:  Phenergan.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 97.2, pulse 104, respiratory rate 20, blood pressure 128/84.
LUNGS:  Clear.
HEART:  Unremarkable.
ABDOMEN:  Soft.  There is diffuse periumbilical tenderness, more on the left lower quadrant than the right lower quadrant.  Positive bowel sounds.  Nondistended.

LABORATORY AND X-RAY DATA:  White count 7.8, hemoglobin 13.6, hematocrit 39.8, MCV of 83.8, platelet count 306,000, calcium 8.9. PT 13.4 with an INR 1.18.  Serum sodium 138, potassium 3.7, chloride 102, CO2 of 27.8, BUN 4, creatinine 0.7, glucose 190.  Urinalysis is pending.  Stool studies, culture and stain are pending.

DIAGNOSIS:  The patient is a (XX)-year-old female with history of ulcerative proctosigmoiditis who presents with bloody diarrhea.

DIFFERENTIAL DIAGNOSES:
1.  Recurrence pseudomembranous colitis.
2.  There is an entity called ampicillin/ampicillin derivative colitis that can present with hemorrhagic colitis. It is more typically in the right colon than left colon, and it gets better with the resolution of taking antibiotic.  This also has been reported with cephalosporin.
3. Infectious colitis.
4. Less likely that of flare of ulcerative proctosigmoiditis.

PLAN:
1. The plan is to repeat C. diff.
2. IV fluids.
3. The patient is scheduled for CT of the abdomen and pelvis.
4. If the C. diff is positive, we do not think any further GI evaluation is required except to treat her positive C. diff.  If her C. diff is negative, then we would recommend sigmoidoscopy with just tap water enema prior to this.  This was discussed in detail with the patient.

Thank you very much for allowing us to participate in this interesting consultation.

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.

Orthopedic Operative Samples #1  Orthopedic Operative Samples #2

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